Recurring concern

Unreliable missing-person response

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First reported 21 Aug 2013•Latest report 19 May 2026

Definition

What this concern includes

Includes failures of controls dedicated to the missing-person response, such as staff understanding of the procedure, risk classification, communication of status, searches, escalation, agency coordination and family notification.

Not included

  • Excludes generic delays in escalation or communication that are not explicitly connected to a missing-person response.
  • Excludes unrelated patient-deterioration, emergency-response or clinical-escalation failures.
  • Excludes general accessibility or communication deficiencies concerning visits, relatives or care unless they concern notification or coordination within a missing-person response.
Reports
45

Distinct published reports

Individual concerns
75

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
112

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Metropolitan Police Service8
College of Policing7
Greater Manchester Police5
Department of Health and Social Care4
Surrey and Borders Partnership NHS Foundation Trust4
West Midlands Police4
East London NHS Foundation Trust3
Home Office3
National Police Chiefs’ Council3
Sussex Partnership NHS Foundation Trust3
Birmingham and Solihull Mental Health NHS Foundation Trust2
NHS England2
North London NHS Foundation Trust2
Sussex Police2
Association Of British Neurologists1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Surrey

    AI-generated summary

    Melanie Jane ELMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Melanie Jane Elms, an informal patient at the Abraham Cowley Unit with a history of schizo-affective disorder and suicidal attempts, left the unit on day leave on 30 January 2018 and was fatally struck by a train. The inquest identified that a mandatory pre-leave risk assessment was not carried out, concerns raised by her husband were not properly recorded or acted upon, and her leave was not adequately documented or managed. The report also raised concerns about the failure to provide the planned care package and the absence of a missing-person plan and contingency planning.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a missing-person plan with timeframes and escalation steps for leave

    Wider context from the report

    “4. There was no missing person plan in place with timeframe and steps of escalation for Melanie’s leave. ”

    Source location

    Melanie Jane ELMS · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report
  2. West Sussex

    AI-generated summary

    Jack Stephen TAYLOR · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jack Stephen TAYLOR was a detained inpatient who left escorted leave on 17 March 2021 and was found unresponsive at premises in Worthing on 19 March 2021, where he died despite urgent medical assistance. The report raised concerns about Mill View Hospital’s reliance on police support and failure to consider the full range of powers for returning absconded patients, as well as weaknesses in joint hospital-police AWOL and missing-person procedures that could delay locating and returning high-risk patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Mismatch between AWOL and missing-person risk assessment grading criteria

    Wider context from the report

    “2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’ I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing. I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded. I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document. I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection. ”

    Source location

    Jack Stephen TAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate monitoring and progression of missing-person investigations

    Wider context from the report

    “3. Sussex Police’s use of their Missing Persons Policy I heard evidence that the trigger for the interventions required by this policy is that the missing persons report should be transferred onto the Niche system within 2 hours of a unit being assigned to take initial details. In this inquest no units were available to be assigned for over 9 hours due to the high level of demand on both the Brighton and Worthing response teams. Throughout this time the control of the investigation remained with the duty response team. I am concerned that the missing persons investigations are not adequately monitored and progressed due to other demands on the duty response teams attention. I am concerned that opportunities to swiftly locate and return a vulnerable or high risk missing person to the secure ward will be missed when the interventions of specialist officers are not triggered. ”

    Source location

    Jack Stephen TAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to trigger specialist-officer interventions for vulnerable or high risk missing persons

    Wider context from the report

    “3. Sussex Police’s use of their Missing Persons Policy I heard evidence that the trigger for the interventions required by this policy is that the missing persons report should be transferred onto the Niche system within 2 hours of a unit being assigned to take initial details. In this inquest no units were available to be assigned for over 9 hours due to the high level of demand on both the Brighton and Worthing response teams. Throughout this time the control of the investigation remained with the duty response team. I am concerned that the missing persons investigations are not adequately monitored and progressed due to other demands on the duty response teams attention. I am concerned that opportunities to swiftly locate and return a vulnerable or high risk missing person to the secure ward will be missed when the interventions of specialist officers are not triggered. ”

    Source location

    Jack Stephen TAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Embed the completed Missing Persons Template, protocol and joint action plan into the revised multi-agency AWOL policy and practice.

    Verbatim wording from the response

    “Work will take place to move towards having a final draft in May 2022, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absence Without Leave (AWOL) policy which is currently subject to multi-agency review and revision.”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 2 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise the multi-agency AWOL Policy and embed the missing persons template, protocol and action plan into policy and practice.

    Verbatim wording from the response

    “Work will take place to move towards having a final draft in May, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absent Without Leave (AWOL) Policy which is currently subject to multi-agency review and revision.”

    Source location

    2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Escalate medium-risk missing-person reports without an assigned officer within two hours to G99 and, if necessary, the Critical Incident Manager.

    Verbatim wording from the response

    “3.1 – Escalation if resources prevent allocation within 2 hours”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 2 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Notify the investigation officer when a missing person’s location is identified and escalate cases without an assigned officer to G99 or the Critical Incident Manager.

    Verbatim wording from the response

    “When information is received relating to the location of a missing person and attendance by an officer is necessary, an officer will be assigned to that location in line with the threat, harm and risk presented.”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 3 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Have the Duty Inspector support sergeants by dip-checking threat assessments and the quality and sufficiency of lines of enquiry for medium-risk cases from mental health facilities.

    Verbatim wording from the response

    “Consideration has been given to whether command responsibility should be transferred to the Divisional Inspector, rather than remain at Sergeant level. However, the demand on the Inspector that this would generate could result in oversight actually being lost rather than improved, so the responsibility will remain at Sergeant level. The Duty Inspector will now instead support sergeants who have command of medium risk persons reported missing from mental health facilities by reviewing threat assessments and the quality and sufficiency of lines of enquiry that are set. This will be done as a dip-check, with random sampling to ensure consistency and quality.”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 3 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review Sergeants’ existing missing-person training to include obtaining and assessing information and intelligence.

    Verbatim wording from the response

    “3.5 Training provided to Sergeants The existing training that is currently provided to Sergeants who oversee missing person investigations will be reviewed by our Learning & Professional Development Team, who are responsible for preparing and delivering training. Current training includes the function of command, assessing threat, risk & harm, setting and monitoring of proportionate lines of enquiry and handover processes. We intend to include now additionally obtaining and assessing information & intelligence (as referred to in 3.3 above). Where the training can be enhanced, additional formal training and/or Continued Professional Development will be introduced.”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 4 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Co-develop a joint missing persons action plan defining proportionate actions and tasks for finding missing patients.

    Verbatim wording from the response

    “Additionally, to improve information flow and the overall response to missing persons, it was agreed that work would commence on co-developing a joint missing persons action plan so both agencies can agree actions and tasks in relation to finding a missing person proportionate to the presenting risks.”

    Source location

    2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the Missing Person Team’s terms of reference to identify enhancements to its support during the initial response phase.

    Verbatim wording from the response

    “3.4 Missing Person Team Terms of Reference to be reviewed The terms of reference to which the missing person team works is to be reviewed by the Force ‘Missing Persons Working Group’.”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 3 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Co-develop a missing persons template and accompanying protocol for timely information-sharing and joint risk assessment.

    Verbatim wording from the response

    “Developing a Missing Persons Template (including an action plan)”

    Source location

    2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Command responsibility for medium-risk missing persons will remain with sergeants because transferring it could reduce oversight through increased inspector demand.

    Verbatim wording from the response

    “Consideration has been given to whether command responsibility should be transferred to the Divisional Inspector, rather than remain at Sergeant level. However, the demand on the Inspector that this would generate could result in oversight actually being lost rather than improved, so the responsibility will remain at Sergeant level. The Duty Inspector will now instead support sergeants who have command of medium risk persons reported missing from mental health facilities by reviewing threat assessments and the quality and sufficiency of lines of enquiry that are set. This will be done as a dip-check, with random sampling to ensure consistency and quality.”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 3 · response
    Published 3 February 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Missing Person Team cannot take all investigations from first report because it is small and lacks 24/7 cover.

    Verbatim wording from the response

    “The team has specialist expertise and effective working relationships with many of our partners, providing real benefit to investigations. However, as a small team, cover is not 24/7 so it would not be possible for the team to take on all investigations from first report. The review will consider what, if any, enhancements can be made to assist their colleagues. We anticipate this review will be completed and presented to our Vulnerability Board in April 2022 and any changes that result will take effect immediately.”

    Source location

    2022-0029-Response-from-Sussex-Police_Published
    Page 4 · response
    Published 3 February 2022

    Open published response
  3. Inner North London

    AI-generated summary

    Joseph MARTIN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joseph Martin approached Metropolitan Police Service officers near Westminster Bridge on 3 June 2021, after concerns had been raised about his mental health and safety. The inquest found that he was suffering a psychotic relapse at the time of his death, but the exact circumstances were unclear. The report raised concerns that important information about his mental health and vulnerability was not shared between police forces and that individual errors and wider system weaknesses failed to provide a safety net.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record safety-critical contacts in missing-person and occurrence records

    Wider context from the report

    “Joseph Martin was reported as a person of concern to the PSNI on 28 May 2021 by staff at the hostel where he lived. His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others. The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further. However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed. I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer. Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts. Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back. I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given. There were individual errors, and more significantly a system that does not seem to have provided a safety net. ”

    Source location

    Joseph MARTIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. West Yorkshire Eastern

    AI-generated summary

    Neil Peter Bastock · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to notify police when a patient at suicide risk goes missing

    Wider context from the report

    “3. When the section was rescinded, Mr Bastock became a voluntary patient on the ward. In the three days following 17 September 2020, various factors should have triggered a need to reconsider the decision, including: a) Mr Bastock left the ward on occasions and once did not return until 5am. b) On his return, there was no recorded evaluation of his situation and what action was required from the team treating him. c) A family member voiced concern that he was unwell and was not ready to be discharged, yet this warning was not heeded. d) Another family member reported that he had gone to his former partner (whom he had not seen for several years) to give her £250 he had withdrawn from a cash machine for his children. The possibility that this act amounted to a farewell gesture was noted in the nursing record, but its significance was not sufficiently considered. e) Mr Bastock had indicated he felt unable to live alone. Although a social work assessment had taken place, no plan in relation to alternative accommodation had materialised. In the absence of such transition infrastructure, it was premature to consider him for discharge from the section. f) When Mr Bastock left the ward, there was a failure to notify the police of him as a missing person, given his suicide risk (irrespective of whether this complied with the prevailing missing person's policy stipulated timescales). ”

    Source location

    Neil Peter Bastock · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and revise the Missing Service User Procedure to incorporate learning from the incident.

    Verbatim wording from the response

    “The Trust Missing Service User Procedure outlines the actions staff should take in the event a service user does not return to the ward. The Missing Service User Procedure, although led by the Trust is jointly agreed with West Yorkshire Police. Both organisations have taken a further review of the procedure to ensure it contains the learning from this incident. The draft procedure has been circulated to stakeholders for comment and will then be ratified and circulated by January 2022. The updated procedure will be disseminated to all staff via Trust wide email, and any required adjustments will also be made to any associated training.”

    Source location

    2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 7 · response
    Published 4 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ratify and disseminate the revised Missing Service User Procedure and adjust associated training as required.

    Verbatim wording from the response

    “The Trust Missing Service User Procedure outlines the actions staff should take in the event a service user does not return to the ward. The Missing Service User Procedure, although led by the Trust is jointly agreed with West Yorkshire Police. Both organisations have taken a further review of the procedure to ensure it contains the learning from this incident. The draft procedure has been circulated to stakeholders for comment and will then be ratified and circulated by January 2022. The updated procedure will be disseminated to all staff via Trust wide email, and any required adjustments will also be made to any associated training.”

    Source location

    2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 7 · response
    Published 4 November 2021

    Open published response
  5. Manchester North

    AI-generated summary

    Zeyna Partington · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Zeyna Partington was reported missing on 8 August 2019 and was believed to be at risk of suicide. Her vehicle was detected by ANPR in Derbyshire, but GMP did not become aware of this until 10 August; she was then found deceased in a nearby field after taking an overdose of prescribed medication. The substantive concerns included inadequate understanding of ACT marker levels, delays or gaps in national ANPR notification, and the absence of a fully implemented national system across all forces.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of GMP Officers’ knowledge and understanding of ACT marker levels and their implications for missing from home investigations

    Wider context from the report

    “1. There is a lack of knowledge and understanding by GMP Officers as to the different level of ACT markers and the implications the varying levels may have on investigations particularly missing from home investigations. ”

    Source location

    Zeyna Partington · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Communicate key changes and learning from relevant policies and guidance to operational officers and staff through a comprehensive communication plan.

    Verbatim wording from the response

    “Although the content of the College of Policing guidance document on the use of markers and the Missing From Home policy are known to specific practitioners, the evidence presented at the Inquest into Zeyna Partington's death indicates there is a need to ensure increased awareness of the content across operational staff; specifically uniform frontline officers and staff from the operational communications branch.”

    Source location

    2021-0181-Response-from-Greater-Manchester-Police_Published
    Page 2 · response
    Published 28 May 2021

    Open published response
  6. Surrey

    AI-generated summary

    Kimberley Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kimberley Smith, who had a history of mental health conditions, alcohol dependency and self-harm, died by suicide after leaving an inpatient psychiatric unit while on unescorted leave and being found with a plastic bag over her head. The concerns included inadequate risk assessment and management of alcohol use and leave, failures in observation and missing-person procedures, and the absence of clear written policies for informal and detained patients leaving the unit.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a written timeframe for reporting informal patients missing when they fail to return at the agreed time

    Wider context from the report

    “1. There is no clear written policy/procedure on the following: - The carrying out of risk assessments when informal patients request to leave the unit; - The relevance of an informal patient being on intermittent observations when they request to leave the unit; - The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit; - The risk management plans to put in place when informal patients do leave the unit; - The recording of assessments and decisions relation to requests made by informal patients to leave the unit; - The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time. ”

    Source location

    Kimberley Smith · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a standalone written policy governing informal-patient leave, including risk assessment, leave decisions, risk management, recording and missing-person reporting.

    Verbatim wording from the response

    “Our response: Guidance in relation to leave for informal patients is currently set out in the Trust’s Section 17 Leave Policy. The Trust has decided to build and strengthen upon this by developing a separate, standalone written policy regarding leave for informal patients. The policy will aim to ensure that the right balance is struck between respecting the rights of informal patients and the need to protect people who may be vulnerable and at risk of harm to themselves. The policy will also require all leave for informal patients to be supported by the patient’s risk assessment and care plan. I have had sight of the new draft policy and am confident that it will cover all the issues that you have highlighted (as outlined above).”

    Source location

    2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 6 January 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update the Section 17 Leave Policy and Absent Without Leave Policy with guidance on reporting patients missing after agreed leave.

    Verbatim wording from the response

    “2. Policy/procedure on reporting patients as missing In the PFD, you identified that there is no clear written policy/procedure on the timeframe for reporting patients to the police as missing persons if they fail to return at the agreed time.”

    Source location

    2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 6 January 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Roll out a competency framework to train staff on the new and updated leave policies and their practical application.

    Verbatim wording from the response

    “Once the new and updated policies have been finalised and approved, a structured roll out of a competency framework will begin, to support our staff in understanding the new policy and the updated policies and how to put them into practice.”

    Source location

    2020-0279-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 6 January 2021

    Open published response
  7. Newcastle upon Tyne and North Tyneside

    AI-generated summary

    Ewan Nathanial Brown · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ewan Nathanial Brown was found dead on 30 April 2019 after absconding while awaiting mental health assessment, following concerns about his behaviour and mental health. The inquest concluded that he died by accidental drowning while experiencing an unassessed and untreated psychotic illness. Concerns included gaps in police and health-service information sharing, multiagency coordination, mental health training, and family contact during the missing-person search.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to allocate a police point of contact for the family of a medium-risk missing person

    Wider context from the report

    “5. Northumbria Police accepted that during the period of time that Ewan was classed as a Medium Risk missing person, no officer was allocated as a point of contact for the family. This prevented information being given by the family that could have better informed the progress of the search and Ewan’s risk assessment as a missing person. ”

    Source location

    Ewan Nathanial Brown · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a multiagency meeting structure for reported missing persons

    Wider context from the report

    “2. There is currently no structure in place at a local or national level to allow for a multiagency meeting or meetings to take place when an adult or child is reported missing to the Police. Such a meeting would be a vital source of information to inform missing person risk assessments and to gather intelligence about where the missing person may be. ”

    Source location

    Ewan Nathanial Brown · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. South Yorkshire (Western)

    AI-generated summary

    Emily Greene · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Emily Greene was found hanging from a tree in fields at the rear of Doghill, Shafton, Barnsley, on 16 November 2018, and the evidence was that she took her own life. The inquest identified concerns including inadequate specialist training, deficiencies in the sexual-assault investigation, unclear referral handling, failure to sensitively explain the decision not to pursue the allegation, unsuitable facilities for recording victim video, and mishandling of the missing-person report.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Mishandling of missing person's reports

    Wider context from the report

    “6. There was mishandling of the missing person's report. ”

    Source location

    Emily Greene · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Maintain the Smart Contact incident-management system with trained communications staff and ongoing developmental training.

    Verbatim wording from the response

    “The new incident management system is now fully embedded within the Communications Centre and all staff are fully trained, understand and are familiar with the grading process. Staff receive ongoing developmental training. The force is due to implement a new 'missing from home' IT system called 'Compact' which will improve the forces management and recording of persons reported missing. This new system commences in April 2021.”

    Source location

    2020-0288-Response-from-South-Yorkshire-Police_Redacted.pdf
    Page 11 · response
    Published 7 January 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the Compact information-technology system for managing and recording persons reported missing.

    Verbatim wording from the response

    “The new incident management system is now fully embedded within the Communications Centre and all staff are fully trained, understand and are familiar with the grading process. Staff receive ongoing developmental training. The force is due to implement a new 'missing from home' IT system called 'Compact' which will improve the forces management and recording of persons reported missing. This new system commences in April 2021.”

    Source location

    2020-0288-Response-from-South-Yorkshire-Police_Redacted.pdf
    Page 11 · response
    Published 7 January 2021

    Open published response
  9. Cornwall and Isles of Scilly

    AI-generated summary

    Name not published · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    The deceased was reported missing after telling his wife he was going to a supermarket, and was later found hanged in woodland on 30 April 2018. The report considered whether police should have raised the missing-person risk level from medium to high earlier. The concern was that clearer national guidance might support more consistent decision-making in complex cases.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient clarity of police guidance for missing-person risk-level decisions

    Wider context from the report

    “The appropriateness of the police response to the report of ████████ as a missing person on 29 April was considered by the IOPC. In evidence at the inquest, I heard from their ████████ who concluded that there had been an opportunity to raise the risk to high at an earlier stage. He did note, however, that the matter had ostensibly been dealt with as a high-risk response for some time prior to its re-categorisation at that level. I was not able to conclude that the delay in raising the level of risk to high had been causative of the death as it was not known at what time ████████ had, in fact, hanged himself. It had to be noted that there was a period of approximately eight hours before he was first reported to police as a missing person. It was accepted in evidence that the decision as to the appropriate level of risk was essentially a “judgement call” on the part of the individual officer. It was further accepted that there would be occasions when these judgements would be very finely balanced. It was not felt that there had been any failure to follow practice or protocol at a local level. It was noted, however, that it would be sensible to share the salient facts with you in order that there could be a proper review of the guidance contained within the relevant College of Policing APP upon which the police officers relied. It was recognised that if the guidance could be clearer this may assist different officers from achieving a greater level of consistency in decision-making when faced with the same, complex set of facts. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Inner North London

    AI-generated summary

    Nimo Younis · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Nimo Younis was detained in a psychiatric intensive care unit and was granted unescorted leave on 24 January 2019, but did not return. She was found at a friend's home the following day after hanging herself. The concerns included shortcomings in communication and understanding between ward staff and the police, the escalation and handling of the missing-person enquiry, the information provided to police decision-makers, and the use of the patient's friends in searching for her.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to promptly and fully utilise patients’ friends in missing-person searches

    Wider context from the report

    “5. C&I ward staff did not promptly or fully utilise the significant potential of their patient’s friends, who were ultimately the route by which Nimo Younis was found, and who would certainly have acted sooner if they had appreciated the lack of action being taken - whatever the reason for that lack of action. ”

    Source location

    Nimo Younis · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026