Recurring concern

Unreliable monitoring and emergency response during detainee transport

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First reported 2 Jul 2014•Latest report 20 Feb 2026

Definition

What this concern includes

Includes failures in the dedicated custody-transport process for monitoring detainees and responding to distress or medical emergencies, including vehicle visibility or audibility, crew attention, welfare checks, emergency alerts, prompt entry or access, first aid, resuscitation and communication with emergency services.

Not included

  • Excludes general prison, police-custody or hospital observation failures where detainee transport is not the bounded setting.
  • Excludes routine vehicle design, maintenance or restraint deficiencies that do not impair monitoring or emergency response to detainees during transport.
  • Excludes generic first-aid, staffing, training or communication deficiencies unless they directly impair detainee-transport monitoring or emergency response.
  • Excludes failures occurring after a detainee has been safely transferred from the vehicle and the transport process is no longer the deficient control.
Reports
2

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
8

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.

Home Office1
Metropolitan Police Service1
North Wales Police1
Security Industry Authority1
Serco Group plc1

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. Inner North London

    AI-generated summary

    Sean Perry WILLIAMS · 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

    Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.

    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 provide the transport vehicle location to emergency services

    Wider context from the report

    “For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

    Source location

    Sean Perry WILLIAMS · 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

    Delays in opening a detainee cell and administering emergency first aid

    Wider context from the report

    “For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

    Source location

    Sean Perry WILLIAMS · 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 of transport crew to maintain focus on monitoring and assisting a detainee in distress

    Wider context from the report

    “For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

    Source location

    Sean Perry WILLIAMS · 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 operate and provide clear guidance on emergency button procedures

    Wider context from the report

    “For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

    Source location

    Sean Perry WILLIAMS · 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 of first aid staff to provide complete resuscitation measures

    Wider context from the report

    “For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

    Source location

    Sean Perry WILLIAMS · Prevention of Future Deaths report
    Page 3 · 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

    Revise relevant prisoner welfare, vehicle escort, death-in-custody and associated procedures, and align corresponding training materials.

    Verbatim wording from the response

    “Since the death of Mr Williams we have revised Standard Operating Procedure (SOP) 038 Prisoner Welfare on a Vehicle, SOP 009 Duties of a Vehicle Escort Officer and SOP 047 Death or attempted suicide of a prisoner in custody, to improve the clarity of the steps to be taken where a medical emergency is suspected and I understand copies of the updated SOPs have been provided to you. The changes have also been reflected in other SOPs and training documents to ensure consistency.”

    Source location

    Response from Serco
    Page 1 · response
    Published 24 February 2026

    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

    Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.

    Verbatim wording from the response

    “In addition, in order to remind staff of the required process and aid their retention of the information provided during the training, in March 2025 we created a new online course on Serco’s LMS. This is a mandatory course for all staff members and includes what to do in an emergency medical incident, basic life support, self-harm incidents, vehicle breakdown, fire and anything deemed a vehicle emergency. The content provides a refresher of the training covered in the ITC course, to reinforce learning and gives additional prominence by being a separate module and links together the concepts that staff have learned during their Highfield First Aid training.”

    Source location

    Response from Serco
    Page 3 · response
    Published 24 February 2026

    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

    Develop and display laminated emergency-response flowcharts in escort vehicles to clarify required actions and support consistent responses.

    Verbatim wording from the response

    “As outlined by Serco’s Head of Professional Standards and Security in his evidence, and to support staff on scene in following the correct process, Serco has developed a flowchart for escort officers following the death of Mr Williams. A copy appears in the Inquest bundle. This has since been incorporated into training, and laminated copies are now displayed within all escort vehicles in a position visible from the escort seat. The intention is that this readily accessible guide will reinforce existing training, clarify the required steps, and support escort officers in responding with confidence and consistency during suspected medical emergencies.”

    Source location

    Response from Serco
    Page 4 · response
    Published 24 February 2026

    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

    Develop and display an OCC emergency flowchart with structured prompt questions at controller desks to standardise alarm-activation responses.

    Verbatim wording from the response

    “Serco has also developed a corresponding flowchart for the OCC to reflect that provided to PCOs, together with structured prompt questions to assist OCC controllers in identifying the nature of an emergency and providing appropriate support and direction to PCOs when an incident occurs. A copy of the OCC flowchart has also been provided.”

    Source location

    Response from Serco
    Page 4 · response
    Published 24 February 2026

    Open published response

  2. North West Wales

    AI-generated summary

    Mr Hywel Llewelyn Hughes · 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

    Mr Hywel Llewelyn Hughes was forcibly removed from a nightclub, restrained face down by door staff, and later declared deceased in hospital on 3 May 2003. The inquest concluded that the medical cause of death was traumatic asphyxia and that police actions were inappropriate and more probably than not contributed more than minimally to his death. Concerns included training and monitoring of detainees during restraint and transport, and shortcomings in the licensing, training, auditing and review of door supervisors.

    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 of existing bubble-car design to enable easy monitoring of rear-seat detainees

    Wider context from the report

    “(2) The design of the ‘bubble cars’ in existence at the time of Mr Hughes’ death and apparently still in use pending their phasing out, is such that the condition of a detainee held in the rear of the vehicle may not be easily monitored (because of the presence of a Perspex screen that may affect the ability to see and hear a detainee). ”

    Source location

    Mr Hywel Llewelyn Hughes · 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

    Design a single-cell containment compartment for bubble cars in conjunction with the vehicle manufacturer.

    Verbatim wording from the response

    “Accordingly, to assist with these problems, NWP have designed a single cell compartment bubble car in conjunction with the manufacturer and are testing the single cell compartment, which appears so far to present significant improvements to the existing double cell compartment arrangement. It allows better monitoring as the police officer is closer to the detainee from visual and auditory perspectives.”

    Source location

    2014-0311-Response-by-North-Wales-Police
    Page 2 · response
    Published 2 July 2014

    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

    Test the single-cell bubble-car containment compartment to assess improvements in detainee monitoring.

    Verbatim wording from the response

    “Accordingly, to assist with these problems, NWP have designed a single cell compartment bubble car in conjunction with the manufacturer and are testing the single cell compartment, which appears so far to present significant improvements to the existing double cell compartment arrangement. It allows better monitoring as the police officer is closer to the detainee from visual and auditory perspectives.”

    Source location

    2014-0311-Response-by-North-Wales-Police
    Page 2 · response
    Published 2 July 2014

    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

    Scope an automated intercom solution and identify a suitable product for testing on a demonstrator bubble car.

    Verbatim wording from the response

    “Proposed auditory Improvements NWP are considering the following:-”

    Source location

    2014-0311-Response-by-North-Wales-Police
    Page 2 · response
    Published 2 July 2014

    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

    Investigate whether a hole in the protective screen could improve detainee monitoring without compromising screen integrity or safety.

    Verbatim wording from the response

    “Proposed auditory Improvements NWP are considering the following:-”

    Source location

    2014-0311-Response-by-North-Wales-Police
    Page 2 · response
    Published 2 July 2014

    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

    Officers can effectively monitor detainees despite the sight and hearing issues associated with bubble-car protective screens.

    Verbatim wording from the response

    “NWP consider that police officers can effectively monitor detainees irrespective of the issues highlighted over sight and hearing connected to the protective screens in the existing double compartment bubble car or proposed single compartment bubble car when transporting detainees. Monitoring is achievable to acceptable levels if officers pay sufficient attention to the task and abide by their detainee risk assessments and force policies when transporting detainees. However, NWP are considering improvements to assist with monitoring as set out below.”

    Source location

    2014-0311-Response-by-North-Wales-Police
    Page 2 · response
    Published 2 July 2014

    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

    Existing detainee risk assessments, force policies, officer attention, vehicle checks and timely repairs provide acceptable monitoring and screen performance.

    Verbatim wording from the response

    “NWP consider that police officers can effectively monitor detainees irrespective of the issues highlighted over sight and hearing connected to the protective screens in the existing double compartment bubble car or proposed single compartment bubble car when transporting detainees. Monitoring is achievable to acceptable levels if officers pay sufficient attention to the task and abide by their detainee risk assessments and force policies when transporting detainees. However, NWP are considering improvements to assist with monitoring as set out below.”

    Source location

    2014-0311-Response-by-North-Wales-Police
    Page 2 · response
    Published 2 July 2014

    Open published response
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Data last updated 7 September 2026