Recurring concern

Failure to ensure custody staff understand and apply detention procedures

First to latest report 15 Oct 2014 — 25 Jul 2025

Reports that mention this concern
6
Times this concern has been raised
7
Stated actions linked to this concern
4

What this concern includes

Includes failures in the custody-staff competence process for understanding and applying detention law, powers, codes, custody procedures and management requirements, including inadequate initial training, insufficient refresher provision, unclear guidance and failures to assure continuing knowledge among police, detention, nursing or other staff performing custody functions.

What is not included
  • Excludes generic staff training or competence deficiencies where detention or custody procedures are not the material safety concern.
  • Excludes prison reception, healthcare, observation, emergency-response and other custody processes when the reported deficiency is not staff understanding or application of detention procedures.
  • Excludes failures in the substantive law or design of detention powers where staff competence, training or application is not the shared unsafe condition.
  • Excludes clinical competence, treatment and safeguarding training unrelated to staff exercising or supporting detention and custody functions.

Reports and published responses 6 reports

See individual reports that have raised this concern, and the actions taken in response

  1. South Yorkshire (Western)

    AI-generated summary

    Kaine Regan FLETCHER · 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

    Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.

    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 police training on communicating s.136 detention decisions and reasons

    Wider context from the report

    “4. Police training on s.136 MHA 1983 detention and mental health I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee. Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances. I am concerned that training in the area of mental health generally is lacking, which is impacting upon the approach of the police officers dealing with mental health related incidents. ”

    Source location

    Kaine Regan FLETCHER · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

  2. Southampton and New Forest

    AI-generated summary

    Eleanor Valerie Fyfe BRABANT · 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

    On 2 November 2017, Eleanor Brabant hanged herself while alone in a room at Trinity Ward, Antelope House, Southampton. She had a history of mental illness, and her behaviour and mental state had deteriorated after her compulsory detention was rescinded without a clear care plan in place. Concerns included the application and staff training relating to patient observations, safeguarding and reporting crimes involving vulnerable patients, use of Mental Health Act powers for informal patients, and involving families in care planning when consent had been withdrawn.

    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 ward nurses to use section 5(4) powers to prevent unsafe patient departure

    Wider context from the report

    “5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently. ”

    Source location

    Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. West Yorkshire Eastern

    AI-generated summary

    Adam RICE · 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

    Adam RICE was taken to hospital after being found asleep in a skateboard park, later self-discharged without a CT head scan, and was subsequently detained at a police station after being arrested. He exhibited signs of alcohol withdrawal, collapsed and died in his cell on 12 May 2014. The report identified concerns about communication between hospital staff and police, custody staffing and training, welfare checks, observation levels, handovers and monitoring practices.

    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 comprehensive knowledge of custody law and procedures among custody staff

    Wider context from the report

    “1. To ensure that Custody staff to which I mean Police Officers of all ranks, Civilian Detention Officers and Nursing staff have a full and comprehensive knowledge of the Police and Criminal Evidence Act and the relevant Codes of Practice and the relevant provisions of the College of Policing Authorised Professional Practice Provisions in respect of Detention and Custody and Custody Management Planning. ”

    Source location

    Adam RICE · 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

    Provide comprehensive PACE and APP training before custody work and annual refresher training for custody staff.

    Verbatim wording from the response

    “All Custody Staff employed by West Yorkshire Police undergo a full training programme in line with the College of Policing requirements prior to working in a live custody suite. During this initial course, Custody Officers, Detention Officers and PC Gaolers all receive training on the Police and Criminal Evidence Act (Code C) and Authorised Professional Practice (APP).”

    Source location

    Adam-Rice-Response_Redacted
    Page 2 · response
    Published 3 March 2016

    Open published response

  4. Central Lincolnshire

    AI-generated summary

    Rubel Ahmed · 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

    Rubel Ahmed, who was detained at Morton Hall Immigration Removal Centre, was found hanging in his room on the evening of 5 September 2014 and was pronounced deceased shortly after midnight on 6 September 2014. The concerns included overnight locking of detainees in rooms, the adequacy of detention-awareness training, staff awareness of changes in detainees’ circumstances, insufficient protected time for personal officers, and the use of electrical leads that could be used as ligatures.

    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 regular detention awareness refresher training

    Wider context from the report

    “ii. DETENTION AWARENESS TRAINING: I am concerned that the detention awareness training given to the staff at Morton Hall I.R.C was not sufficiently robust to be of continuing assistance to staff in their understanding of detainees needs or to have an ongoing impact on their working practices. Further, little or no provision had been made to provide regular refresher training. I consider that there is a need for an urgent review of the provision of detention awareness training to detention staff at Morton Hall IRC with a view to effective training and refresher training courses being provided. ”

    Source location

    Rubel Ahmed · 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

    Implement regular refresher Detention Awareness training for Morton Hall staff.

    Verbatim wording from the response

    “We agree that it is important that all staff working in an IRC have a broad understanding of the needs of detainees. There is a comprehensive Detention Awareness training package in place for all staff at Morton Hall IRC and work is underway to implement a programme of regular refresher training.”

    Source location

    2015-0308-Response-by-Home-Office
    Page 2 · response
    Published 5 August 2015

    Open published response

  5. Carmarthenshire & Pembrokeshire

    AI-generated summary

    Laura Hill · 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

    Laura Hill, aged 21, was admitted to a psychiatric ward after a serious overdose and later absconded twice before being found hanging from a tree in a wooded area. The concerns identified included information-sharing failures, stretched staffing, training needs around police handovers, absconding, personality disorders and detention powers, and the ward door policy.

    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 staff training in the section 136 procedure for police handovers

    Wider context from the report

    “(3) There was a training need identified in relation to the section 136 procedure when patients are handed over by the Police. ”

    Source location

    Laura Hill · 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

    Insufficient staff training in powers of detention and their appropriate use

    Wider context from the report

    “(7) There was a training need identified in relation to powers of detention and when those powers can and should be used. ”

    Source location

    Laura Hill · 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

    Provide Section 136 procedure training to nursing and medical staff through induction, follow-up training and continuing medical education.

    Verbatim wording from the response

    “A multi-agency Section 136 Protocol was signed off in November 2014. This Protocol details partner responsibilities in relation to Section 136. There are clear guidelines to be followed and these include points of transition with associated documentation. Nursing staff on St Caradog Ward receive training in respect of their responsibilities as part of their induction. Further follow up training is thereafter provided directly to staff on the ward. Medical staff also receive training on induction as well as on-going through the Post Graduate Medical Training Forum. Medical staff have protected training on a weekly basis.”

    Source location

    2015-0092-Response-by-University-Health-Board
    Page 2 · response
    Published 20 February 2015

    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

    Provide ongoing Mental Health Act and Mental Capacity Act training to update clinicians on detention powers.

    Verbatim wording from the response

    “Registered clinical practitioners are aware of the powers of detention which are available to them. On-going Mental Health Act and Mental Capacity Act training (as detailed previously) ensure that clinicians are updated in relation to the application of powers of detention.”

    Source location

    2015-0092-Response-by-University-Health-Board
    Page 3 · response
    Published 20 February 2015

    Open published response

  6. Worcestershire

    AI-generated summary

    Severyn Witold Glowinski · 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

    Severyn Witold Glowinski, a serving prisoner diagnosed with paranoid schizophrenia, was transferred to segregation and remained there for a little under a fortnight. He was found hanging in his cell on the evening of 3 July 2013 while subject to an open ACCT for self-harm. Concerns included poor communication about his care plan, inaccurate paperwork copied from another prisoner’s file, and a lack of awareness of requirements concerning the segregation of prisoners on an open ACCT.

    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 knowledge among Senior Custodial Managers of segregation transfer requirements

    Wider context from the report

    “(3) The Senior Custodial Managers in the wing were unaware of the requirements of prison service orders which meant that an individual on an open ACCT should not be transferred to segregation unless there were exceptional reasons for doing so. ”

    Source location

    Severyn Witold Glowinski · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026