Recurring concern

Failure of police operational communications to reliably share safety-critical information

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First reported 21 Oct 2013•Latest report 17 Mar 2026

Definition

What this concern includes

Includes failures in police force control, incident, custody or inter-force communications where relevant risk or safety information is not reliably shared with attending personnel or partner services, including the anchor's omission of recent s136 detention information and failures to pass complete incident information to attending officers.

Not included

  • Excludes generic clinical, social-care or non-police handover and documentation failures unless they are explicitly part of a police operational communication pathway.
  • Excludes failures concerning the content, training or policy of a police process where communication of safety-critical information is not itself the shared unsafe condition.
  • Excludes generic information-technology, staffing or supervision deficiencies that are not explicitly tied to the reliability of police operational communications.
  • Excludes communications about non-safety-critical administrative information.
Reports
34

Distinct published reports

Individual concerns
40

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
65

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.

Department of Health and Social Care7
Metropolitan Police Service7
Home Office6
National Police Chiefs’ Council6
College of Policing5
West Midlands Police5
Crown Prosecution Service2
Devon & Cornwall Police2
Greater Manchester Police2
London Ambulance Service NHS Trust2
Ministry of Justice2
NHS England2
Northumbria Police2
Pennine Care NHS Foundation Trust2
South Western Ambulance Service NHS Foundation Trust2

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

    Agnès Blandine Marthe MARCHESSOU · 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

    Agnès Marchessou had experienced fragile mental health for four or five years before her death. After her arrest on 4 July 2020, she was knocked over by a bus on 8 July and taken to hospital. The principal concerns were that police did not pass key information about the incident and her stated reasons for stepping into the road to ambulance or hospital staff, did not promptly make relevant enquiries or record her potential vulnerability, and showed confusion about the required process.

    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 pass relevant incident and vulnerability information to ambulance and hospital staff

    Wider context from the report

    “The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms Marchessou to hospital, nor to any of the doctors or nurses at the hospital. 2. Ms Marchessou told the police officers that she had blacked out and could not remember what had happened, then that she thought she had stepped into the road as the result of a panic attack. She also said that she had stepped in front of the bus because she was upset about being denied contact with her children. The police officers did not pass on the crucial information that Ms Marchessou said she had stepped in front of the bus because she was upset about being denied contact with her children, either to the emergency ambulance crew or to the treating doctors or nurses. ”

    Source location

    Agnès Blandine Marthe MARCHESSOU · 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

    Improve officers’ sharing of vital incident information with colleagues, ambulance crews and medical staff.

    Verbatim wording from the response

    “Officer 1 interviewed the bus driver at the scene of the collision whilst Officer 2 dealt with Ms Marchessou in the ambulance. This would be normal practice where two parties were involved, with each officer initially dealing with their casualty, witness or other party involved. The senior officer has discussed this incident in detail with Officer 1, providing him with the opportunity to reflect on the decisions he made. It was evident from their discussion that the officer was reflective as he recognised that he would deal with a similar incident differently next time. He would now relay the bus driver’s account to his colleague who was dealing with Ms Marchessou at the scene and subsequently provide this information to the medical staff at the scene and at the hospital.”

    Source location

    2020-0255-Letter-from-Metropolitan-Police-Redacted.pdf
    Page 2 · response
    Published 30 December 2020

    Open published response
  2. Manchester South

    AI-generated summary

    Alfie Gildea · 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

    Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

    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 share complete relevant information between police and CPS

    Wider context from the report

    “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information. ”

    Source location

    Alfie Gildea · 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

    Re-issue guidance to CPS Direct prosecutors requiring MG3 records to include details of relevant police conversations.

    Verbatim wording from the response

    “We also take on board the importance of a consistent and transparent approach to recording whether there has been a telephone call with the police as part of the charging decision. Senior managers within CPS Direct have confirmed that guidance has been re-issued to all of their prosecutors on the need to include within the MG3 details of any conversation relevant to an issue in the case, where it is not already included within the documentation submitted.”

    Source location

    2020-0242-Response-from-CPS-Redacted.pdf
    Page 3 · response
    Published 24 December 2020

    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 police are responsible for complying with prosecutor action plans and providing further evidence, material or information within agreed periods.

    Verbatim wording from the response

    “Paragraph 3.1 (concerning the responsibility of the police):”

    Source location

    2020-0242-Response-from-CPS-Redacted.pdf
    Page 3 · response
    Published 24 December 2020

    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

    Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.

    Verbatim wording from the response

    “I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted.pdf
    Page 1 · response
    Published 24 December 2020

    Open published response
  3. Sunderland

    AI-generated summary

    Miss Nguyen Ngoc Quyen · 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

    Miss Nguyen Ngoc Quyen died on 15 August 2017 at Success Road, Shiney Row, Houghton Le Spring; her death was consistent with the effects of fire. The report identified concerns about failures to act sufficiently, promptly and in a coordinated manner on known breaches of life licence conditions, including failures in information sharing between the Police and Probation Service, alongside wider organisational and supervision failings.

    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 share relevant police information with Probation

    Wider context from the report

    “In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log. As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders. The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated, and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer. The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident. ”

    Source location

    Miss Nguyen Ngoc Quyen · 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

    Operate the MK-flag and MASH process to queue relevant offender-record changes, share information with NPS, and retain emails for audit.

    Verbatim wording from the response

    “In December 2018 Northumbria Police devised a process to ensure compliance for the purpose of information/intelligence sharing on every record for a Category 2 (violent) Level 1 MAPPA offender.”

    Source location

    2019-0194-Response-by-Northumbria-Police
    Page 2 · response
    Published 15 August 2019

    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 Category 2 Level 1 offender warning screens with instructions requiring officers to share risk-relevant information with the relevant probation area.

    Verbatim wording from the response

    “Included within the process implemented in December 2018 was that all Category 2 Level 1 offenders would also have an NPICCS warning marker updated with a new instruction on the IS record for that offender. This will highlight the requirement for any officer who is in possession of relevant information to inform the relevant probation area.”

    Source location

    2019-0194-Response-by-Northumbria-Police
    Page 3 · response
    Published 15 August 2019

    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

    Disseminate force-wide bulletins informing and reinforcing officers’ responsibility to share relevant information with NPS.

    Verbatim wording from the response

    “To ensure staff were aware of this change, a force wide bulletin was sent to officers and staff informing them of the process and that it was their responsibility to share any relevant information/intelligence with NPS.”

    Source location

    2019-0194-Response-by-Northumbria-Police
    Page 3 · response
    Published 15 August 2019

    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

    Add newly notified Category 2 Level 1 offenders to Northumbria Police systems immediately upon notification from NPS.

    Verbatim wording from the response

    “In relation to new Category 2 Level 1 offenders, when we receive notification from NPS to the MOSOVO Department, they will be added to Northumbria Police systems immediately.”

    Source location

    2019-0194-Response-by-Northumbria-Police
    Page 3 · response
    Published 15 August 2019

    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 Northumbria Constabulary information-sharing steps are accepted by MAPPA and NPS representatives as a permanent solution at this time.

    Verbatim wording from the response

    “The regulation 28 report acknowledges that some of the issues identified by the investigation into the death have already been addressed by Northumbria Constabulary. However, you raised concern that actions taken provided an interim rather than a permanent solution. By way of confirmation, I have set out below in an addendum to this response, the actions I am advised have been taken by Northumbria Constabulary and am able to confirm that these steps are acknowledged and accepted by the MAPPA representatives and Heads of Service in the NPS North East Division in both the North of Tyne and South of Tyne Local Delivery Units as being correct and a permanent solution at this time.”

    Source location

    2019-0194-Response-by-HM-Prison-and-Probation-Service
    Page 2 · response
    Published 15 August 2019

    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 agreed police and probation information-sharing process is considered definitive and sufficient, although it may evolve with future IT development.

    Verbatim wording from the response

    “The final point in relation to the current process was your concern that the Police were of the view this was a permanent solution to this issue, whereas NPS were viewing it as an interim solution. This concern may have emerged because of the way the evidence came out at the inquest. We have contacted NPS with regards to the content of this letter and they confirm that they agree this process is definitive going forward. It may of course evolve in the future as IT systems are further developed and the two organisations co-operate to further improve the system but at present the system outlined above is agreed as the operating model going forward.”

    Source location

    2019-0194-Response-by-Northumbria-Police
    Page 3 · response
    Published 15 August 2019

    Open published response
  4. Inner West London

    AI-generated summary

    Tyereece Johnson · 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

    Tyereece Johnson, aged 16, died following a collision with a police vehicle while driving a moped with two passengers. The report raised concern that the approximate age of the moped riders was not passed to the Police Control Centre, despite witnesses considering it relevant to risk assessment and tactical decision-making.

    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 pass relevant rider age information to tactical decision-makers

    Wider context from the report

    “The first CAD messages gave an approximate age of the riders of the moped (aged 15 to 16). However this was not passed on to the team in the Police Control Centre who were formulating tactics to bring the moped to a stop. All witnesses from the police control room and police helicopter agreed that the age of the riders was a relevant factor to take into account when formulating a risk assessment in order to inform their tactical decision making. (However I did not find that it caused or contributed to the death in this instance.) ”

    Source location

    Tyereece Johnson · 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 a dedicated six-role police pursuits and follows pod supporting risk assessment and information gathering.

    Verbatim wording from the response

    “Since 2016 a number of changes have been made within Met Command and Control (MetCC). There is now a dedicated pod for police pursuits and follows as occurred here, which consists of the following six roles;”

    Source location

    2019-0166-Response-by-Metropolitan-Police
    Page 1 · response
    Published 29 July 2019

    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 pod’s roles and responsibilities to maximise information and intelligence opportunities by 31 October 2019.

    Verbatim wording from the response

    “The MPS considers that the changes implemented since 2016 are sufficient, however as a result of this Regulation 28 Report to Prevent Future Deaths, MetCC led by Superintendent Gary Warby in charge of Service Delivery, will take the following action;”

    Source location

    2019-0166-Response-by-Metropolitan-Police
    Page 2 · response
    Published 29 July 2019

    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

    Consider whether to introduce a mandatory checklist of information sources at the start of pursuits.

    Verbatim wording from the response

    “The MPS considers that the changes implemented since 2016 are sufficient, however as a result of this Regulation 28 Report to Prevent Future Deaths, MetCC led by Superintendent Gary Warby in charge of Service Delivery, will take the following action;”

    Source location

    2019-0166-Response-by-Metropolitan-Police
    Page 2 · response
    Published 29 July 2019

    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

    Ensure Pan London courses and refresher training include information and intelligence-gathering instruction.

    Verbatim wording from the response

    “The MPS considers that the changes implemented since 2016 are sufficient, however as a result of this Regulation 28 Report to Prevent Future Deaths, MetCC led by Superintendent Gary Warby in charge of Service Delivery, will take the following action;”

    Source location

    2019-0166-Response-by-Metropolitan-Police
    Page 2 · response
    Published 29 July 2019

    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 dedicated pursuits pod and its resources are considered sufficient to address the concern, although its practices will be reviewed further.

    Verbatim wording from the response

    “In the last couple of years MetCC has created a dedicated police pursuits pod. This contains the necessary resources to support the Pan London Supervisor, who has overall control of pursuits/follows, with the information and intelligence required so risk assess the incident using the National Decision Model. MetCC believes this is sufficient to address the matter of concern raised by the Coroner, however they seek to improve their practices further and will conduct a review of the roles and responsibilities contained within the pod to ensure they maximise all available information and intelligence opportunities. This review will be completed within the next four months.”

    Source location

    2019-0166-Response-by-Metropolitan-Police
    Page 2 · response
    Published 29 July 2019

    Open published response
  5. Wiltshire and Swindon

    AI-generated summary

    Eugeniusz Niedziolko · 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

    Eugeniusz Niedziolko, who was heavily intoxicated and vulnerable, was left alone in an unheated public lavatory after police and ambulance staff decided he did not require hospital care. He was found unresponsive several hours later and died from acute alcohol toxicity and hypothermia. The report identifies concerns about failures to follow protocols, assess and communicate critical information, provide appropriate training, and consider available options for keeping him safe and monitored.

    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 radio read-back checks for critical information

    Wider context from the report

    “a) RADIO PROTOCOL When listening to the radio communications there appeared to be a non-existent radio protocol of any form. My concern relative to this particular point is the absence of a protocol which for example requires the recipient of important information such as PNC markers to reflect or even repeat the information that has been given so that it can be established both ends that the information has been correctly and effectively communicated. The situation that appears to have arisen in this case is that the controller says that all 3 markers were communicated but the transcript supports the 2 officers on the ground recollections that they only received notification of 1. I am concerned that the absence of any check could lead to critical information not being communicated which could lead in certain circumstances to errors occurring that could result in a worst case scenario to a death occurring. This issue of relaying critical information was highlighted by the jury in their Narrative Conclusion. ”

    Source location

    Eugeniusz Niedziolko · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  6. North Northumberland

    AI-generated summary

    Joshua Harry 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

    Joshua Harry Smith, aged 16, fell from cliffs near Spittal Beach and was later swept out to sea while clinging to a rock. He was rescued unconscious and died at Wansbeck General Hospital. The report identified delays in locating him, unclear overall command and coordination, and failure to follow JESIP principles.

    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 police control with essential incident information

    Wider context from the report

    “Two Police Officers on Berwick Town Centre duties (which is north of the River Tweed) were asked in the street by paramedics for assistance in locating Joshua, and while paramedics went to look for Joshua on the north side of Berwick near the Holiday Park and cliffs, the police officers travelled to Spittal looking for Joshua although they had no name or further details at that time. A brief search of Spittal beach near to the cliffs by Police Officers was unsuccessful, before they returned to Town Centre duties. A report to Police Control was not made at that time. ”

    Source location

    Joshua Harry Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Coventry

    AI-generated summary

    Ozeilivo Andrew AKERELE · 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

    Ozeilivo Andrew Akerele disappeared, and his body was found 15 months later in a disused graveyard close to the last confirmed sighting of him. The concerns relate to failures to search the area adequately and promptly, failure to follow up a recommendation for a more thorough search, and gaps in communication with the Police Search Advisor. The inquest concluded with a finding of misadventure.

    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 ensure the Police Search Advisor is aware of recommendations for a more thorough search

    Wider context from the report

    “(4)The Police Search Advisor was unaware of the recommendation for a more thorough search by ████████ ”

    Source location

    Ozeilivo Andrew AKERELE · 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 ensure the Police Search Advisor is aware of the cursory nature of a graveyard search

    Wider context from the report

    “(5) The Police Search Advisor was unaware of the (cursory) nature of the search of the graveyard in February 2015 ”

    Source location

    Ozeilivo Andrew AKERELE · 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

    Refer the case to the National Missing Persons Operational Group to consider working with POLSA on amending search-coordination guidance.

    Verbatim wording from the response

    “The case will now be referred to the National Missing Persons Operational Group to consider working with the Police Search Advisor (POLSA) to amend guidance around how a search is co-ordinated in similar cases; specifically providing clarity around the tasking of the search, what is being searched for and the accurate recording of search, completed with oversight by Senior Investigating Officer (SIO) and POLSA.”

    Source location

    2017-0337-Response-by-West-Midland-Police
    Page 2 · response
    Published 2 December 2017

    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 individual search decisions appeared reasonable, although a more comprehensive search strategy and recording process was needed.

    Verbatim wording from the response

    “In relation to the searching, it does appear that a more comprehensive search strategy and updates could have been compiled, with absolute clarity around who had searched what area, to what extent and at what time. The individual decisions by ████████ and ████████ appear reasonable, but a more comprehensive effort would have ensured that the relevant information that ████████ had accessed the land that ████████ thought inaccessible, and the relative limitations of the search that ████████ had carried out, would have been more apparent at an earlier stage. It also appears that an earlier invitation to the POLSA may have assisted in the tasking and recording of searches at the earliest opportunity.”

    Source location

    2017-0337-Response-by-West-Midland-Police
    Page 1 · response
    Published 2 December 2017

    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 National Missing Persons Operational Group will consider amending guidance on coordinating, tasking and recording similar searches with POLSA involvement.

    Verbatim wording from the response

    “The case will now be referred to the National Missing Persons Operational Group to consider working with the Police Search Advisor (POLSA) to amend guidance around how a search is co-ordinated in similar cases; specifically providing clarity around the tasking of the search, what is being searched for and the accurate recording of search, completed with oversight by Senior Investigating Officer (SIO) and POLSA.”

    Source location

    2017-0337-Response-by-West-Midland-Police
    Page 2 · response
    Published 2 December 2017

    Open published response
  8. Inner North London

    AI-generated summary

    Matthew Marc GROOM · 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

    Matthew Marc Groom stood in front of a lorry after spending seven hours in the emergency unit of Whittington Hospital, where he was seen by emergency medicine and mental health staff. Concerns included delays in his mental health assessment, prescribed diazepam not being administered, inadequate planning for his possible departure, failure to seek urgent hospital security assistance, and incomplete communication with police.

    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 convey the need for urgent police intervention in a welfare-check request

    Wider context from the report

    “5. The nurse who then contacted the police did not then convey this to them, but requested a welfare check that would be satisfied by knowing he was with a family member. ”

    Source location

    Matthew Marc GROOM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 patient did not display behaviour indicating immediate risk, requiring detention, restraint, or an active police search.

    Verbatim wording from the response

    “The Mental Health Act enables appropriately trained staff to deprive someone of their liberty and enforce treatment; rightly this assessment requires a high threshold to be met. Alongside this the assessors have to consider the persons capacity to make this decision. Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that was sufficiently concerning that it required Mr Groom to be immediately detained under the Mental Health Act or any other Act.”

    Source location

    Matthew-Groom-Response
    Page 3 · response
    Published 12 November 2015

    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 patient was not considered an immediate risk requiring detention, restraint, or an active police search.

    Verbatim wording from the response

    “The Mental Health Act enables appropriately trained staff to deprive someone of their liberty and enforce treatment; rightly this assessment requires a high threshold to be met. Alongside this assessment, staff have to consider the person’s capacity to make this decision. Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that was sufficiently concerning that it required Mr Groom to be immediately detained under the Mental Health Act or any other Act.”

    Source location

    2015-0503-Response
    Page 3 · response
    Published 12 November 2015

    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 joint police protocols already govern communication about people who abscond or go missing, including conveying immediate-risk information.

    Verbatim wording from the response

    “Improvement in response to concern For the reasons described above (in response to concern 3) Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that indicated that he was at immediate risk of harm to himself or others to require that the police perform an active search for him. Had this been the case then the Trusts practice is to convey this information to the police. Camden & Islington NHS FT already has joint protocols with the Police, concerning people who have absconded and / or go missing. As I understand it the police were alerted that if they were to see Mr Groom, they should consider bringing him back to hospital if the family members he left with were concerned. As we understand it, this would also normally entail the police’s consideration of the use of section 136 legislation if thought appropriate.”

    Source location

    2015-0503-Response
    Page 5 · response
    Published 12 November 2015

    Open published response
  9. South London

    AI-generated summary

    Anne Wilson · 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

    Anne Wilson had a history of depression, had recently been discharged from psychiatric hospital, and was found deceased in her flat after failing to attend appointments and following concerns raised to the police. The principal concerns were the downgrading of the welfare-check request without informing her GP, inadequate training and guidance under the Metropolitan Police Service welfare-check policy, and failures in communication and joint working between the Metropolitan Police Service and London Ambulance Service.

    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 inform the GP when a welfare check request is downgraded

    Wider context from the report

    “(4) The MPS call handler informed Miss Wilson’s G.P that the police would attend Miss Wilson’s flat within the hour however the request for a welfare check was downgraded without informing the G.P of the change in decision or to seek further clarification of his concerns. ”

    Source location

    Anne Wilson · 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 share welfare check policy changes with the London Ambulance Service

    Wider context from the report

    “(1) In 2014 the Metropolitan Police Service (MPS) introduced a new policy for dealing with requests for and attending welfare checks. The precise date of the implementation of the new policy could not be established at inquest. The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that time. ”

    Source location

    Anne Wilson · 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 the current Metropolitan Police welfare-check briefing note to address uncertainty about the policy version in force.

    Verbatim wording from the response

    “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.”

    Source location

    2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 21 July 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

    Incorporate the March 2015 Metropolitan Police welfare-check policy into the LAS/MPS Joint Memorandum of Understanding through the annual review process.

    Verbatim wording from the response

    “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.”

    Source location

    2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 21 July 2015

    Open published response
  10. Manchester South

    AI-generated summary

    Kesia Lena Mary Leatherbarrow · 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

    Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

    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 pass complete incident information to attending officers

    Wider context from the report

    “The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife. The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding. ”

    Source location

    Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
    Page 7 · 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 provide Appropriate Adults with relevant custody risk information

    Wider context from the report

    “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS, nor that she had threatened to jump off a bridge on her release. ”

    Source location

    Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report
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Data last updated 7 September 2026