2 Feb 2026 Scott Darren TAYLOR · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to remove arm and leg restraints from unconscious patients during conveyance to hospital View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Scott Darren 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
Scott Darren Taylor died at Basildon Hospital on 13 August 2022 following multiorgan failure and rhabdomyolysis associated with cocaine use, physical exertion, prone restraint and Neuroleptic Malignant Syndrome. The report raised concerns about inconsistent ambulance response categorisation for acute behavioural disturbance with active restraint, terminology and training, police training, and the removal of restraints during conveyance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to remove arm and leg restraints from unconscious patients during conveyance to hospital
Wider context from the report “b. Whilst it would not have changed the outcome for Mr Taylor, arm and leg restraints were not removed by police officers in this case when it was understood that Mr Taylor was unconscious and when Mr Taylor was being conveyed to hospital . Police officers who gave evidence were not clear that this was a requirement of the policy .
” Source location Scott Darren TAYLOR · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update restraint guidance to require removal where safe and appropriate, informed by circumstances and the National Decision Model.
Verbatim wording from the response “You also expressed concern that police officers did not remove handcuffs or leg restraints when Mr Taylor appeared unconscious, and that officers did not appear clear that the relevant policy required them to do so. The policy in place at the time contained an absolute instruction to “remove all methods of restraint,” in the case of unconsciousness which, when considered against the operational realities of ABD and the unpredictable nature of such presentations, was not sufficiently aligned with safe decision-making or with the principles of the National Decision Model.” Source location Response from Essex Police
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How this respondent action was interpreted
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PFD Monitor interpretation Incorporate the updated restraint policy into initial and regular refresher training for all officers.
Verbatim wording from the response “Following review at the inquest and subsequent policy analysis, Essex Police has updated this guidance to provide officers with clearer, more realistic direction. The revised policy now states that officers must remove restraints where it is considered safe and appropriate to do so, and that this decision must be informed by the prevailing circumstances and assessed through the National Decision Model. This updated wording removes the absolute instruction that did not reflect the operational complexities faced by officers, and instead reinforces the requirement for a considered, risk-assessed approach that is consistent with officer training and the realities of managing individuals experiencing ABD.” Source location Response from Essex Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop, revise and publish clinical practice guidance for recognising, assessing and managing suspected acute behavioural disturbance, including safe restraint and urgent transfer.
Verbatim wording from the response “With regard to the ABD, over a number of years we have developed and further revised UK ambulance service clinical practice guidelines for clinicians. This has been based on learning from ABD cases we have been involved with, some of these via coroners’ inquests and preventing future death reports. We have published guidance for patients that are agitated, have delirium and have suspected ABD. This is to ensure that the recognition, assessment and management of these patient presentations are considered by ambulance clinicians. We emphasise in the ABD guidance that the condition is a clinical emergency and that the patient may suffer sudden cardiovascular collapse or cardiac arrest or both with little or no warning.” Source location Response from Association of Ambulance Chief Executives
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25 Nov 2025 Andrew Thomas MCCLEARY · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 4
Lack of awareness and training regarding the risks and effects of force and restraint View source Failure to undertake collaborative planning with attending ambulance staff before using force or restraint View source Lack of knowledge and/or concern regarding Mental Capacity Act requirements for using force and restraint View source
Failure to provide adequate attention and monitoring during and after restraint View source See 1 more concern
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andrew Thomas MCCLEARY · 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
Andrew Thomas MCCLEARY died after cocaine use and the physiological and psychological effects of restraint, with his death confirmed at Bedford Hospital on 30 May 2021. The report identified concerns about failures to establish his capacity under the Mental Capacity Act, collaborative planning before restraint, monitoring of his physical and psychological wellbeing, and responding when he said he could not breathe.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of awareness and training regarding the risks and effects of force and restraint
Wider context from the report “1) There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain Andrew.
2) There was an evident lack of awareness on the part of the attending officers of the risks/effects of using force against and restraining Andrew and of the need for collaborative planning with attending ambulance staff before doing so.
3) There was an evident lack of attention to and/or concern for Andrew on the part of the attending officers both during and after the restraint.
The above matters were of particular concern in view of the previous Regulation 28 Report made on 21 October 2021, following the Inquest into the death of Leon Briggs in 2013, which highlighted a lack of training regarding the effects of restraint as well as inadequate monitoring of a detainee subject to restraint on the part of Bedfordshire Police Officers.
” Source location Andrew Thomas MCCLEARY · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to undertake collaborative planning with attending ambulance staff before using force or restraint
Wider context from the report “1) There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain Andrew.
2) There was an evident lack of awareness on the part of the attending officers of the risks/effects of using force against and restraining Andrew and of the need for collaborative planning with attending ambulance staff before doing so .
3) There was an evident lack of attention to and/or concern for Andrew on the part of the attending officers both during and after the restraint.
The above matters were of particular concern in view of the previous Regulation 28 Report made on 21 October 2021, following the Inquest into the death of Leon Briggs in 2013, which highlighted a lack of training regarding the effects of restraint as well as inadequate monitoring of a detainee subject to restraint on the part of Bedfordshire Police Officers.
” Source location Andrew Thomas MCCLEARY · Prevention of Future Deaths report
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 knowledge and/or concern regarding Mental Capacity Act requirements for using force and restraint
Wider context from the report “1) There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain Andrew.
2) There was an evident lack of awareness on the part of the attending officers of the risks/effects of using force against and restraining Andrew and of the need for collaborative planning with attending ambulance staff before doing so.
3) There was an evident lack of attention to and/or concern for Andrew on the part of the attending officers both during and after the restraint.
The above matters were of particular concern in view of the previous Regulation 28 Report made on 21 October 2021, following the Inquest into the death of Leon Briggs in 2013, which highlighted a lack of training regarding the effects of restraint as well as inadequate monitoring of a detainee subject to restraint on the part of Bedfordshire Police Officers.
” Source location Andrew Thomas MCCLEARY · Prevention of Future Deaths report
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 adequate attention and monitoring during and after restraint
Wider context from the report “1) There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain Andrew.
2) There was an evident lack of awareness on the part of the attending officers of the risks/effects of using force against and restraining Andrew and of the need for collaborative planning with attending ambulance staff before doing so.
3) There was an evident lack of attention to and/or concern for Andrew on the part of the attending officers both during and after the restraint.
The above matters were of particular concern in view of the previous Regulation 28 Report made on 21 October 2021, following the Inquest into the death of Leon Briggs in 2013, which highlighted a lack of training regarding the effects of restraint as well as inadequate monitoring of a detainee subject to restraint on the part of Bedfordshire Police Officers .
” Source location Andrew Thomas MCCLEARY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review use-of-force policies, processes and training following the death.
Verbatim wording from the response “Since the death of Mr McCleary we have reviewed our use of force policies, processes and training. All Police Officers receive mandatory Personal Safety Training (“PST”) which includes a specific element on dealing with individuals suspected of being impaired by Acute Behavioural Disturbance (“ABD”).” Source location Response from Bedfordshire Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide mandatory Personal Safety Training incorporating the Acute Behavioural Disturbance programme and guidance on recognition, restraint risks, monitoring and multi-agency working.
Verbatim wording from the response “Since the death of Mr McCleary we have reviewed our use of force policies, processes and training. All Police Officers receive mandatory Personal Safety Training (“PST”) which includes a specific element on dealing with individuals suspected of being impaired by Acute Behavioural Disturbance (“ABD”).” Source location Response from Bedfordshire Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a joint Bedfordshire Police–EEAST memorandum of understanding defining roles for suspected Acute Behavioural Disturbance and access to rapid tranquilisation, pending EEAST sign-off.
Verbatim wording from the response “Additionally, Bedfordshire Police and EEAST have developed a Memorandum Of Understanding (“MOU”) to reinforce clear roles and responsibilities of both partner agencies in managing the needs of patients with suspected ABD and increasing the access to rapid tranquilisation at scene via appropriately trained paramedics. This MOU is awaiting imminent sign-off from EEAST Clinical Best Practice Group (already signed off by Bedfordshire Police). The MOU has been created in compliance with the CoP and Royal College of Emergency Medicine guidance.” Source location Response from Bedfordshire Police
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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 launch joint police–ambulance scenario training for multi-agency incidents involving vulnerable patients.
Verbatim wording from the response “We have strengthened collaborative working with EEAST through the development and launch of joint scenario training which focusses on the ways in which Police and Ambulance personnel work together during multi-agency incidents, such as in the case of Mr McCleary. This improves communication, understanding of roles and responsibilities and importantly, maintains focus on the wellbeing of the patient.” Source location Response from Bedfordshire Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory Mental Capacity Act training to all frontline police officers, including capacity assessment, lawful restraint and recording requirements.
Verbatim wording from the response “I can confirm that all frontline Police Officers receive mandatory MCA training which includes, the statutory principles of the MCA (presumption of capacity, enabling decision-making, respect for unwise decisions, acting in best interests, and least restrictive option), capacity assessments, emergency interventions under Sections 5 and 6 MCA (including lawful authority for proportionate restraint), and the requirement to record decisions and rationale. Our MCA training is reinforced through scenario-based exercises and reference to case law, including R (Sessay) v South London and Maudsley NHS Foundation Trust.” Source location Response from Bedfordshire Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation For health-related incidents, the agency with the appropriate skills and legal responsibility should lead rather than police.
Verbatim wording from the response “We acknowledge your reference to Mr Briggs’ PFD dated 21 October 2021 but note this post-dated Mr McCleary’s death. However, Bedfordshire Police and partners have worked together since 2024 to introduce and embed the national programme of Right Care, Right Person (RCRP). This is of particular relevance as the core principles are that Police should only respond where there is a clear policing purpose and the agency with the right skills and legal responsibility should lead.” Source location Response from Bedfordshire Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police officers may defer to attending health professionals’ capacity assessments and rely on their advice when applying force.
Verbatim wording from the response “However, Police Officers are trained to defer to health professionals when making decisions regarding a person’s capacity status, with an assumption that the health professional has better training and experience than a Police Officer. Indeed, College of Policing national guidance states, “In situations where health or social care professionals are on the scene, police should defer to their expertise and provide support as appropriate and in accordance with local protocols”.” Source location Response from Bedfordshire Police
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1 Aug 2025 Brian Thomas RINGROSE · Prevention of Future Deaths report Milton Keynes
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Concerns raised 9
Failure to communicate before dragging a restrained person by the arms View source Failure to avoid extreme arm positioning during handcuffed restraint View source Failure to check airways and breathing rate during restraint View source
Failure to move restrained people onto their side as soon as practicable View source Failure to hand over critical restraint information View source Failure of officers to challenge inappropriate restraint View source Failure to reassess restraint actions using the National Decision Model View source Failure to limit prolonged prone restraint View source Failure to raise concerns about changing pallor during restraint View source See 6 more concerns
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Include communication and handover protocols in training scenarios and instruct officers to engage actively with medical staff during incidents.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Update trainer notes for prone handcuffing and ground-pin techniques, clarifying arm restraint and prohibiting arm elevation or lowering for compliance.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Review and publish mobile Snap Guides covering safety-officer duties, welfare monitoring, restraint, spit guards, acute behavioural disturbance and prone ground-pin risks.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Introduce positional-asphyxia training for student officers covering risks, signs, symptoms, situational awareness, communication and response.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Implement scenario-based PPST Foundation and Recertification programmes assessing restraint, decision-making, communication, subject welfare and safety-officer use.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Mandate and roll out Safer Restraint e-learning on prolonged restraint, welfare monitoring, situational awareness and safety-officer responsibilities, with completion actively monitored.
Stated by Thames Valley PoliceStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2025. View source
Action
Introduce online Time on Tasks training covering management of subjects restrained in the prone position.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Expand operational guidance defining when safety officers are used, their responsibilities and officers’ duty to challenge welfare concerns.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Roll out Upstander e-learning to officers and staff, teaching practical Direct, Distract, Delegate and Delay strategies for speaking up.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source
Action
Review the clinical restraint and restrictive-practices training programme under the redrafted policy.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2025. View source
Action
Redraft the Trust restraint and restrictive-practices policy with Emergency Department-specific guidance and clearer staff roles and responsibilities.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025. View source See 8 more actions
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AI-generated summary
Brian Thomas RINGROSE · 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
Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.
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 communicate before dragging a restrained person by the arms
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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 avoid extreme arm positioning during handcuffed restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back , causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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 check airways and breathing rate during restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate , despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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 move restrained people onto their side as soon as practicable
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints , contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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 hand over critical restraint information
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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 officers to challenge inappropriate restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint , despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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 reassess restraint actions using the National Decision Model
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint , particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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 limit prolonged prone restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
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 raise concerns about changing pallor during restraint
Wider context from the report “Thames Valley Police
Inadequate application of police restraint training
The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects:
a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position.
b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising.
c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done.
d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian.
Failure to apply the National Decision Model
Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly:
a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification.
b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so.
Ineffective welfare monitoring
The officers failed to adequately monitor Mr. Ringrose's welfare during restraint:
a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions.
b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals.
c) Officers failed to voice concerns about Mr. Ringrose's changing pallor , which progressed from extremely pale to blue, red, and even purple.
Failure of officers to "speak up and speak out"
The officers failed to challenge inappropriate restraint techniques:
a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out."
b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks.
c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event.
Inadequate communication and handover
There were significant failures in communication between officers:
a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that.
b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition.
Inappropriate prioritisation of transport over welfare
After the arrival of additional officers at approximately 15:45:
a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare.
b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of.
Central and Northwest London NHS Foundation Trust
a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition.
b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose.
c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police.
d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients.
e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety.
Milton Keynes University Hospital NHS Foundation Trust
a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation.
b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be.
c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements.
d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge.
e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it.
f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened.
g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed)
” Source location Brian Thomas RINGROSE · Prevention of Future Deaths report
Open source report
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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 Include communication and handover protocols in training scenarios and instruct officers to engage actively with medical staff during incidents.
Verbatim wording from the response “Training scenarios now include communication and handover protocols. Officers are instructed to actively engage with medical staff during incidents.” Source location Response from Thames Valley Police
Open published response
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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 trainer notes for prone handcuffing and ground-pin techniques, clarifying arm restraint and prohibiting arm elevation or lowering for compliance.
Verbatim wording from the response “Following review, TVP have made changes to their handcuffing from prone trainer notes and their ground pin trainer notes. This will provide further clarity on how a subject’s arms are to be restrained during and after the application of handcuffs.” Source location Response from Thames Valley Police
Open published response
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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 publish mobile Snap Guides covering safety-officer duties, welfare monitoring, restraint, spit guards, acute behavioural disturbance and prone ground-pin risks.
Verbatim wording from the response “TVP have also reviewed and published the following Snap Guides. These are summary documents available to officers through their mobile devices and are designed to be used whilst operationally deployed. They address identified matters such as ineffective welfare monitoring; inadequate application of police restraint training and risks associated with handcuffing to the rear and prone restraint.” Source location Response from Thames Valley Police
Open published response
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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 Introduce positional-asphyxia training for student officers covering risks, signs, symptoms, situational awareness, communication and response.
Verbatim wording from the response “TVP have introduced a PowerPoint presentation on positional asphyxia into our Foundation Training for student officers. This presentation covers the definition of positional asphyxia, the position it may occur in including the increased risk around prone restraint, signs and symptoms and officer response. Officer response is centred on situational awareness, communication and decision-making. These areas promote the use of a safety officer where numbers permit.” Source location Response from Thames Valley Police
Open published response
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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 scenario-based PPST Foundation and Recertification programmes assessing restraint, decision-making, communication, subject welfare and safety-officer use.
Verbatim wording from the response “It is of note that there has been considerable National development of PPST by the College of Policing and NPCC, with new Recertification and Foundation programmes, introduced into TVP in November 2023 and April 2024 respectively. The introduction of these training programmes has seen the PPST portfolio evolve significantly since the time of the incident.” Source location Response from Thames Valley Police
Open published response
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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 Mandate and roll out Safer Restraint e-learning on prolonged restraint, welfare monitoring, situational awareness and safety-officer responsibilities, with completion actively monitored.
Verbatim wording from the response “In mid-March 2025, ACC Bunt delivered a force wide communication to all officers and staff. This included changes to training and guidance as a consequence of the death of Mr Ringrose. All police officers and police staff detention officers were mandated to complete an online E-Learning package titled ‘Safer Restraint.’ This training covers the medical issues that can arise with prolonged restraint, welfare monitoring, situational awareness and the importance of the role of Safety Officer. The completion of this learning is being actively monitored and to date 4760 Officers and Detention Officers have completed this training (95% of the target audience).” Source location Response from Thames Valley Police
Open published response
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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 Introduce online Time on Tasks training covering management of subjects restrained in the prone position.
Verbatim wording from the response “During this training and between the physical exposition and practice, TVP have introduced online training known as Time on Tasks. Mandated topic areas include managing a subject being restrained in the prone position.” Source location Response from Thames Valley Police
Open published response
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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 Expand operational guidance defining when safety officers are used, their responsibilities and officers’ duty to challenge welfare concerns.
Verbatim wording from the response “TVP have reviewed and expanded its operational guidance on the role of the safety officer. This can found within Mental Health Operational Guidance and follows a section on Acute Behavioural Disorder.” Source location Response from Thames Valley Police
Open published response
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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 Upstander e-learning to officers and staff, teaching practical Direct, Distract, Delegate and Delay strategies for speaking up.
Verbatim wording from the response “In addition, in June 2025, TVP rolled out the College of Policing’s ‘Upstander’ E-Learning to all officers and staff, designed to encourage people to ‘speak up and speak out’. A key part of this training is the 4Ds model, which provides practical strategies for being an effective upstander.” Source location Response from Thames Valley Police
Open published response
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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 clinical restraint and restrictive-practices training programme under the redrafted policy.
Verbatim wording from the response “The Trust’s Restraint and Restrictive Practices policy has been re-drafted post the inquest (appended at Appendix 3) to incorporate Emergency Department specific guidelines (NICE NG10) and to make the roles and responsibilities of healthcare staff during any restraint unambiguously clear. The Trust’s training programme on restraint and restrictive practices for clinical staff is being reviewed under the new draft policy (Appendix 3). Breakaway and” Source location Response from Milton Keynes University Hospitals
Open published response
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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 Redraft the Trust restraint and restrictive-practices policy with Emergency Department-specific guidance and clearer staff roles and responsibilities.
Verbatim wording from the response “The Trust’s Restraint and Restrictive Practices policy has been re-drafted post the inquest (appended at Appendix 3) to incorporate Emergency Department specific guidelines (NICE NG10) and to make the roles and responsibilities of healthcare staff during any restraint unambiguously clear. The Trust’s training programme on restraint and restrictive practices for clinical staff is being reviewed under the new draft policy (Appendix 3). Breakaway and” Source location Response from Milton Keynes University Hospitals
Open published response
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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 Training does not teach elevating or lowering the arms of a handcuffed person to achieve compliance or control.
Verbatim wording from the response “Following review, TVP have made changes to their handcuffing from prone trainer notes and their ground pin trainer notes. This will provide further clarity on how a subject’s arms are to be restrained during and after the application of handcuffs.” Source location Response from Thames Valley Police
Open published response
29 Jul 2025 Azroy Dawes-Clarke · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 1
Inconsistent decision-making about handcuffing prisoners during emergency hospital conveyance View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Azroy Dawes-Clarke · 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
Azroy Dawes-Clarke died in hospital on 10 November 2021 after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and treatment. The substantive concerns included inadequate communication and healthcare involvement, disproportionate and prolonged restraint, delays in recognising the arrest and starting CPR, unsuitable ligature-resistant materials, and gaps in staff training on ACCT procedures, first aid, basic life support, and the legal framework for medical emergencies.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistent decision-making about handcuffing prisoners during emergency hospital conveyance
Wider context from the report “(4) Whilst the use of force paperwork completed following Mr Dawes-Clarke’s physical restraint made mention of the Mental Capacity Act 2005, none of the officers (including the individual who completed the paperwork) appeared to have any basic understanding of the circumstances when the Mental Capacity Act may apply in a custodial setting. Equally, many were unclear as to what their role would be in conveying a prisoner who lacked the capacity to consent to their conveyance to hospital in a medical emergency. Answers in respect of handcuffing prisoners for the purpose of conveying them to hospital in a medical emergency varied. Answers in respect of the legal framework which applied when prison officers are involved in care and treatment of a prisoner (the particular issue in the present case being the conveyance to hospital and the decision to dress him) were inconsistent or incomplete.
” Source location Azroy Dawes-Clarke · Prevention of Future Deaths report
Open source report
3 Jul 2023 Andre Felipe Mendes Moura · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to recognise and perform the safety officer role during restraint incidents View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andre Felipe Mendes Moura · 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
Andre Moura died on 7 July 2018 after suffering cardiac arrest in a police vehicle while under arrest and being transported following a significant struggle. The report identified concerns about officers’ recognition and training in acute behavioural disturbance, use of objective responsiveness checks, the safety officer role, and the absence of body-worn camera recording during escort.
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 recognise and perform the safety officer role during restraint incidents
Wider context from the report “3. The role for a safety officer which is part of the College of Policing training in a situation such as this was not recognised . The Inquest heard evidence from an expert witness that a safety officer plays a key role in an incident such as the one involving Mr Moura and ensures key information is not lost/shared. This lack of an officer at his head taking on such a role emphasised the fact that although officers had attended the PST training key points had not been retained. Greater emphasis on this role in training would be beneficial in reducing the risk to prisoners being restrained;
” Source location Andre Felipe Mendes Moura · Prevention of Future Deaths report
Open source report
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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 Require officers to demonstrate appropriate use of a Safety Officer during ABD responses and multi-officer restraints within PPST.
Verbatim wording from the response “Assessment criteria for the new PPST includes a requirement that officers must be able to demonstrate to trainers the correct response to a person experiencing ABD. This includes the appropriate use of a Safety Officer. The requirement for the use of a Safety Officer is also a learning outcome for all multi-officer restraints within the PPST programme. From April 2024, the College of Policing will be conducting a quality assurance process and will undertake licence moderation visits to ensure that forces comply with the new national standards.” Source location Response from College of Policing
Open published response
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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 Conduct quality-assurance and licence-moderation visits to check forces’ compliance with the new national training standards.
Verbatim wording from the response “Assessment criteria for the new PPST includes a requirement that officers must be able to demonstrate to trainers the correct response to a person experiencing ABD. This includes the appropriate use of a Safety Officer. The requirement for the use of a Safety Officer is also a learning outcome for all multi-officer restraints within the PPST programme. From April 2024, the College of Policing will be conducting a quality assurance process and will undertake licence moderation visits to ensure that forces comply with the new national standards.” Source location Response from College of Policing
Open published response
11 May 2021 Paul Steven Reynolds · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Failure to closely and effectively monitor breathing during prone restraint View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Steven Reynolds · 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
Paul Steven Reynolds died on 16 February 2017 after being restrained by the neck and placed in a prone position at Pontins Pakefield in Lowestoft. The principal concerns included inadequate monitoring of his breathing, failure to place him in the recovery position, insufficient staff training, unclear responsibilities, and poor sharing of information with police.
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× 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 closely and effectively monitor breathing during prone restraint
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” Source location Paul Steven Reynolds · Prevention of Future Deaths report
Open source report
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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 acute behaviour disorder and positional asphyxia learning in Personal Safety Training through supplementary videos and Learning Management System guidance.
Verbatim wording from the response “However, we recognise that nationally there have been changes to the programme that may have created a perception of a reduction in the time assigned to positional asphyxia. The time allocated to individual areas of the curriculum are subject to change and nationally the focus of positional asphyxia has shifted towards the signals and signs of acute behaviour disorder. This is a precursor behaviour but is part of the same continuum. Material surrounding both acute behaviour disorder and positional asphyxia is delivered in accordance with national guidance and time allocations, but the Constabulary will do more to embed this learning within the wider aspects of its Personal Safety Training through supplementary videos and guidance on its Learning Management System.” Source location 2021-0151-Response-from-Suffolk-Constabulary-Redacted
Open published response
27 Jun 2019 Edir Frederico Araujo DA COSTA · Prevention of Future Deaths report East London
View report summary
Concerns raised 3
Failure to ensure that a safety officer takes control of restraint View source Failure to designate an officer to lead communication and monitor condition View source Inadequate understanding of the safety officer role in a street setting View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Edir Frederico Araujo DA COSTA · 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
Edir Frederico Araujo DA COSTA died after his airway became obstructed by a plastic bag containing drugs while he was being restrained by police. The report identified concerns about emergency life-support training, supervision and safety-officer roles during restraint, risks associated with plastic bags and CS spray, recognition of agonal breathing, and communication with the 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 ensure that a safety officer takes control of restraint
Wider context from the report “(2) The evidence at the Inquest did not provide assurance that a safety officer had taken control of the restraint or that one officer was taking the lead in communicating with Mr Da Costa and/or monitoring his condition. In addition, the officers who gave evidence considered that the role of the safety officer mainly applied to restraint in a controlled custody setting. The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise).
” Source location Edir Frederico Araujo DA COSTA · Prevention of Future Deaths report
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 designate an officer to lead communication and monitor condition
Wider context from the report “(2) The evidence at the Inquest did not provide assurance that a safety officer had taken control of the restraint or that one officer was taking the lead in communicating with Mr Da Costa and/or monitoring his condition . In addition, the officers who gave evidence considered that the role of the safety officer mainly applied to restraint in a controlled custody setting. The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise).
” Source location Edir Frederico Araujo DA COSTA · Prevention of Future Deaths report
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 understanding of the safety officer role in a street setting
Wider context from the report “(2) The evidence at the Inquest did not provide assurance that a safety officer had taken control of the restraint or that one officer was taking the lead in communicating with Mr Da Costa and/or monitoring his condition. In addition, the officers who gave evidence considered that the role of the safety officer mainly applied to restraint in a controlled custody setting . The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise).
” Source location Edir Frederico Araujo DA COSTA · Prevention of Future Deaths report
Open source report
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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 safety-officer role reminders and incident evidence requirements to the Officer Safety Training refresher package.
Verbatim wording from the response “The current training for the role of the safety officer covers environments to include custody and street settings. The practice of instructing officers to take the lead when they are controlling the head of a subject works well. The safety officer has a better communication and monitoring ability with the subject of the restraint and all other officers have the training to “speak up, speak out”. This method ensures everyone present is responsible for the subject’s safety. We will however include this reminder in the OST refresher training package from 1st October 2019. This new package will incorporate a presentation delivered by MPS trainers reminding officers of the importance of identifying themselves as the safety officer throughout the incident. In addition, they must provide evidence as to what action they took throughout the incident referencing when they were the safety officer.” Source location 2019-0211-Response-by-Metropolitan-Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current safety officer training already covers both custody and street settings, although refresher training will reinforce the role in street incidents.
Verbatim wording from the response “(2) The evidence at the Inquest did not provide assurance that a safety officer had taken control of the restraint or that one officer was taking the lead in communicating with Mr Da Costa and/or monitoring his condition. In addition, the officers who gave evidence considered that the role of the safety officer mainly applied to restraint in a controlled custody setting. The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise).” Source location 2019-0211-Response-by-Metropolitan-Police
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16 Sep 2015 Adil HABIB · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of prison officer training on choking risks during searches and control and restraint View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Adil HABIB · Prevention of Future Deaths report
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Report summary
Adil Habib died at HMP Pentonville after swallowing a package containing crack cocaine during a search while subject to control and restraint; he choked on it. The inquest recorded the death as accidental, with acute respiratory failure due to mechanical obstruction of the upper airway by a foreign object. A concern was raised that the 999 caller did not immediately provide the prison gate location for attending paramedics, and that ambulance call-handling systems did not then show alternative gates for all London prisons.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of prison officer training on choking risks during searches and control and restraint
Wider context from the report “I heard evidence at inquest that there is no training for prison officers that specifically covers the risk of prisoners choking as a result of attempts to conceal an item from prison officers, most especially during a search and/or control & restraint . It seems to me that this is a significant omission, and it would be helpful if such training were mandatory and refreshed regularly.
” Source location Adil HABIB · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a training DVD covering medical advice and safe use of control and restraint.
Verbatim wording from the response “In your letter you raise concern that the national training for search and restraint does not cover those situations where a prisoner is at risk of choking after attempting to conceal an item during control and restraint procedures. You will be aware that the Chief Executive of NOMS accepted the Prisons and Probation Ombudsman’s recommendation that clear guidance and training be given on the safe use of force, including pain compliance techniques, when resistant prisoners have items in their mouths, which might compromise their breathing. In the response, NOMS confirmed that a DVD was being produced to aid staff training in the safe use of force, in conjunction with current medical advice, and that NOMS would consider the best way to include specific guidance within the DVD on what action should be taken where items are concealed in a resistant prisoner’s mouth.” Source location 2015-0380-Response-by-NOMS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult key stakeholders on the accompanying training material for the control and restraint DVD.
Verbatim wording from the response “I can confirm that the DVD has been completed and that the accompanying training material has been prepared and is out for consultation with key stakeholders. I can also confirm that the DVD includes medical advice related to the use of control and restraint and covers:” Source location 2015-0380-Response-by-NOMS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send the DVD and a Notice to Governors to all prison Governors for viewing by operational staff.
Verbatim wording from the response “The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December.” Source location 2015-0380-Response-by-NOMS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide updated control and restraint training to operational staff through National Control & Restraint Instructors.
Verbatim wording from the response “The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December.” Source location 2015-0380-Response-by-NOMS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Prison Officer Entry Level Trainees with training on the DVD’s contents.
Verbatim wording from the response “The DVD will be sent to all prison Governors by Christmas along with a Notice to Governors advising them of the content and that it should be made available for all operational staff to view. The content will be reinforced in due course when all operation staff receive updated control and restraint training from the National Control & Restraint Instructors. It is expected that the roll out of training will commence in January 2016. All Prison Officer Entry Level Trainees (POELTs) will receive training relating to the contents of this DVD from in December.” Source location 2015-0380-Response-by-NOMS
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10 Jun 2015 Darren NEVILLE · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to give sufficient consideration to the risk of death associated with prolonged restraint of a person suffering from acute behavioural disturbance View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Darren NEVILLE · 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
Darren Neville died after taking cocaine, experiencing acute behavioural disturbance, and being restrained by police. The principal concern was that police did not sufficiently consider the risks of prolonged restraint, including the risk of death, for a person experiencing acute behavioural disturbance; the extent to which this factor caused his death was unclear.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to give sufficient consideration to the risk of death associated with prolonged restraint of a person suffering from acute behavioural disturbance
Wider context from the report ““Police did not give sufficient consideration to the risks associated with prolonged restraint to a person suffering from acute behavioural disturbance ; more specifically, the risk of death following prolonged restraint . It is unclear the extent to which this single factor caused Darren’s death.”
” Source location Darren NEVILLE · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory officer-safety training covering acute behavioural disorder, de-escalation, safer restraint, positional-asphyxia risks and medical implications of restraint.
Verbatim wording from the response “This resource sits alongside a continuing emphasis on de-escalation tactics in the OST sessions. The classroom element of the current cycle of the mandatory training includes a section called ‘Mental Health - Safety In Mind’, a DVD and tutor led interactive session. This has been developed in conjunction with South London & Maudsley Hospital (SLAM) and the LAS and is aimed at improving the management of a situation involving a person identified as vulnerable. This package discusses the importance of the VAF and ABCDE models; and offers practical guidance on de-escalation tactics using the ‘CARES’ model (see below.)” Source location 2015-0220-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue fast-tracking learning from the national mental-health restraint expert group into corporate officer-safety training.
Verbatim wording from the response “The MPS is also promoting the newly formed National Mental Health Restraint Expert Reference Group, which is independently chaired by Lord Carlisle. This group of leading experts from partnership groups and organisations has been convened to help ensure a unified response to best practice across the UK. The OST learning outcomes from such groups will continue to be fast-tracked into corporate training as an on-going process of development, in line with College of Policing principles. For these reasons, work is ‘on-going’ from an OST perspective.”” Source location 2015-0220-Response-by-Metropolitan-Police
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Includes failures in the dedicated police restraint process, including restraint selection and positioning, movement or transfer of restrained people, monitoring and welfare checks, risk balancing and reassessment, communication between officers, safety-officer arrangements, restraint removal or adjustment during medical conveyance, and related policy, training or operational controls.
