Recurring concern

Failure to ensure frontline personnel recognise mental-health indicators

First to latest report 18 Sep 2014 — 8 Apr 2026

Reports that mention this concern
13
Times this concern has been raised
14
Stated actions linked to this concern
22

What this concern includes

Includes failures of training, guidance, awareness or operational recognition controls intended to help frontline police, detention or comparable personnel identify behavioural or experiential indicators of mental-health problems and bring concerns to responsible healthcare staff.

What is not included
  • Excludes clinical failures by mental-health professionals after a concern has been appropriately recognised and referred.
  • Excludes generic workforce training or communication deficiencies with no specific mental-health-indicator recognition component.
  • Excludes failures to recognise physical illness, acute behavioural disturbance or other hazards unless mental-health indicators are the material shared concern.
  • Excludes broader mental-health service access, treatment, referral or care-coordination failures where frontline recognition is not the deficient control.

Reports and published responses 13 reports

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

  1. Nottinghamshire

    AI-generated summary

    Jonathan Mark Thornton · 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

    Jonathan Mark Thornton died at Queens Medical Centre in Nottingham on 12 July 2024 after sustaining a severe head injury in an attack by a fellow inmate at HMP Nottingham on 28 June 2024. The report raises concerns about inadequate information sharing between community forensic, prison healthcare and operational prison staff, and about the categorisation and visibility of risk alerts on NOMIS/DPS, creating a risk of future deaths.

    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 equip operational prison staff to identify and report behavioural deterioration

    Wider context from the report

    “2. Information sharing between Prison Healthcare and Operational Prison Staff. This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team, but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for. Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners. It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this. I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death. ”

    Source location

    Jonathan Mark Thornton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Healthcare information-sharing concerns have been referred to the relevant NHS trusts for separate consideration and response.

    Verbatim wording from the response

    “Although your concerns about the sharing of information between healthcare and prison staff have been referred to Nottinghamshire Healthcare NHS Foundation Trust and Northampton Healthcare NHS Foundation Trust for their separate consideration and response, HMPPS has also considered whether there is any supportive action that it can take.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 13 April 2026

    Open published response

  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Abigail Eleanor Ann Jelly · 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

    Abigail Eleanor Ann Jelly, a 34-year-old mother of two experiencing post-natal depression, died on 12 November 2024 after intentionally harming herself, causing fatal blood loss. The report identified concerns about inadequate perinatal mental-health training, limits on urgent specialist visits, insufficient engagement with her parents, and wider failings in professional curiosity, escalation, decision-making and risk assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of mandatory perinatal red-flag training for community mental health teams

    Wider context from the report

    “Community Mental Health Teams do not receive mandatory training on the perinatal red flags that are used when assessing patients with postnatal mental health issues. The team concerned with Abigail did request training but, a year after Abigail’s death, they had not received it. They were told that an assessment had been made by those senior to them that such training is not mandatory. That women suffer poor mental health before and after giving birth is sadly common and I am concerned that there is a risk of future deaths and that a large and vulnerable group of patients will not receive appropriate care. ”

    Source location

    Abigail Eleanor Ann Jelly · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Roll out a redesigned mental-health risk assessment and management training programme incorporating perinatal risks.

    Verbatim wording from the response

    “The “Perinatal Red Flags” is information that is primarily targeted towards non-mental health professionals. It is not mandatory training for Mental Health Registrants, for whom it will have been an integral part of their core education in becoming a qualified mental health practitioner. What we are doing, however, is rolling out a redesigned training programme for assessing and managing all risk in mental health, and perinatal risks will be part of that programme.”

    Source location

    Response from Hampshire and Isle of Wight Healthcare
    Page 1 · response
    Published 14 October 2025

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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

    Perinatal Red Flags training need not be mandatory for Mental Health Registrants because the content is covered in their core education.

    Verbatim wording from the response

    “The “Perinatal Red Flags” is information that is primarily targeted towards non-mental health professionals. It is not mandatory training for Mental Health Registrants, for whom it will have been an integral part of their core education in becoming a qualified mental health practitioner. What we are doing, however, is rolling out a redesigned training programme for assessing and managing all risk in mental health, and perinatal risks will be part of that programme.”

    Source location

    Response from Hampshire and Isle of Wight Healthcare
    Page 1 · response
    Published 14 October 2025

    Open published response

  3. Birmingham and Solihull

    AI-generated summary

    JAVED IQBAL · 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

    Javed died on 1 June 2024 after deliberately igniting his room with flammable liquid and sustaining major burn injuries and smoke inhalation, followed by multi-organ failure. The report identified concerns that staff did not recognise and appropriately act on serious acute mental health issues, including not escalating worsening mood and irrational behaviour to the GP in writing. It also identified the absence of a formal internal post-death investigation and outstanding internal training that had not addressed these concerns.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of staff to recognise serious acute mental health issues

    Wider context from the report

    “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example: (1) At a fundamental level staff did not understand what is in the best interests of a service user: (a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing. (2) There was no formal internal post-death investigation report. (3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above concerns. ”

    Source location

    JAVED IQBAL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide supervision that develops staff understanding, reflection, performance, policy compliance and responses to deteriorating mental health.

    Verbatim wording from the response

    “Action plan: Guidance and Development: We are Ensuring that carers and coordinators fully understand their duties, including acting in the best interests of service users and recognizing signs of deteriorating mental health.”

    Source location

    Response from All Care In One Ltd
    Page 3 · response
    Published 4 March 2025

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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

    Establish and implement a pin-chart process requiring escalation of concerns, written documentation and follow-through with appropriate support.

    Verbatim wording from the response

    “New ways of working – pin chart”

    Source location

    Response from All Care In One Ltd
    Page 4 · response
    Published 4 March 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise internal safeguarding policies to clarify recognition, escalation and record-keeping for acute mental health issues.

    Verbatim wording from the response

    “appendix 8 Reviewed new policies and procedures of the safeguarding.”

    Source location

    Response from All Care In One Ltd
    Page 5 · response
    Published 4 March 2025

    Open published response

  4. Surrey

    AI-generated summary

    Haydar Jefferies · 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

    Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of custody staff training to recognise red flags of declining mental health

    Wider context from the report

    “5. Custody staff are not trained in mental health presentations and are unable to recognise red flag indicators of declining mental health. ”

    Source location

    Haydar Jefferies · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Pilot mandatory online Introduction to Mental Health training for Care and Separation Unit staff, including all new staff applying to work there.

    Verbatim wording from the response

    “The prison is piloting an online e-learning course called ‘Introduction to Mental Health’ for all staff working in the CSU to support staff in identifying indicators of declining mental health and to upskill staff to complete the mental health referral forms with relevant risk information. All new staff applying to work in the CSU must complete this course.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 27 December 2024

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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

    Provide Introduction to Mental Health Awareness training to all new prison officers through initial prison officer training.

    Verbatim wording from the response

    “In addition to the action taken locally at HMP Coldingley, I can confirm that all new prison officers complete a training module called ‘Introduction to Mental Health Awareness’ as part of their initial prison officer training.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 27 December 2024

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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 mental health training for Custodial Managers and CSU staff, requiring completion before new CSU staff take up post.

    Verbatim wording from the response

    “As outlined on page 12 of the December 2024 Safety Strategy, the prison is rolling out mental health training for Custodial Managers and CSU Staff to assist with populating the referral form with all relevant information in respect of risk and to support custodial prison staff in identifying mental health concerns more readily. Custodial Managers can check that mental health training has been completed by accessing officer training records through the online management system. Any new staff that have successfully passed a board to work in the CSU, must have also completed the online training prior to being invited for interview.”

    Source location

    Response from Government Legal Department
    Page 1 · response
    Published 27 December 2024

    Open published response

  5. West Sussex, Brighton and Hove

    AI-generated summary

    Ryan Louis Ouslem · 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

    Ryan Louis Ouslem was found deceased at home on 1 August 2022 after previously posting a Facebook message that raised concerns for his welfare and indicated that his flat was unsafe to enter. The report raises concerns about police mental-health training and assessment, the sharing of relevant information between police and mental-health services, and the lack of joint training under new working arrangements.

    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 police officers understand mental health issues and referral information requirements

    Wider context from the report

    “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner. An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training. I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police. SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service. I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide. Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask. ”

    Source location

    Ryan Louis Ouslem · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Joint training with SPFT is not considered workable because its cost and logistical requirements are disproportionate at this stage.

    Verbatim wording from the response

    “We have carefully considered whether joint training with SPFT could provide anything additional which could assist officers when referring matters and providing information to them, however we do not believe it is workable step and the cost and logistics of doing so would not be proportionate at this stage.”

    Source location

    Response from Sussex Police 2
    Page 3 · response
    Published 25 September 2024

    Open published response

  6. South Yorkshire (Western)

    AI-generated summary

    Matthew Terrill · Prevention of Future Deaths report

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

    Report summary

    Matthew Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision 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

    Lack of police officer training in recognising mental health conditions and their behavioural effects

    Wider context from the report

    “2. Lack of training in First Aid or Personal Safety courses for police officers in relation to recognising the signs and symptoms of mental health conditions and acute mental health crisis. Specifically, when this may be impacting upon the behaviour of the detained person and whether they require medical assistance from a hospital. I have been told that officers are trained in methods of communication with persons who are suffering from mental health episodes, but not how to recognise the symptoms. There is training on ABD, and I am not concerned about the officers’ ability to respond to persons with suicidal ideation. Accepting that police officers are not medical professionals, I am concerned that there is no guidance on recognition of symptoms of mental health conditions falling short of crisis (in particular the way in which this may affect behaviour) and appropriate management, then detained persons suffering from a mental health episode, or with pre-existing mental health conditions, may be at risk of future death. ”

    Source location

    Matthew Terrill · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver mental-health awareness training to frontline officers, including recognition of mental-health problems and crisis indicators.

    Verbatim wording from the response

    “Mental Health training was rolled out to all front line officers via Street Skills in 2018. This was developed and delivered with partners and individuals with lived experience. This gave officers guidance on recognising sign and symptoms of mental health issue including those falling short of a crisis.”

    Source location

    Response from South Yorkshire Police and Humberside Police
    Page 5 · response
    Published 4 April 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing acute behavioural disturbance and mental-health training means generic mental-health conditions will not be added to first-aid training.

    Verbatim wording from the response

    “However, in both Personal Safety Training (PST) and First Aid training since 2014 officers have received an input on Acute Behavioural Disturbance (ABD) and on how to recognise signs and symptoms in both theory and practice.”

    Source location

    Response from South Yorkshire Police and Humberside Police
    Page 4 · response
    Published 4 April 2024

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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

    Force-wide mental-health CPD cannot be delivered before 2025 because current continuing-professional-development capacity is full.

    Verbatim wording from the response

    “South Yorkshire Police CPD is currently booked up until December 2024, a further mental health CPD event will be considered in CPD training from early 2025 where we will look to deliver this force wide.”

    Source location

    Response from South Yorkshire Police and Humberside Police
    Page 5 · response
    Published 4 April 2024

    Open published response

  7. Inner West London

    AI-generated summary

    Daniel LYLE · 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

    Daniel LYLE, who suffered from paranoid psychosis, experienced a psychotic episode on 20 March 2020 and climbed approximately 30 feet into a tree while displaying paranoid and delusional beliefs. He fell from the tree, sustained fatal head and chest injuries, and died despite resuscitation efforts. The principal concern was that police training was not sufficiently focused on understanding mental health symptoms and presentation, or on practical strategies to support decision-making during mental health crises.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient focus in police officer training on symptoms and presentation of mental health conditions

    Wider context from the report

    “(1) Whilst recognising that police officers cannot be doctors or nurses nor should they be, it is a concern that training for officers whether initial or refresher is not sufficiently focused on: (a) an understanding of the symptoms and presentation of mental health conditions; (b) possible practical strategies informed by mental health professionals and those suffering such conditions as will enable officers to optimise their decision making under the national decision making model. ”

    Source location

    Daniel LYLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Gwent

    AI-generated summary

    Siwan Llio SMITH · Prevention of Future Deaths report

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

    Report summary

    Siwan Smith had a long-standing history of anxiety and depression, which worsened during the Covid-19 pandemic, and she died by hanging at home on 23 November 2020. The report raised concern that, when she sought an earlier appointment and was distressed, reception staff did not identify whether she required urgent mental health support or arrange a call from a clinically trained person.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of awareness among reception staff of when patients require urgent clinical assessment for mental health concerns

    Wider context from the report

    “1. Response to Mental Health Concerns by Reception Staff During the course of the inquest, Mr Martin Smith, Siwan’s husband, raised concerns that on 18th November 2020, Siwan telephoned the Medical Centre to obtain an urgent appointment with a doctor. She was informed by the receptionist that the earliest appointment was on 30th November 2020. The Medical Centre provided me with a report which indicated that when Siwan asked about whether there were any emergency appointments for mental health problems she was advised that these are not routinely offered unless a patient is having “bad thoughts”. Your report states that an emergency appointment was not requested and at no point was it suggested the call was a mental health emergency. The Medical Centre provided me with a recording of the telephone exchange between Siwan and the receptionist. I found during the inquest that Siwan asked repeatedly if she could have an earlier appointment and was clearly upset that she could not. She was not asked if she was having bad thoughts or whether she required urgent mental health support. It was clear towards the end of the conversation that Siwan was distressed. I also received in evidence a letter dated 8 March 2021 written By ████████, the Practice Manager to Mr Smith, in which she implies that the receptionists are not clinically trained to make assessments. I accept this, however in the circumstances I determined that Siwan should have received a call back from someone who was clinically trained to ascertain whether she required an urgent mental health assessment. In the circumstances I did not find that a different course of action would have prevented Siwan’s death or would have altered the outcome. However I am concerned that lives could be put at risk in the future if there continues to be a lack of awareness of when a patient may require a clinical assessment in relation to their mental health. ”

    Source location

    Siwan Llio SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Display a high-risk mental-health alert when records of patients with mental-health medication or history are opened.

    Verbatim wording from the response

    “We have implemented the following strategies:”

    Source location

    2021-0306-Response-from-Taffs-Well-Medical-Centre_Published
    Page 1 · response
    Published 17 September 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Offer patients contacting the practice about mental-health concerns the next available appointment and urgent same-day GP triage when requested.

    Verbatim wording from the response

    “We have implemented the following strategies:”

    Source location

    2021-0306-Response-from-Taffs-Well-Medical-Centre_Published
    Page 1 · response
    Published 17 September 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide e-consult depression risk assessment, continuously monitor submissions, and arrange immediate clinician callbacks for high-risk results.

    Verbatim wording from the response

    “• The e-consult platform provides an excellent risk assessment of depression and provides a PHQ-9 depression score. This provides a convenient and safe method of accessing help from the practice. It enables patients who may struggle to get their concerns across verbally, especially when discussing sensitive points, to articulate these in a structured manner with prompts. We hope that providing this service will help our younger, working age population such as Mrs Smith to alert us of their mental health issues promptly at their convenience. E-consults are continuously monitored throughout the day and those flagged as high risk based on PHQ-9 score (which includes a question on suicidal thoughts) are passed to the on-call”

    Source location

    2021-0306-Response-from-Taffs-Well-Medical-Centre_Published
    Page 1 · response
    Published 17 September 2021

    Open published response

  9. Inner North London

    AI-generated summary

    Jaden Matthew FRANCOIS-ESPRIT · 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

    Jaden hanged himself at home on either 25 or 26 August 2020, after becoming increasingly withdrawn and feeling isolated. The principal concern was that his deteriorating mental wellbeing was not recognised by colleagues, so he was not offered psychological counselling or other support. Other concerns included difficulties related to dyslexia, workplace treatment, and the need for a fuller understanding of station culture and Jaden’s experiences.

    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 firefighters’ deteriorating mental ill health

    Wider context from the report

    “I heard at inquest that the London Fire Brigade has quite sophisticated systems in place to support firefighters suffering mental ill health. However, Jaden was not offered the support of, for example, psychological counselling, because it was not appreciated that he was so very low. Obviously if firefighters are to be given the best chance of recovering from mental ill health, their difficulties first need to be recognised. I appreciate that it can be difficult to detect that a person may be depressed or exceptionally unhappy. Signs may be subtle and require a nuanced approach. • Jaden often complained that he was bored because Wembley Green Watch had not been called to many incidents. I heard evidence that boredom in a new firefighter can be quite common. However, I also heard that a complaint of boredom can be a sign of a person with dyslexia avoiding an unpalatable or daunting task. • Jaden had dyslexia and was worried that he would not be able to complete his written work in order to become a fully qualified firefighter, yet the reality was that his station officer was fully aware of his difficulties and had tried to reassure Jaden that he was certainly capable of achieving his goal. • He did need extra time, the space to make mistakes and a degree of sensitivity that was not always afforded him. On the other hand, he asked for help and was given a mentor, but did not make use of him and so eventually the mentorship ceased. That request for help followed by a refusal of help was not explored. Such an exploration might have led to a greater understanding of how Jaden could be helped. • Jaden felt he was being treated unfairly at work and his family have formed the view that there was an element of racism there, driven in part by their belief that Jaden was the only non white person on Wembley Green Watch. Yet the reality was that he joined a watch where a quarter of the firefighters were people of colour. • He described being teased about bringing chicken, rice and peas to work to eat, thinking that this teasing was because the food was Caribbean. Looking at this from the outside, chicken, rice and peas seems a dish without obvious world origin. Moreover, I heard about a huge variety of food being brought to work by firefighters, with some even weighing their food before eating. None of this sits easily with a dish of chicken, rice and peas resulting in a racist comment. Jaden’s interior life did not always accord with what was going on around him. Most of all he felt isolated, and yet it was clear to me that there was a lot of affection for him at the fire station. He did not always feel comfortable there. It is not necessarily an easy task to unearth such feelings in a colleague but, if it results in such a tragedy as this being avoided, it is a worthwhile one. ”

    Source location

    Jaden Matthew FRANCOIS-ESPRIT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Surrey

    AI-generated summary

    KAREN JANE BINGHAM · 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

    Karen died by hanging at her home on 18 November 2017 after contacting police and ambulance services. The jury identified concerns about the safeguarding plan used when she was informed that her perjury allegation was being filed, including insufficient information gathering, failure to involve mental health services, and inadequate multi-agency planning. The report also identified concerns about police mental health training and the understanding between police and ambulance services of each other’s triage and dispatch 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 of police mental health training to provide information about behaviours associated with common mental health conditions

    Wider context from the report

    “1. Police training in respect of mental health does not provide information as to the type of behaviours associated with common mental health conditions. ”

    Source location

    KAREN JANE BINGHAM · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver a one-day common-mental-health-conditions training session to all Contact Centre staff.

    Verbatim wording from the response

    “The Contact Centre (where all 101 and 99 calls into Force are received) are including a one day training session for all of their staff on common mental health conditions later in 2020 to help those dealing with the public over the telephone recognise signs and symptoms.”

    Source location

    2020-0081-Response-from-Chief-Constable-of-Surrey-Police_Redacted
    Page 2 · response
    Published 16 April 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Mandate the revised online Mental Health training package for all officers and staff, including recognition of common behaviours.

    Verbatim wording from the response

    “There is a revised online Mental Health training package which is to be mandated for all officers and staff to refresh their knowledge and skills in this area, including recognising common behaviours in those with mental health conditions. This will feature an input from SECambs Clinical Operations Manager on NHS Pathways and response times. This will also be supplemented by training input at officers’ annual officer safety refresher training during the autumn.”

    Source location

    2020-0081-Response-from-Chief-Constable-of-Surrey-Police_Redacted
    Page 2 · response
    Published 16 April 2020

    Open published response

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

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Data last updated 7 September 2026