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. Wiltshire and Swindon

    AI-generated summary

    Eugeniusz Niedziolko · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to recognise acute alcohol intoxication as a mental disorder or impairment

    Wider context from the report

    “c) AWARENESS OF MENTAL HEALTH ISSUES I have already highlighted a concern with the 2 officers in question who were unaware of the link between mental health and alcoholism that runs in both directions. What was more concerning was that both officers were unaware that acute alcohol intoxication amounts to a mental disorder for the purposes of the Mental Health Act 1983 and a mental impairment for the Mental Capacity Act 2005. This point is being addressed below to the Chief Executive of the College of Policing and also the Council of Chief Police Officers Mental Health Lead as I suspect that the 2 officers involved in this case, as indeed every other Police Officer who gave evidence, was unaware of this until recently. This needs to change as a matter of urgency as in this case the use of Section 136 Mental Health Act 1983 was never considered as an option because neither officer thought that Eugeniusz was suffering from a mental disorder. ████████ a consultant psychiatrist also expressed a view to the court that he doubted that Eugeniusz actually had mental capacity when appearing to agree to being left in the lavatory block. ”

    Source location

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

    Open source report

  2. North Wales (East and Central)

    AI-generated summary

    Joshua James Alexander Hamill · Prevention of Future Deaths report

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

    Report summary

    Joshua James Alexander Hamill, who was known to mental health services and had previously self-harmed, was reported as threatening to kill himself in the early hours of 5 June 2016. Police re-categorised the matter as a domestic incident and left him alone; he was later found dead at Flint Castle as a result of hanging. The concerns were that police training was ineffective in identifying mental health issues and that a “Concern for Safety” could be closed as a domestic incident without a recorded resolution regarding the safety and welfare of the person at risk.

    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

    Ineffective training for police officers to accurately identify mental health issues

    Wider context from the report

    “1. That the current training afforded to police officers in North Wales was ineffective in ensuring that they were able to accurately identify mental health issues in persons they were attending. ”

    Source location

    Joshua James Alexander Hamill · 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

    Deliver enhanced Vulnerable Person training, including a mental-health scenario and health-board advice, on Taser courses.

    Verbatim wording from the response

    “During April 2015 the “Vulnerable Person” package was introduced by the College of Policing, National Taser Course that all Taser officers have to complete. This package dealt with identifying and dealing with persons suffering mental health issues. This was implemented straight away by North Wales Police in both the initial and refresher training.”

    Source location

    2017-0351-Response-by-North-Wales-Police
    Page 1 · response
    Published 11 February 2018

    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

    Deliver Acute Behavioural Disorder training within mandatory personal-safety training for all officers.

    Verbatim wording from the response

    “During August 2016 the Acute Behavioural Disorder (ABD) package developed by the College of Policing was introduced to the classroom session of personal safety training. Although dealing primarily with persons suffering from ABD, it followed the same principles for dealing with persons suffering mental health problems. All officers in North Wales Police are required to undergo personal safety training; therefore every officer will receive this package. This package is still being delivered and some officers have now received it more than once. This is auditable through changes made to lesson plans and officer training records.”

    Source location

    2017-0351-Response-by-North-Wales-Police
    Page 2 · response
    Published 11 February 2018

    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

    Embed early-intervention vulnerability training, including signposting to external support, within the vulnerability course.

    Verbatim wording from the response

    “An early intervention training package was developed in force and delivered between November 2016 and July 2017. This package addressed concerns around dealing with vulnerable persons including those with mental health issues. As part of this package officers were provided with details of external partners that persons they were dealing could be signposted to. Although this package does not continue to be delivered as a stand-alone it does continue to be delivered as part of the vulnerability course. This is auditable through officer training records.”

    Source location

    2017-0351-Response-by-North-Wales-Police
    Page 2 · response
    Published 11 February 2018

    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

    Deliver mental-health training webinars covering mental-health conditions, places of safety, support, suicide, self-harm and learning disabilities.

    Verbatim wording from the response

    “A mental health training package was developed by the Training Department and delivered as a webinar package. This detailed different types of mental health issues, places of safety, support/advice contacts, suicide, self-harm and learning disabilities. Due to the way in which it was delivered it is not auditable. I can confirm that this was delivered on 10th May 2017 and 16th August 2017 but I cannot identify which officers received the input. I trust that this information assists in demonstrating that the training provided in relation to mental health issues has developed since the death of Joshua Hamill on 5th June 2016.”

    Source location

    2017-0351-Response-by-North-Wales-Police
    Page 2 · response
    Published 11 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop a mental-health training package using learning from other forces and national working groups.

    Verbatim wording from the response

    “The Training Department are currently developing a mental health training package. Other Forces have been contacted in relation to their mental health training. The Training Department will be following this up through roles on the national working groups for personal safety training and Taser training as they bring trainers into contact with all forces. This will provide a definitive idea of what other forces are already doing and assist in developing best practice.”

    Source location

    2017-0351-Response-by-North-Wales-Police
    Page 3 · response
    Published 11 February 2018

    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

    Seek mental-health team input to identify improvements to training delivery.

    Verbatim wording from the response

    “The training department will also contact the BCUHB mental health team to seek an input from them for Force trainers to identify any areas where we could improve delivery.”

    Source location

    2017-0351-Response-by-North-Wales-Police
    Page 3 · response
    Published 11 February 2018

    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

    Adapt the College of Policing vulnerable-person Taser package for personal-safety training and deliver it to all officers with auditable attendance.

    Verbatim wording from the response

    “5. The College of Policing vulnerable person Taser package be adapted and extended into personal safety training. All officers will receive the package. This also ensures the training is auditable. This will be ready in the near future.”

    Source location

    2017-0351-Response-by-North-Wales-Police
    Page 3 · response
    Published 11 February 2018

    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

    Convert the mental-health webinar package into an auditable classroom package and deliver it to officers.

    Verbatim wording from the response

    “6. The webinar package will be adapted and delivered as a classroom package. This will take time to develop and implement but officers attendance can be audited. Whilst this is still being developed it should be available to go live post April 2018.”

    Source location

    2017-0351-Response-by-North-Wales-Police
    Page 3 · response
    Published 11 February 2018

    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

    Continue liaison with other forces and the local health board to improve mental-health training and share best practice.

    Verbatim wording from the response

    “The North Wales Police training department are liaising with other forces and the local health board to improve the training.”

    Source location

    2017-0351-Response-by-North-Wales-Police
    Page 5 · response
    Published 11 February 2018

    Open published response

  3. West London

    AI-generated summary

    Brian Christopher Dalrymple · 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 Christopher Dalrymple died at Colnbrook Immigration Removal Centre on 31 July 2011 after a fatal rupture associated with extreme hypertension, which he declined to have treated and monitored for most of his detention. The report raised concerns that indicators of his deteriorating mental health were not recognised or communicated to healthcare staff, that medical practitioners lacked necessary knowledge, that medical visits to segregated detainees were inadequate, and that clinical records were not comprehensive or accessible.

    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 detention staff awareness and recognition of mental-health indicators

    Wider context from the report

    “(1) There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare. Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth. The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth. It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath. ”

    Source location

    Brian Christopher Dalrymple · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to bring potential mental-health indicators to responsible healthcare staff

    Wider context from the report

    “(1) There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare. Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth. The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth. It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath. ”

    Source location

    Brian Christopher Dalrymple · 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

    No practicable steps can be taken concerning Harmondsworth working practices because management responsibility transferred to Mitie.

    Verbatim wording from the response

    “As the Contract for the management of Harmondsworth IRC passed to Mitie on 01st September 2014, there is of course no practicable steps GEO can take in relation to the working practices at Harmondsworth.”

    Source location

    2014-0410-Response-by-The-GEO-Group-UK-Ltd
    Page 1 · response
    Published 18 September 2014

    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