Recurring concern

Unreliable recording of safety-critical police contacts

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First reported 16 Apr 2015•Latest report 26 Nov 2025

Definition

What this concern includes

Includes failures in police processes to recognise, record, update or preserve safety-critical contacts and their material information, including contacts concerning missing or vulnerable people, welfare concerns, suicidal intent or other risks requiring operational assessment.

Not included

  • Excludes general police record-keeping deficiencies where the omitted information is not safety-critical or does not affect risk assessment or protective response.
  • Excludes failures to communicate, review or act on accurately recorded police-contact information when the recording process itself was reliable.
  • Excludes the broader missing-person response, including search, classification, location and escalation failures, unless the specific deficiency is recording safety-critical police contacts.
  • Excludes clinical, care-home, prison or ambulance records unless the assertion explicitly concerns recording a safety-critical contact within a police process.
Reports
4

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2015–2025

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Crown Prosecution Service1
Department of Health and Social Care1
Essex Police1
Greater Manchester Combined Authority1
Greater Manchester Police1
Home Office1
Lancashire County Council1
Medacs Healthcare Limited1
Metropolitan Police Service1
Ministry of Housing, Communities and Local Government1
National Police Chiefs’ Council1
North London NHS Foundation Trust1
Pennine Care NHS Foundation Trust1
Police Service of Northern Ireland1
Tameside Borough Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Essex

    AI-generated summary

    Aminata Coulibaly · 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

    Aminata Coulibaly died at home between the evening of 24 June and the morning of 25 June 2022 from acute alcohol toxicity, with respiratory depression as the mechanism; the manner in which the alcohol entered her system could not be determined. The report identifies concerns about safeguarding, information-sharing and recording by Essex Police and the mental health trust, including failures relating to her expressed suicidal thoughts and the handling of the hate crime investigation.

    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 record relevant police contacts on Athena

    Wider context from the report

    “(1) Essex Police were aware that Aminata Coulibaly was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime. Essex Police did not update the mental health Trust that Aminata Coulibaly sent 2 emails on 22 June 2022 in response to her being informed (incorrectly) that the Hate Crime investigation by Essex Police had been closed: i. to the officer in the case, setting out elements of how she is being treated, elements of the hate crime and that she is not happy with the decisions made by Essex Police and she feels like taking her life. ii. to the Quality Service Team that was forwarded to the Hate Crime police sergeant on 23 June 2022, stating that Aminata Coulibaly wants to contest the decision made by the officer to close the case and that she is facing suicidal thoughts, anxiety and depression. These were not uploaded to Athena or the shared with the mental health Trust. 2. Aminata made a very distressed phone call to the officer in the case on 24 June 2022 and this was not placed on Athena or shared with the mental health Trust. 3. On 26 June 2022 the mental health Trust called Essex Police reporting concerns for Ms Coulibaly’s welfare. The Essex Police contact handler did not record important information reported by the mental health Trust that: a. Aminata had suffered assault and racial abuse by her neighbours b. The mental health Trust had texted Aminata Coulibaly to say that if they did not hear from her by 5pm then they would contact the police for a welfare check. c. Aminata Coulibaly has been having strong thoughts to end her life. 4. On 26 June 2022 a different Essex Police contact handler contacted the mental health Trust to update them on the outcome of their concern for welfare that the police would not attend as it did not meet the criteria. The contact did not ask for clarification when the mental health Trust nurse raised concern when informed that the decision was made that police were not going to attend when he asked, “even though it is life and limb?”. The contact handler did not clarify if there had been any update in the circumstances, these words had not been used by the Trust nurse in the first call. The evidence from the Force Control Room Inspector was that the contact handlers should have recorded relevant information and sought further clarification that this should have been relayed back to her. This would not have made a difference for Aminata Coulibaly as she was probably deceased but is relevant to prevent a future death and ensure that the Inspector has all relevant information when applying THRIVE to assess risk and response. ”

    Source location

    Aminata Coulibaly · Prevention of Future Deaths report
    Page 3 · 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 record relevant welfare information reported by the mental health Trust

    Wider context from the report

    “(1) Essex Police were aware that Aminata Coulibaly was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime. Essex Police did not update the mental health Trust that Aminata Coulibaly sent 2 emails on 22 June 2022 in response to her being informed (incorrectly) that the Hate Crime investigation by Essex Police had been closed: i. to the officer in the case, setting out elements of how she is being treated, elements of the hate crime and that she is not happy with the decisions made by Essex Police and she feels like taking her life. ii. to the Quality Service Team that was forwarded to the Hate Crime police sergeant on 23 June 2022, stating that Aminata Coulibaly wants to contest the decision made by the officer to close the case and that she is facing suicidal thoughts, anxiety and depression. These were not uploaded to Athena or the shared with the mental health Trust. 2. Aminata made a very distressed phone call to the officer in the case on 24 June 2022 and this was not placed on Athena or shared with the mental health Trust. 3. On 26 June 2022 the mental health Trust called Essex Police reporting concerns for Ms Coulibaly’s welfare. The Essex Police contact handler did not record important information reported by the mental health Trust that: a. Aminata had suffered assault and racial abuse by her neighbours b. The mental health Trust had texted Aminata Coulibaly to say that if they did not hear from her by 5pm then they would contact the police for a welfare check. c. Aminata Coulibaly has been having strong thoughts to end her life. 4. On 26 June 2022 a different Essex Police contact handler contacted the mental health Trust to update them on the outcome of their concern for welfare that the police would not attend as it did not meet the criteria. The contact did not ask for clarification when the mental health Trust nurse raised concern when informed that the decision was made that police were not going to attend when he asked, “even though it is life and limb?”. The contact handler did not clarify if there had been any update in the circumstances, these words had not been used by the Trust nurse in the first call. The evidence from the Force Control Room Inspector was that the contact handlers should have recorded relevant information and sought further clarification that this should have been relayed back to her. This would not have made a difference for Aminata Coulibaly as she was probably deceased but is relevant to prevent a future death and ensure that the Inspector has all relevant information when applying THRIVE to assess risk and response. ”

    Source location

    Aminata Coulibaly · 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

    Update investigation policy and procedure to require safeguarding reassessment, referrals, referral documentation, outcomes and recorded justification before case closure.

    Verbatim wording from the response

    “• Essex Police has updated policy and procedure to direct action to be taken to investigate crime, support victims, and share information. Of key importance is procedure B0602 Investigation of Crime, updated in September 2025 which states at 3.7:”

    Source location

    Response from Essex Police
    Page 2 · response
    Published 1 December 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

    Train Contact Management staff in Right Care, Right Person, incident recording, National Decision Model, THRIVE, escalation and supervisory requirements through recruit and continuing-development programmes.

    Verbatim wording from the response

    “To ensure these procedures are understood and consistently delivered by operational officers and staff in our Control Centre, the following has been implemented:”

    Source location

    Response from Essex Police
    Page 5 · response
    Published 1 December 2025

    Open published response

  2. Inner North London

    AI-generated summary

    Joseph MARTIN · 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

    Joseph Martin approached Metropolitan Police Service officers near Westminster Bridge on 3 June 2021, after concerns had been raised about his mental health and safety. The inquest found that he was suffering a psychotic relapse at the time of his death, but the exact circumstances were unclear. The report raised concerns that important information about his mental health and vulnerability was not shared between police forces and that individual errors and wider system weaknesses failed to provide a safety net.

    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 record safety-critical contacts in missing-person and occurrence records

    Wider context from the report

    “Joseph Martin was reported as a person of concern to the PSNI on 28 May 2021 by staff at the hostel where he lived. His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others. The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further. However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed. I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer. Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts. Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back. I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given. There were individual errors, and more significantly a system that does not seem to have provided a safety net. ”

    Source location

    Joseph MARTIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    Finnulla Catherine MARTIN · 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

    Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.

    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 record critical information disclosed to police call handlers

    Wider context from the report

    “1. The police call handler who spoke to Ms Martin did not record that she said: “I need to jump a balcony”. This was important information. ”

    Source location

    Finnulla Catherine MARTIN · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to record safeguarding intelligence on nominal profiles

    Wider context from the report

    “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers. It is a core function of the police to submit such intelligence. ”

    Source location

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

    Open source report
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Data last updated 7 September 2026