Recurring concern

Unreliable joint emergency-service attendance at risk-marked properties

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First reported 21 Jul 2015•Latest report 24 Nov 2020

Definition

What this concern includes

Includes failures in dedicated police and emergency-service arrangements for joint attendance or welfare checks at risk-marked properties, including unclear communication lines, operating procedures, responsibilities, escalation arrangements and failure to establish or maintain joint-working arrangements; include the anchor's EEAS–Essex Police concern and the MPS–LAS welfare-check coordination concern.

Not included

  • Excludes generic inter-agency communication, cooperation or meeting deficiencies where no joint emergency-service attendance or welfare-check process is involved.
  • Excludes police-hospital joint risk assessments, mental-health service coordination and other specialist interfaces unless the assertion specifically concerns joint emergency-service attendance at a risk-marked property.
  • Excludes emergency-service resource shortages, delayed attendance or individual response failures where no deficiency in the joint-attendance arrangement is identified.
  • Excludes failures limited to risk assessment, information sharing or care planning when joint emergency-service attendance is not the shared unsafe condition.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2015–2020

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.

East of England Ambulance Service NHS Trust1
Essex Partnership University NHS Foundation Trust1
Essex Police1
London Ambulance Service NHS Trust1
Metropolitan Police Service1

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

    Sharon Louise Kelly · 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

    Sharon Louise Kelly, who had a long history of mental health and alcohol problems and frequent suicide attempts, informed a family member that she would kill herself on the anniversary of her baby son’s death. On 27 June 2019, an ambulance attended her property but did not enter while awaiting delayed police attendance; when services eventually entered, Ms Kelly was deceased. The concerns included delays and communication between ambulance and police services, risk assessment and police response procedures, and arrangements for urgent mental health assessments.

    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

    Insufficiently clear communication lines and operating arrangements between EEAS and Essex Police for potential joint attendance at a risk-marked property

    Wider context from the report

    “Whether lines of communication and the modus operandi between EEAS and Essex Police are sufficiently clear in relation to a potential joint attendance at a property where there is a risk marker (given the delays on 27 June 2019) ”

    Source location

    Sharon Louise Kelly · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South London

    AI-generated summary

    Anne Wilson · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to share welfare check policy changes with the London Ambulance Service

    Wider context from the report

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

    Source location

    Anne Wilson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response
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Data last updated 7 September 2026