11 Feb 2026 Chloe Angela Ulett · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to embed RCEM acute behavioural disturbance guidance in adult emergency medicine View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Royal College of Midwives
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AI-generated summary
Chloe Angela Ulett · 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
Chloe Angela Ulett died at Birmingham Heartlands Hospital on 28 September 2024 from a previously undiagnosed urea cycle disorder that had been unmasked by giving birth. She developed confusion and excessive drowsiness after childbirth, was initially diagnosed with iron deficiency and discharged, and ammonia testing was delayed until several days later. The principal concerns were that early ammonia testing was not routine, relevant guidance was unclear and not embedded in adult medicine, and there remained a national risk of delayed diagnosis.
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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 embed RCEM acute behavioural disturbance guidance in adult emergency medicine
Wider context from the report “4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels.
5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology).
6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department .
7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version.
8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance.
” Source location Chloe Angela Ulett · Prevention of Future Deaths report
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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 Matters in points 3–11 are outside the respondent’s role, so it will not comment further on them.
Verbatim wording from the response “Points 3-11 do not relate to the role of the RCM and therefore we feel unable to comment further.” Source location 2026-0086 - Response from Royal College of Midwives
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9 Feb 2026 Josh Yemi TARRANT · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1
Failure of prison nurses to recognise ABD and treat it as a medical emergency View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Develop and communicate a national framework defining healthcare roles and responsibilities for use-of-force incidents and ABD warning signs.
View source
NHS England
Ensure establishments include clear ABD red-flag criteria and emergency escalation pathways in healthcare training and operational briefings, with governance review of incidents.
View source
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AI-generated summary
Josh Yemi TARRANT · 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
Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine intoxication and exertion during a lengthy and challenging restraint. The principal concern was that acute behavioural disturbance was not recognised by healthcare staff, who lacked relevant training, and that an ambulance was not called at the earliest appropriate opportunity.
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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 of prison nurses to recognise ABD and treat it as a medical emergency
Wider context from the report “I am concerned that:
(a) No training is provided to prison healthcare staff in relation to ABD (despite the clear advice of PSO 1600).
(b) If prison nurses remain unaware of ABD and the need to treat it as a medical emergency , then further deaths are likely in future.
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by from ABD. In particular, training of prison clinicians should be carefully reviewed at a national level.
” Source location Josh Yemi TARRANT · 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 Develop and communicate a national framework defining healthcare roles and responsibilities for use-of-force incidents and ABD warning signs.
Verbatim wording from the response “In 2025 NHS England developed a framework for healthcare roles and responsibilities for planned and unplanned use of force in adult prisons and immigration removal centres which was communicated to all healthcare providers in August 2025. This framework supports HMPPS and Home Office policy documents and makes clear healthcare requirement to attend all planned, and where possible, unplanned use of force incidents.” Source location Response from NHS England
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 Ensure establishments include clear ABD red-flag criteria and emergency escalation pathways in healthcare training and operational briefings, with governance review of incidents.
Verbatim wording from the response “We will be sharing the details of this report with all prison and Immigration Removal Centre healthcare providers with an action to ensure all establishments have a clear red flag criteria and emergency escalation pathway within existing healthcare training structures and operation briefings. This should include a focus on early recognition of deterioration, prompt ambulance activation where indicated, minimising restraint duration and maintaining continuous observation until handover, with routine governance review of such incidents.” Source location Response from NHS England
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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 Prison healthcare staff cannot reasonably be expected to diagnose ABD reliably; safety depends on recognising severe agitation, physiological red flags and emergency escalation.
Verbatim wording from the response “Given the rarity and complexity of ABD and the operational realities of prisons, it is not reasonable to expect prison healthcare staff to diagnose ABD reliably. The critical safety issue is recognition of severe agitation accompanied by physiological red flags and escalation as a medical emergency.” Source location Response from NHS England
Open published response
9 Feb 2026 Josh Yemi TARRANT · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2
Lack of prison officer training in acute behavioural disturbance (ABD) View source Failure of prison officers to recognise ABD as a medical emergency View source
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AI-generated summary
Josh Yemi TARRANT · 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
Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine toxicity following a lengthy and challenging restraint while experiencing an acute behavioural disturbance. The principal concerns were that the disturbance was not recognised by healthcare staff, that an ambulance was not called at the earliest appropriate opportunity, and that prison and healthcare staff lacked training in acute behavioural disturbance. The inquest jury found that the failure to provide sufficient medical treatment probably significantly contributed to his death and that his death was contributed to by neglect.
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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 in acute behavioural disturbance (ABD)
Wider context from the report “HMPPS acknowledged that, despite this clear guidance, the Prison Service stopped teaching officers about ABD (aka ‘Excited Delirium’) in 2015 and have not taught it since then .
None of the officers who gave evidence in this inquest said that they had never been given any training in relation to ABD.
Dr ████████ explained that ABD is a well-recognised condition. Indeed, SEAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”).
Dr ████████ also stated that:
(1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been apparent to a properly trained person within a matter of minutes;
(2) It was clearly a medical emergency that required the attendance of a CCP who would have provided sedation and other treatments;
(3) Had treatment been initiated at any time before 1 am Mr Tarrant probably would have survived.
I am concerned that:
(a) No training is provided to prison officers in relation to ABD (despite the clear advice of PSO 1600).
(b) If officers who are required to restrain prisoners remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future.
” Source location Josh Yemi TARRANT · 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 prison officers to recognise ABD as a medical emergency
Wider context from the report “HMPPS acknowledged that, despite this clear guidance, the Prison Service stopped teaching officers about ABD (aka ‘Excited Delirium’) in 2015 and have not taught it since then.
None of the officers who gave evidence in this inquest said that they had never been given any training in relation to ABD.
Dr ████████ explained that ABD is a well-recognised condition. Indeed, SEAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”).
Dr ████████ also stated that:
(1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been apparent to a properly trained person within a matter of minutes;
(2) It was clearly a medical emergency that required the attendance of a CCP who would have provided sedation and other treatments;
(3) Had treatment been initiated at any time before 1 am Mr Tarrant probably would have survived.
I am concerned that:
(a) No training is provided to prison officers in relation to ABD (despite the clear advice of PSO 1600).
(b) If officers who are required to restrain prisoners remain unaware of ABD and the need to treat it as a medical emergency , then further deaths are likely in future .
” Source location Josh Yemi TARRANT · 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 Consult clinical expertise to inform written guidance on recognising and escalating potential Acute Behavioural Disturbance emergencies.
Verbatim wording from the response “In the period following the inquest, HMPPS has taken active steps to ensure staff are better supported in recognising and responding to behavioural and physiological indicators associated with ABD. We are currently consulting with ████████, whose clinical expertise is informing written guidance that will be issued to staff. This guidance is designed to equip officers with a clearer understanding of what signs may indicate ABD, while emphasising that the diagnosis and response to ABD rests solely with healthcare professionals. The intention is to ensure officers recognise potential medical emergencies quickly and escalate concerns appropriately.” Source location Response from HMP Elmley
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 Issue staff guidance explaining signs of Acute Behavioural Disturbance and appropriate escalation to healthcare professionals.
Verbatim wording from the response “In the period following the inquest, HMPPS has taken active steps to ensure staff are better supported in recognising and responding to behavioural and physiological indicators associated with ABD. We are currently consulting with ████████, whose clinical expertise is informing written guidance that will be issued to staff. This guidance is designed to equip officers with a clearer understanding of what signs may indicate ABD, while emphasising that the diagnosis and response to ABD rests solely with healthcare professionals. The intention is to ensure officers recognise potential medical emergencies quickly and escalate concerns appropriately.” Source location Response from HMP Elmley
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 Diagnosis and response to Acute Behavioural Disturbance rest solely with healthcare professionals, while officers recognise indicators and escalate concerns.
Verbatim wording from the response “In the period following the inquest, HMPPS has taken active steps to ensure staff are better supported in recognising and responding to behavioural and physiological indicators associated with ABD. We are currently consulting with ████████, whose clinical expertise is informing written guidance that will be issued to staff. This guidance is designed to equip officers with a clearer understanding of what signs may indicate ABD, while emphasising that the diagnosis and response to ABD rests solely with healthcare professionals. The intention is to ensure officers recognise potential medical emergencies quickly and escalate concerns appropriately.” Source location Response from HMP Elmley
Open published response
9 Feb 2026 Josh Yemi TARRANT · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2
Lack of training for prison officers in relation to ABD View source Failure of prison officers who restrain prisoners to recognise ABD and treat it as a medical emergency View source
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
Josh Yemi TARRANT · 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
Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine intoxication and a lengthy, challenging restraint while he was experiencing acute behavioural disturbance. The report raises concerns that acute behavioural disturbance was not recognised, that sufficient medical treatment was not provided at the earliest appropriate opportunity, and that prison staff lacked training to identify and respond to it.
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 training for prison officers in relation to ABD
Wider context from the report “HMPPS acknowledged that, despite this clear guidance, the Prison Service stopped teaching officers about ABD (aka ‘Excited Delirium’) in 2015 and have not taught it since then .
None of the officers who gave evidence in this inquest said that they had never been given any training in relation to ABD.
Dr████████ explained that ABD is a well-recognised condition. Indeed, SEAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”).
Dr████████ also stated that:
(1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been apparent to a properly trained person within a matter of minutes;
(2) It was clearly a medical emergency that required the attendance of a CCP who would have provided sedation and other treatments;
(3) Had treatment been initiated at any time before 1 am Mr Tarrant probably would have survived.
I am concerned that:
(a) No training is provided to prison officers in relation to ABD (despite the clear advice of PSO 1600).
(b) If officers who are required to restrain prisoners remain unaware of ABD and the need to treat it as a medical emergency, then further deaths are likely in future.
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by from ABD. In particular, training should be reviewed and assessed by the Prison Service with assistance from appropriately qualified clinicians.
” Source location Josh Yemi TARRANT · 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 prison officers who restrain prisoners to recognise ABD and treat it as a medical emergency
Wider context from the report “HMPPS acknowledged that, despite this clear guidance, the Prison Service stopped teaching officers about ABD (aka ‘Excited Delirium’) in 2015 and have not taught it since then.
None of the officers who gave evidence in this inquest said that they had never been given any training in relation to ABD.
Dr████████ explained that ABD is a well-recognised condition. Indeed, SEAmb witnesses provided evidence in this inquest that, if their call handlers are told that a person is displaying signs of ABD whilst under restraint, the response would be upgraded to aa Category 1 response and the immediate despatch of a Critical Care Paramedic (“CCP”).
Dr████████ also stated that:
(1) Mr Tarrant was displaying ‘textbook’ signs of ABD which would have been apparent to a properly trained person within a matter of minutes;
(2) It was clearly a medical emergency that required the attendance of a CCP who would have provided sedation and other treatments;
(3) Had treatment been initiated at any time before 1 am Mr Tarrant probably would have survived.
I am concerned that:
(a) No training is provided to prison officers in relation to ABD (despite the clear advice of PSO 1600).
(b) If officers who are required to restrain prisoners remain unaware of ABD and the need to treat it as a medical emergency , then further deaths are likely in future .
Accordingly, this situation should be reviewed and consideration given as to whether any steps should be taken to reduce the risk of death by from ABD. In particular, training should be reviewed and assessed by the Prison Service with assistance from appropriately qualified clinicians.
” Source location Josh Yemi TARRANT · Prevention of Future Deaths report
Open source report
2 Feb 2026 Scott Darren TAYLOR · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5
Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint View source Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage View source Lack of a national ambulance response standard for Acute Behavioural Disturbance with active restraint View source
Discrepancy in Acute Behavioural Disturbance recognition and alert training for Police Officers and Special Constables View source Confusing terminology for Acute Behavioural Disturbance in ambulance triage training materials View source See 2 more concerns
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
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 Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint
Wider context from the report “b. The East of England Ambulance NHS Trust provide ambulance services across 6 counties and that also includes police/healthcare professionals reporting Acute Behavioural Disturbance and active police restraint. There is concern that there is a different response applied and that this discrepancy between Category 1 and Category 2 responses is significant and could affect the survival of patients . Evidence heard from police trainers and expert witnesses is that Acute Behavioural Disturbance has a high rate of fatality and requires an urgent response, particularly where police officers with training in this condition are reporting to ambulance service and with active restraint.
” Source location Scott Darren TAYLOR · 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 clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage
Wider context from the report “a. Members of the public were restraining Scott Taylor on arrival of the police who quickly became concerned that Mr Taylor was exhibiting signs of Acute Behavioural Disturbance and made an emergency call to the ambulance service. The police, during the 999 call, were put on hold on three occasions by the ambulance service and became increasingly concerned about Mr Taylor’s deteriorating condition over an 18 minute period and confirmation that this remained a Category 2 call despite active police restraint with suspected Acute Behavioural Disturbance. Police decided to ‘scoop and run’ and urgently convey Mr Taylor to hospital due to the severity of their concerns. The EEAST Standard Operating Procedure requires escalation to Category 1 where there is active restraint, but this is not linked to Acute Behavioural Disturbance and remains unclear and may continue to cause confusion during triage by contact call handlers .
” Source location Scott Darren TAYLOR · 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 a national ambulance response standard for Acute Behavioural Disturbance with active restraint
Wider context from the report “a. It was agreed in evidence that the set of symptoms consistent with Acute Behavioural Disturbance amount to a medical emergency with a significant mortality risk. The evidence was that the Association of Ambulance Chief Executives set the Categories nationally that dictate the required classification for ambulance response to emergencies, however in some ambulance localities the required response is allocated Category 2 and in others Category 1 . This means that there is not a national standard for response Acute Behavioural Disturbance with active restraint .
” Source location Scott Darren TAYLOR · 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 Discrepancy in Acute Behavioural Disturbance recognition and alert training for Police Officers and Special Constables
Wider context from the report “a. Whilst it was not causative of Mr Taylor’s death, there appears to be a discrepancy in the training for Police Officers and Special Constables in the potential recognition and actions for Acute Behaviours Disturbance . Special Constables are a valuable resource for police forces and may often be first on scene as in this case and should receive the same training in the potential recognition and alert of potential life-threatening conditions.
” Source location Scott Darren TAYLOR · 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 Confusing terminology for Acute Behavioural Disturbance in ambulance triage training materials
Wider context from the report “d. The EEAST documents continue to use the term ‘Excited Delirium’ interchangeable in some of the training materials and this may lead to confusion with contact handlers triaging calls .
” Source location Scott Darren TAYLOR · 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 Implement a standalone procedure for suspected or confirmed Acute Behavioural Disturbance, removing “excited delirium” terminology and requiring Category 1 escalation with clinical review for possible downgrade.
Verbatim wording from the response “Following the inquest a working group was set up with the intention of revising the guidance for patients exhibiting signs of Acute Behavioural Disturbance and establishing the most appropriate way to respond to those patients within the Emergency Operations Centre.” Source location Response from East of England Ambulance Service
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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, approve and disseminate the detained-patient procedure and Emergency Operations Centre escalation guidance to reflect the Acute Behavioural Disturbance procedure.
Verbatim wording from the response “The procedure has also been updated to reflect that a Category 1 coding is now applied to all calls where the police are actively restraining a patient; or reporting agitation/behaviour changes; or the police use the term Acute Behavioural Disturbance. The call handler will immediately escalate this to a Call Handler Team Leader who will upgrade the call to a Category 1 and the response will be dispatched on this basis. If, at this point, the Call Handler Team Leader or Dispatcher believe this may not be a Category 1 call, the call will be highlighted to a Clinical Navigator who will complete a clinical review and triage to establish if a downgrade is required.” Source location Response from East of England Ambulance Service
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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 Standardise Acute Behavioural Disturbance training for regular officers and Special Constables across initial and refresher training.
Verbatim wording from the response “In relation to ABD, you noted that Special Constables may not have received the same depth of training as regular officers. Essex Police acknowledges the importance of ensuring that all officers, regardless of role, are equipped to identify life-threatening medical emergencies and respond consistently. As a result, all officers—regular and Special Constabulary—now receive the same level of training in relation to ABD.” Source location Response from Essex Police
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 National ambulance response categories are determined by NHS England’s ECPAG, not by AACE.
Verbatim wording from the response “With regard to the required classification for ambulance response to emergencies, AACE do not set the categories nationally of ambulance response. Ambulance call codes are determined by NHS England by the Emergency Call Prioritisation Advisory Group (ECPAG). We are aware that cases of suspected ABD should be assigned a Category 2 response, which is the immediate dispatch of an emergency ambulance. However, ambulance services are advised that a senior clinician within the” Source location Response from Association of Ambulance Chief Executives
Open published response
6 Jan 2026 Robert Shaun GRACEY · Prevention of Future Deaths report Greater Lincolnshire
View report summary
Concerns raised 3
Lack of an ABD protocol between police forces and the local ambulance service View source Allocation of ABD referrals to only a category 2 response in the absence of police restraint View source Lack of an NHS Pathways allocation pathway for ABD View source
Linked responses
East Midlands Ambulance Service NHS Trust Lincolnshire Police NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Lincolnshire Police
Work with EMAS and the Clinical Governance Forum to implement an ABD joint-working policy.
View source
Lincolnshire Police
Share learning from the coronial process with EMAS to support ABD guidance development and implementation.
View source
Lincolnshire Police
Work with EMAS and Forum partners to develop and align ABD practices and training, including response times and restraint practices.
View source
East Midlands Ambulance Service NHS Trust
Continue participating in the Police Regional Clinical Governance Forum to align ABD training and response protocols.
View source
East Midlands Ambulance Service NHS Trust
Continue working with regional police forces and health partners to explore a single joint operational framework for ABD management.
View source
NHS England
Continue reviewing the ambulance response categorisation for ABD through NHS England and relevant ambulance-sector governance bodies.
View source
East Midlands Ambulance Service NHS Trust
Maintain the Emergency Call Handling Protocols process governing responses to suspected ABD incidents.
View source
NHS England
Continue monitoring ABD incidents to develop the NHS Pathways system and associated user training in response to emerging evidence.
View source See 5 more actions
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AI-generated summary
Robert Shaun GRACEY · 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
Robert Shaun Gracey died in hospital on 29 September 2021 after police restraint and transportation following behaviour associated with cocaine use. The jury found that the effects of cocaine, restraint and struggle against restraint contributed to his death. Concerns included the absence of a Lincolnshire protocol for treating suspected excited delirium as a medical emergency, inadequate police training and monitoring, and delays or shortcomings in medical response and de-escalation.
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 an ABD protocol between police forces and the local ambulance service
Wider context from the report “1. Despite a very clear recommendation made in a letter dated 24 July 2019 by DAC Twist on behalf of the NPCC that "police forces have established ABD protocols with their local ambulance service so that suspected ABD incidents are treated as medical emergencies (i.e. Cat 1, with a response time of 8 minutes)", there is still no such protocol in Lincolnshire .
” Source location Robert Shaun GRACEY · 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 Allocation of ABD referrals to only a category 2 response in the absence of police restraint
Wider context from the report “3. Under the current NHS Pathways system a referral for ABD will only be allocated a category 2 response in the absence of police restraint .
” Source location Robert Shaun GRACEY · 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 an NHS Pathways allocation pathway for ABD
Wider context from the report “2. Under the current NHS Pathways system, ABD does not have its own allocation pathway .
” Source location Robert Shaun GRACEY · 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 Work with EMAS and the Clinical Governance Forum to implement an ABD joint-working policy.
Verbatim wording from the response “Lincolnshire Police is working with the East Midlands Police Force Clinical Governance Forum (‘the Forum’) to implement a policy in relation to ABD. The Forum includes the East Midlands Ambulance Service (EMAS) and since September 2025 learning from the Coronial process has been shared with EMAS with a view to creating and then implementing guidance in relation to this issue.” Source location 2026-0004 - Response from Lincolnshire 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 Share learning from the coronial process with EMAS to support ABD guidance development and implementation.
Verbatim wording from the response “Lincolnshire Police is working with the East Midlands Police Force Clinical Governance Forum (‘the Forum’) to implement a policy in relation to ABD. The Forum includes the East Midlands Ambulance Service (EMAS) and since September 2025 learning from the Coronial process has been shared with EMAS with a view to creating and then implementing guidance in relation to this issue.” Source location 2026-0004 - Response from Lincolnshire 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 Work with EMAS and Forum partners to develop and align ABD practices and training, including response times and restraint practices.
Verbatim wording from the response “Lincolnshire Police will continue to work with EMAS and partners within the Forum in order to develop and align practices and training to deal with ABD, response times, and restraint practices.” Source location 2026-0004 - Response from Lincolnshire 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 Continue participating in the Police Regional Clinical Governance Forum to align ABD training and response protocols.
Verbatim wording from the response “The Trust currently operates across six counties within the East Midlands, creating logistical hurdles when ensuring policies and response protocols are consistent across multiple counties and multiple police forces. The Trust will, however, continue its participation in the Police Regional Clinical Governance Forum to align training and response protocols for ABD.” Source location Response from East Midlands Ambulance Service NHS Trust
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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 Continue working with regional police forces and health partners to explore a single joint operational framework for ABD management.
Verbatim wording from the response “The Trust will also continue to work with regional police forces and health partners to explore the development of a single joint operational framework for ABD management.” Source location Response from East Midlands Ambulance Service NHS Trust
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 Continue reviewing the ambulance response categorisation for ABD through NHS England and relevant ambulance-sector governance bodies.
Verbatim wording from the response “The categorisation of 999 calls is managed through a specific process within NHS England. The mapping of triage outcomes to response categories is undertaken by an expert group which has representatives from both NHS Pathways and MPDS ambulance trusts. The coding groups engage with the ambulance sector within England and consider reviews triggered by coroner, patient safety concerns identified by the ambulance services or changes in national guidance. This group makes recommendations to the NHS England Emergency Call Prioritisation Advisory Group (ECPAG) for implementation across all NHS England ambulance service providers. This ensures appropriate prioritisation, equity of access and uniformity of response across the English ambulance services.” Source location Response from NHS England
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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 Maintain the Emergency Call Handling Protocols process governing responses to suspected ABD incidents.
Verbatim wording from the response “In addition, the Trust recognises that there is not currently a national pathway for ABD, however the Trust has in place a process for a response to ABD as governed by the Emergency Call Handling Protocols that was ratified by the” Source location Response from East Midlands Ambulance Service NHS Trust
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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 Continue monitoring ABD incidents to develop the NHS Pathways system and associated user training in response to emerging evidence.
Verbatim wording from the response “Additional Training” Source location Response from NHS England
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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 East Midlands Ambulance Service is responsible for responding directly to the concerns and revising relevant clinical presentation protocols with system partners.
Verbatim wording from the response “NHS England’s Midlands regional colleagues have reached out to Derby and Derbyshire Integrated Care Board (ICB) who has advised that East Midlands Ambulance Service will be responding directly to the concerns you raised. The Trust has confirmed that, as part of the learning and actions arising from this process, a review of all existing Memorandums of Understanding (MOUs) is underway to ensure appropriate governance arrangements are in place for each agreement. Through their Mental Health lead, the Trust is also working collaboratively with system partners to revise the relevant clinical presentation protocols.” Source location Response from NHS England
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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 EMAS is responsible for leading the joint ABD policy because the medical response is a crucial element and EMAS is best placed to lead.
Verbatim wording from the response “All Forces in the East Midlands contribute to the work of the Forum. The Forum as a whole decided that the basis of the work should be carried out by EMAS given that the medical response was a crucial element of the policy and therefore EMAS were best placed to lead upon it. The joint working policy will therefore inform the response on the part of other Police Forces within the East Midlands.” Source location 2026-0004 - Response from Lincolnshire Police
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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 ABD can receive Category 1 where life-threatening symptoms are present; otherwise Category 2 is a medical emergency with possible local upgrading.
Verbatim wording from the response “Under the current NHS Pathways system, a referral for ABD will only be allocated a Category 2 ambulance response in the absence of police restraint” Source location Response from NHS England
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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 A dedicated ABD allocation pathway is unnecessary because NHS Pathways assesses symptoms rather than allocating patients by diagnosis.
Verbatim wording from the response “Under the current NHS Pathways system, ABD does not have its own allocation pathway” Source location Response from NHS England
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 Changing the nationally mandated NHS Pathways system to create an ABD pathway must be initiated by NHS England.
Verbatim wording from the response “The Future” Source location Response from East Midlands Ambulance Service NHS Trust
Open published response
Concerns raised 1
Lack of cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
College of Policing Nottinghamshire Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
College of Policing
Review the mental health Approved Professional Practice to align ABD guidance with updated health policy.
View source
College of Policing
Support forces to develop local protocols with partner agencies.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Develop and finalise Trustwide clinical guidance for acute behavioural disorder with emergency-service pathways and wider-agency consultation.
View source
Nottinghamshire Healthcare NHS Foundation Trust
Continue discussions with Nottinghamshire Police and EMAS to establish collaborative acute behavioural disorder training, pathways and clinical guidance.
View source See 1 more action
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AI-generated summary
Kaine Regan FLETCHER · 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
Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.
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 cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance
Wider context from the report “1. Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance
In September 2022, the Royal College of Psychiatrists issued a position statement on Acute Behavioural Disturbance and Excited Delirium. The RCP recommend that:
• A cross-sector working group should be convened to develop an interim consensus on ‘ABD’, with active involvement of patients and carers, to agree terminology, key principles for professional guidance, and priorities for further research.
• This group should include representatives from police, custodial, ambulance, emergency medicine, mental health, and the judicial and coronial system. Support from relevant government departments would help ensure consistency across services.
• Further research should be urgently commissioned, including detailed investigation into how racial bias plays into the application of terminology such as ‘ABD’.
• Members of the cross-sector working group should collaborate on the development and delivery of training materials for staff working across public services
• All services should seek to improve standardised collection of disaggregated data on presentations and outcomes, and to conduct regular multi-disciplinary reviews to support high-quality research on this topic.
I have heard evidence that in Nottingham and Nottinghamshire, no such cross-sector working is in place or joint agency policy is in place . I have also heard evidence that there is no knowledge of such cross-sector working or joint agency policy in place within the East Midlands generally, or nationally. The consequence of this is that there is no joined up thinking, procedure or policy, between front-line services who are regularly dealing with cases of ABD . That lack of collaborative working between services gives rise to a risk of future death for persons who develop ABD both in the community or in custody. People at risk of developing ABD often also fall into categories of vulnerability, such as suffering with a mental health disorder or using illicit substances. To my mind, this increases the risk of future death in the absence of any collaboration. I am concerned that this appears to be a national issue.
” Source location Kaine Regan FLETCHER · 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 Review the mental health Approved Professional Practice to align ABD guidance with updated health policy.
Verbatim wording from the response “The College is currently undertaking a review of the mental health Approved Professional Practice (APP), which will ensure that any development in the published guidelines in relation to ABD are updated to ensure consistency with updated health policy.” 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 Support forces to develop local protocols with partner agencies.
Verbatim wording from the response “• Support forces in developing local protocols with partner agencies” 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 Develop and finalise Trustwide clinical guidance for acute behavioural disorder with emergency-service pathways and wider-agency consultation.
Verbatim wording from the response “A clinical guidance document is being developed for Trustwide clinical staff and developed in conjunction with pathways established within EMAS and Nottinghamshire Police. This will be finalised by the end of September 2025. This will be supported by a revised version of the clinical algorithm within Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and Royal College of Emergency Medicine. The Trust have in development a clinical decision support tool that will be available for front facing acute mental health clinicians in supporting the knowledge and actions should ABD be a suspected clinical presentation. This will be finalised following consultation with wider agencies (Nottinghamshire Police and EMAS).” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
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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 Continue discussions with Nottinghamshire Police and EMAS to establish collaborative acute behavioural disorder training, pathways and clinical guidance.
Verbatim wording from the response “The Trust is in discussions with Nottinghamshire Police and EMAS to establish a collaborative approach to address the concerns relating to patients with a clinical presentation of ABD including training, pathways and clinical guidance. There is an agreement with EMAS to meet with the Trust to explore opportunities for collaboration. This will be continued through to completion and take into consideration any wider national guidance from any response to this Regulation 28 Report received from Secretary of State for Health and Social Care.” Source location Response from Nottinghamshire Healthcare NHS Foundation Trust
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 National health-related policy on ABD should be led by health partners, with policing informed by agreed health guidance.
Verbatim wording from the response “This is an area that requires further research and an evidence base to inform national policy. The police’s role in responding to ABD, particularly as a medical risk, needs to be informed and based on agreed guidance from our partners in Health – it is imperative that health should lead on areas of national health-related policy.” Source location Response from College of Policing
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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 Further research and an evidence base are required before national policy on ABD can be developed.
Verbatim wording from the response “This is an area that requires further research and an evidence base to inform national policy. The police’s role in responding to ABD, particularly as a medical risk, needs to be informed and based on agreed guidance from our partners in Health – it is imperative that health should lead on areas of national health-related policy.” Source location Response from College of Policing
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 Operational and local partnership concerns are being addressed by Nottinghamshire Police, which is providing the full response.
Verbatim wording from the response “We have carefully considered the matters of concern raised in your Regulation 28 report. This response outlines the College of Policing’s position on Acute Behavioural Disturbance, and police training in respect of the Mental Health Act. In relation to the operational elements and local partnership working, we have been in contact with Nottinghamshire Police and understand that a number of measures are being implemented and a full response to the concerns you have raised is being provided.” Source location Response from College of Policing
Open published response
13 Jun 2024 Harry Roland Ian Vass · Prevention of Future Deaths report Avon
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Concerns raised 2
Lack of mental health nursing staff awareness that ABD is a medical emergency View source Failure to reliably identify acute behavioural disturbance in vulnerable patients View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Harry Roland Ian Vass · 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
Harry Roland Ian Vass attended Southmead Hospital on 26 December 2022 with agitation, paranoid thoughts and recent cocaine use, and was later admitted to the Mason Unit. He became unresponsive after vomiting, low oxygen saturations, a high temperature and discolouration of his extremities, and died after transfer back to the emergency department. Concerns included inadequate physical and non-contact observations, and a lack of awareness among mental health nursing staff that acute behavioural disturbance is a medical emergency.
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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 mental health nursing staff awareness that ABD is a medical emergency
Wider context from the report “• Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health.
• It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency .
• The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.”
” Source location Harry Roland Ian Vass · 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 reliably identify acute behavioural disturbance in vulnerable patients
Wider context from the report “• Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health.
• It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency.
• The decision as to whether a person has ABD is important , Dr Delaney said that” this group are vulnerable to cardiac arrest ”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters .”
” Source location Harry Roland Ian Vass · Prevention of Future Deaths report
Open source report
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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 ABD is neither a formal diagnosis nor explicitly embedded in nurses’ professional proficiencies.
Verbatim wording from the response “We agree with Mr Delaney’s statement. However, as stated above, ABD is neither a formal diagnosis nor explicitly embedded in nurses' proficiencies for professional practice.³ The only inferred related proficiency could be:” Source location Response from RCN
Open published response
12 Feb 2024 Mouayed Mamoun Bashir · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1
Failure of officers to speak up about ABD concerns View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Gwent Police
Review national training for all police officers on Acute Behavioural Disturbance.
View source
Gwent Police
Introduce and publish a new Acute Behavioural Disturbance learning package through the College Learn system for officers and relevant police staff.
View source
Gwent Police
Incorporate the Acute Behavioural Disturbance package into mandatory Public and Personal Safety Training and First Aid Training.
View source
Gwent Police
Provide bespoke standalone Acute Behavioural Disturbance training to frontline officers who recently completed mandatory safety and first aid training.
View source See 1 more action
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AI-generated summary
Mouayed Mamoun Bashir · 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
Mouayed Mamoun Bashir took an unknown quantity of cocaine and developed symptoms consistent with Acute Behavioural Disturbance (ABD). After police restraint and transfer to an ambulance, he suffered cardiac arrest and died despite CPR and attempts at hospital revival. The report raised concerns about insufficient knowledge of ABD and ambiguity about whether officers recognised or communicated their concerns about it.
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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 of officers to speak up about ABD concerns
Wider context from the report “At the inquest all the police officers who attended MB gave evidence and they all stated under oath that they did not consider that MB was suffering from ABD at the time. However, when completing the Use of Force forms afterwards, all bar one of the officers involved in restraint indicated that ABD had been an impact factor. There is an ambiguity which could not be properly explored at the inquest, largely due to the passage of time.
However, this suggests that officers may have thought about ABD but did not mention it to others , which would be contrary to the “Speak Up and Speak Out” principle .
This is a principle, the inquest heard, that is critical to ensuing that the voices of junior officers are heard in these difficult and potentially life-threatening situations .
” Source location Mouayed Mamoun Bashir · 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 Review national training for all police officers on Acute Behavioural Disturbance.
Verbatim wording from the response ““Confirmation as to whether the training on ABD has been reviewed and the principle of “Speak Up and Speak Out” enshrined therein, reflecting the acknowledged difficulties in identifying ABD even by experienced officers.”” Source location Response from Heddlu Gwent 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 and publish a new Acute Behavioural Disturbance learning package through the College Learn system for officers and relevant police staff.
Verbatim wording from the response “I confirm that the national training for all police officers on Acute Behavioural Disturbance (ABD) has been reviewed. The College of Policing has introduced a new learning package, specifically on ABD. The training package consists of an ABD PowerPoint which has been uploaded onto the “College Learn” system and made available to police officers and relevant police staff officers from 14 February 2024.” Source location Response from Heddlu Gwent Police
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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 Incorporate the Acute Behavioural Disturbance package into mandatory Public and Personal Safety Training and First Aid Training.
Verbatim wording from the response “I have attached the training package consisting of Power Point Presentation and accompanying Training Notes, which you will see is extensive. I confirm that training package this has been incorporated into the mandatory Public and Personal Safety Training programme and First Aid Training. This in effect means that from 14 February 2024 all officers and relevant police staff will have access to important updated training.” Source location Response from Heddlu Gwent 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 Provide bespoke standalone Acute Behavioural Disturbance training to frontline officers who recently completed mandatory safety and first aid training.
Verbatim wording from the response “In addition, as from 3 April 2024 onwards, in Gwent Police all frontline police officers who have only recently completed their mandatory Public and Personal Safety Training and First Aid Training will receive bespoke standalone specific ABD training using the College of Policing Power Point.” Source location Response from Heddlu Gwent Police
Open published response
25 Oct 2023 Carl FULLALOVE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1
Rigid ABD training focused on specific symptoms and failing to support recognition of other signs View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Carl FULLALOVE · 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
Carl Fullalove was arrested after being observed jumping on cars, behaving bizarrely and appearing to be under the influence of a substance. He was placed in prone restraint during a search in custody, became non-responsive and suffered cardiac arrest, and subsequently died in hospital. The principal concerns were that signs of acute behavioural disturbance or illness were not recognised, the risks of prone restraint and stimulant drugs were not sufficiently considered, and training did not adequately address calming intervention in an upright position.
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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 Rigid ABD training focused on specific symptoms and failing to support recognition of other signs
Wider context from the report “(2)A research paper before the inquest, namely ‘Consensus on Acute Behavioural Disturbance in the UK, September 2023 recommends that the focus remain on the triad of warning signs. ABD is clearly difficult to distinguish from drug intoxication by a non-medical practitioner. The rigidity of the training with focus on specific symptoms can cause police officers to miss other signs. The Superintendent, and head of ‘Protecting Vulnerable People’ for Cheshire accepted that with hindsight the use of prone restraint was inadvisable in this case.
” Source location Carl FULLALOVE · 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 Publish the revised First Aid Learning Programme outcome requiring officers to recognise signs and symptoms of acute behavioural disturbance.
Verbatim wording from the response “In 2020, the College of Policing commenced a national working group to update the First Aid Learning Programme (FALP). The review that took place considered recommendations made by Coroners and” 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 Develop and update Public and Personal Safety Training to cover ABD presentation and causes, de-escalation, restraint risks, medical assistance, monitoring, and scenario-based decision-making.
Verbatim wording from the response “The College of Policing have designed and developed a new Public and Personal Safety Training (PPST) package for all police officers with the emphasis on de-escalation. It is twelve hours, scenario-based method of delivering training and is focused on learning, decision making, understanding decisions and de-briefing decisions. Some forces have already implemented the new training package, and all forces are to go live with this training in April 2024. From the evaluation of the training pilot, early, statistically significant data shows a reduction in police use of force incidents. The updated training will include a recently updated training package for ABD.” Source location Response from College of Policing
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.