Concerns raised 1
Lack of mandatory or refresher police officer training in constant observations View source
This report raised 8 other concerns. 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. 1
South Yorkshire Police
Deliver scenario-based training on Acute Behavioural Disturbance, positional asphyxia, safer restraint and continuous observation of restrained subjects.
View source
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AI-generated summary
Matthew Terrill · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.
Read the report on judiciary.uk
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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 mandatory or refresher police officer training in constant observations
Wider context from the report “4. Lack of refresher or mandatory annual training for police officers in relation to constant observations.
I am told that there is no specific mandatory training for police officers on constant observations , but that trainee police officers are now given training on constant supervision as part of their introduction to the custody suite. I have been told that there is an optional CPD module available to officers on constant observation training. I am concerned that police officers are being regularly asked to perform constant observations on detainees of the highest risk levels without any mandatory training or refresher training on the subject . Whilst the Custody Sergeant is tasked with providing a briefing to officers who are tasked with constant observations, I am concerned that there is no evidence of consistency in this task being completed to an appropriate standard or at all. There is a risk that in a busy custody suite, this briefing will be overlooked or omitted (and in fact that was the evidence in this case). There is no evidence to reassure me that this was a one-off incident, rather the evidence before me suggested that it was not. This gives rise to a risk of future death for detained persons on level 4 constant observation.
” Source location Matthew Terrill · Prevention of Future Deaths report
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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 Deliver scenario-based training on Acute Behavioural Disturbance, positional asphyxia, safer restraint and continuous observation of restrained subjects.
Verbatim wording from the response “The PST delivery for this year commencing in April 2024 is all scenario-based delivery. There are six different scenarios mandated by the College of Policing. One scenario is based on ‘vulnerable person.’ The Trainers can introduce ABD by slightly adapting the vulnerable person scenario, to having the role player displaying some of the signs and symptoms of ABD, with the trainer also providing input to the role player to display varying signs and symptoms of ABD such as, the person is hot to touch, incredibly strong or sweating heavily etc. From this the student should realise that they are dealing with someone who is having an ABD episode and deal with them accordingly.” Source location Response from South Yorkshire Police and Humberside Police
Open published response
6 Feb 2024 Mark PRYOR · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1
Lack of sufficient training for health care professionals working in police custody suites View source
Linked responses
CRG Medical Services Faculty of Forensic & Legal Medicine of the Royal College of Physicians of London
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Faculty of Forensic & Legal Medicine of the Royal College of Physicians of London
Developed and published recommendations and guidance supporting education and supervised training in forensic medicine, including police custody healthcare.
View source
Faculty of Forensic & Legal Medicine of the Royal College of Physicians of London
Contacted members through a bulletin to highlight the report and reaffirm the importance of initial and continuing education and supervised training.
View source
CRG Medical Services
Review and develop the two-day foundation training materials into an interactive learning experience for newly recruited healthcare professionals.
View source
CRG Medical Services
Extend foundation training for newly recruited healthcare professionals from two days to five days.
View source
CRG Medical Services
Train Clinical Leads and senior healthcare professionals in presentation skills to improve consistency and quality during foundation training.
View source
CRG Medical Services
Require new recruits to complete foundation training and obtain Clinical Lead-approved certification before undertaking clinical shifts.
View source
CRG Medical Services
Provide five intensive-supervision shifts for new recruits, with role-specific expectations, senior HCP feedback and Clinical Lead sign-off before completing induction.
View source See 4 more actions
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AI-generated summary
Mark PRYOR · 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
Mark Pryor died at the emergency department of Royal Derby Hospital on 5 September 2020 after suffering an alcohol-withdrawal-related seizure and cardiorespiratory arrest while in police custody. The inquest jury found deficiencies in the health care professionals’ assessment and treatment of his alcohol withdrawal that probably made more than a minimal contribution to his death. The report raises concerns that health care professionals may not receive sufficient training to practise effectively and safely in police custody suites.
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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 sufficient training for health care professionals working in police custody suites
Wider context from the report “I am concerned that Health Care Professionals (HCPs) may not be receiving sufficient and adequate training to enable them to practice effectively or safely in police custody suites. This is based on the evidence and findings in Mr Pryor’s inquest and my understanding that the training provided by HCRG may be very similar to that given by other providers of HCP police custody services nationally.
Clinical assessment and treatment is provided to police custody detainees by HCPs with the support of an on-call doctor. Typically there will be one HCP per shift. Nationally, HCP services are provided by a number of independent providers under contract to individual police forces. Professionals eligible to be recruited as HCPs (as taken from HCRG personal specification) are registered nurses (general or mental health), or paramedics with a minimum of two years post-qualification with NMC or HCPC registration and ‘nursing experience in the following: A&E, ITU, EAU, SAU, Nurse Practitioner, Practice Nurse, EAU, SAU (other nursing backgrounds will be considered)'.
Current training provided to newly appointed HCPs (by HCRG) consists of shadowing shifts with an experienced HCP, potentially for up to six or eight shifts; a two-day induction course; a medication related course of less than a day which includes a pass or fail test. There is also formal supervision and a three-month probationary period.
The two-day induction course covers the following topics: -
Day 1
Overview of the role of HCPs in custody; Consent, confidentiality and ethics – covering topics including the relevant laws, regulations and regulatory issues, the importance and limitations of concept, assessing capacity, nature of the HCPs dual responsibility and how it affects disclosure of sensitive information. and importance of record keeping; Fitness to detain – covering topics including the need to assess detainees for injuries, illness, and drug and alcohol problems, formulating a care plan in custody to manage risk and identifying those who are not fit to detain who may need alternative support; Fitness to interview / charge/ transfer / release – covering topics including a recap on assessing capacity and assessing, safeguards to prevent the risk of involuntary/false confessions, overview of illnesses that might be worsened by interview and facts to consider when assessing detainees’ fitness to release; Drugs and alcohol is police custody – covering topics including examination features of alcohol and/ or opiate intoxication, examination features of alcohol or opiate withdrawal, key assessment details in the detainee with alcohol dependence, treatment of alcohol / opiate withdrawal in police custody; Mental health in custody - covering topics including the relevant sections of the Mental Health Act, the overlap of learning difficulties with mental health in police custody, the role of liaison and diversion (L&D) teams and the approved mental health professional (AMHP) and when to refer to specialist services; Mental state examination (MSE) – covering topics including purpose of MSE, format of MSE, communicating MSE findings and risk assessments.
Day 2
Forensic science and samples – covering topics including understanding Locard’s Principle, which offences may trigger sample requests, taking non intimate and intimate samples and relevant procedural steps; Traffic Medicine – covering relevant procedures under the Road Traffic Act; Restraint, TASER and irritant sprays – covering an overview of different types of restraint and when a detainee may need hospital following restraint; Documentation of injury – covering how to take history for injuries, how to describe, document and classify injuries; Statement writing – covering topics including overview on preparing a witness statement, format of a witness statement and information required to complete a statement and importance of good clinical notation on the assessment forms provided in custody.
I have reproduced the summary of training, which was given in evidence at the inquest, to illustrate that there are obviously a very extensive number of topics which are listed to be covered.
I find it difficult to see that necessary training can be given within the specified time to equip a paramedic or nurse who is fresh to the custody setting to practice effectively and safely. The inquest heard evidence from the more experienced HCP that when she started, with a different provider some eight years prior, she had six weeks classroom-based training before she commenced full duties as an HCP. The injunction also heard that The Faculty of Forensic & Legal Medicine recommends a five-day induction course for HCPs.
” Source location Mark PRYOR · 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 Developed and published recommendations and guidance supporting education and supervised training in forensic medicine, including police custody healthcare.
Verbatim wording from the response “As a result, we have developed and published recommendations and guidance to support education and supervised training in Forensic Medicine, including for the police custodial setting, which can be found on our website, and I highlight, below:” Source location Response from The Faculty of Forensic & Legal Medicine
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 Contacted members through a bulletin to highlight the report and reaffirm the importance of initial and continuing education and supervised training.
Verbatim wording from the response “We have contacted our membership via the bulletin, highlighting your report, which is now available on the Chief Coroner’s website. We have re-confirmed the importance of initial and continuing education and supervised training and all forensic clinicians have access to senior advice, at all times; this is a responsibility of the clinician and the employer. In addition, we are looking at offering additional training, particularly, in the management and care of detainees who are dependent on drugs or alcohol, or both.” Source location Response from The Faculty of Forensic & Legal Medicine
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 Review and develop the two-day foundation training materials into an interactive learning experience for newly recruited healthcare professionals.
Verbatim wording from the response “CRG Medical Services has been in the process of reviewing the training material for the two-day induction course, known as foundation training, to ensure it is an interactive learning experience for newly recruited HCPs. As part of this process and further to the Coroner’s concerns, as of this financial year 2024/25 the foundation training course will be provided over five days.” Source location Response from CRG Medical Services
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 Extend foundation training for newly recruited healthcare professionals from two days to five days.
Verbatim wording from the response “CRG Medical Services has been in the process of reviewing the training material for the two-day induction course, known as foundation training, to ensure it is an interactive learning experience for newly recruited HCPs. As part of this process and further to the Coroner’s concerns, as of this financial year 2024/25 the foundation training course will be provided over five days.” Source location Response from CRG Medical Services
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 Train Clinical Leads and senior healthcare professionals in presentation skills to improve consistency and quality during foundation training.
Verbatim wording from the response “The Clinical Leads and senior HCP’s will be attending a training course on presentation skills in May 2024, to ensure that a uniformly high-quality level of training will be provided to all new recruits during the foundation training and intensive supervision shifts from June 2024.” Source location Response from CRG Medical Services
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 Require new recruits to complete foundation training and obtain Clinical Lead-approved certification before undertaking clinical shifts.
Verbatim wording from the response “The foundation training course will be scheduled to take place during the first week of each month and new recruits will not be able to work clinical shifts until they have received a certificate to show they have completed the foundation training. Certificates will be signed off by the Clinical Lead of the contract once feedback has been received from course presenters in respect of each HCP.” Source location Response from CRG Medical Services
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 five intensive-supervision shifts for new recruits, with role-specific expectations, senior HCP feedback and Clinical Lead sign-off before completing induction.
Verbatim wording from the response “The Clinical Leads and senior HCP’s will be attending a training course on presentation skills in May 2024, to ensure that a uniformly high-quality level of training will be provided to all new recruits during the foundation training and intensive supervision shifts from June 2024.” Source location Response from CRG Medical Services
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 Responsibility for ensuring forensic clinicians receive senior advice rests with the clinician and employer.
Verbatim wording from the response “We have contacted our membership via the bulletin, highlighting your report, which is now available on the Chief Coroner’s website. We have re-confirmed the importance of initial and continuing education and supervised training and all forensic clinicians have access to senior advice, at all times; this is a responsibility of the clinician and the employer. In addition, we are looking at offering additional training, particularly, in the management and care of detainees who are dependent on drugs or alcohol, or both.” Source location Response from The Faculty of Forensic & Legal Medicine
Open published response
2 Oct 2023 Jack Peter Zarrop · Prevention of Future Deaths report West London
View report summary
Concerns raised 1
Lack of adequate mental health training for Custodial Nurse Practitioners seeing high-risk and complex patients in police custody View source
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
Jack Peter Zarrop · 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
Jack Peter Zarrop, who had a history of mental-health difficulties, alcohol abuse and previous suicide attempts, died by suicide while in custody. The jury identified failures relating to referral to Liaison and Diversion services, opening an ACCT, access to relevant history, and removal of a bedsheet and closure of a hatch as main contributing factors. The report raised concerns about the use and training of Custodial Nurse Practitioners in police custody and the training of agency prison healthcare staff in the ACCT process.
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 adequate mental health training for Custodial Nurse Practitioners seeing high-risk and complex patients in police custody
Wider context from the report “1. The use of Custodial Nurse Practitioners (CNPs) in Police custody instead of doctors. The 2003 Home Office circular appeared to envisage nurses working alongside doctors, when this is not how they are deployed. CNPs are also seeing high risk and complex patients without adequate training in mental health . The deployment in Police custody of CNPs places detained persons at risk of death in the future . The 2003 Home Office circular also does not recognise the risk of suicide and self-harm as being a core competency.
” Source location Jack Peter Zarrop · 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 NHS England and other stakeholders to deliver a fit-for-purpose police custody healthcare service specification.
Verbatim wording from the response “I have reviewed the 2003 circular and would like to highlight that custodial healthcare has changed considerably since that point. The 2003 circular refers to the practice of using Police Surgeons in custody, this role is no longer in existence. Police Custody is a very regulated and scrutinised area of policing, it plays a pivotal role in the criminal justice process and cares for some of the most challenging and vulnerable people in society at what is often a very testing time. Our aim is to be effective, safe and to ensure that people are treated fairly, with as much dignity as possible. Having professional officers and staff who are well trained is essential. The NPCC Custody Portfolio works closely with NHS England, partners, and other stakeholders to deliver a service specification that is fit for purpose.” Source location Response from National Police Chief's Council
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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 the latest draft National Healthcare Specification, including requirements for governance, qualifications, competency assessment and clinical supervision.
Verbatim wording from the response “Chief Officers are able to use the National Healthcare Specification to determine the type of medical care they require. The Specification can be tailored by forces should they not require all elements, and they can tender for the services they need; but the document is clear with regard training and qualifications. I attach the latest version of the service specification (draft until ratified by NHSE Clinical Reference Group – Nov 2023), which may be useful, and would like to highlight the following sections which I hope will provide you with reassurance:” Source location Response from National Police Chief's Council
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 Responsibility for custodial nurse practitioners in police custody settings lies with the Police Chiefs’ Council, not NHS England.
Verbatim wording from the response “Regarding the matter of concern around the use of Custodial Nurse Practitioners, this is for the Police Chief Council to respond to. NHS England does not hold responsibility for commissioning healthcare in police custody settings, therefore cannot comment.” Source location Response from NHSE
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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 The NPCC response addresses the remaining content of the first matter of concern.
Verbatim wording from the response “However, this in no way represents a lack of interest in the issues which you have identified. As the response to your report from the Chair of the NPCC sets out, the 2003 Circular has effectively been superseded by the publication of the National Healthcare Specification for police custody, which is written by NHS England on behalf of the NPCC, College of Policing and Home Office, and which Chief Constables may use when tendering for healthcare provision. That document is far more comprehensive than the 2003 Circular. The Home Office has a close interest in the content of the Specification, and in ensuring that highly qualified and capable medical personnel work in police custody. I understand that the NPCC response also represents the response to the remaining content of your first matter of concern.” Source location Response from the Home Office
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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 The national healthcare specification adequately addresses custody healthcare qualifications, competency, supervision and training for doctors, nurses and paramedics.
Verbatim wording from the response “Chief Officers are able to use the National Healthcare Specification to determine the type of medical care they require. The Specification can be tailored by forces should they not require all elements, and they can tender for the services they need; but the document is clear with regard training and qualifications. I attach the latest version of the service specification (draft until ratified by NHSE Clinical Reference Group – Nov 2023), which may be useful, and would like to highlight the following sections which I hope will provide you with reassurance:” Source location Response from National Police Chief's Council
Open published response
23 Jun 2022 Khalid Seneen Yousef · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Insufficient understanding of the L&D police custody suite model’s role and limitations View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham and Solihull Mental Health NHS Foundation Trust NHS England West Midlands Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Birmingham and Solihull Mental Health NHS Foundation Trust
Discuss interagency responsibility and information-sharing for mentally unwell people in custody at the next JSOG meeting.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Develop and publish a weekly bulletin explaining the Liaison and Diversion Service’s role and limitations.
View source
NHS England
Present the respective PCHS and L&D responsibilities for mental health crises at the NPCC Custody Forum Conference.
View source
NHS England
Commission and publish a career and competency framework defining L&D roles and required competencies.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Discuss cross-agency information sharing and clarify Liaison and Diversion Service responsibilities at the Joint Strategic Operational Group meeting.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Publish a weekly bulletin explaining the Liaison and Diversion Service’s role and limitations to improve internal understanding.
View source
West Midlands Police
Provide frontline staff with clear advice on the nature, scope and limitations of the current Liaison and Diversion function.
View source
NHS England
Present the respective PCHS and L&D responsibilities for mental health crises at the NPCC Custody Forum Conference.
View source
NHS England
Continue collaborative work with Police and Crime Commissioner counterparts to align PCHS, Liaison and Diversion specifications, responsibilities and locally commissioned services.
View source
West Midlands Police
Provide all frontline staff with clear advice about the nature, scope and limitations of the current Liaison and Diversion function.
View source See 7 more actions
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AI-generated summary
Khalid Seneen Yousef · 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
Khalid Seneen Yousef was decapitated during a sustained knife assault at a premises in Birmingham on 4 January 2018. The report identifies concerns that a Liaison and Diversion clinician failed to recognise the perpetrator’s psychosis and refer him for mental health assessment, and that the custody-suite model lacked commissioned psychiatrists, with wider concerns about responsibility, training and supervision.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient understanding of the L&D police custody suite model’s role and limitations
Wider context from the report “3. West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model .
” Source location Khalid Seneen Yousef · 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 Discuss interagency responsibility and information-sharing for mentally unwell people in custody at the next JSOG meeting.
Verbatim wording from the response “The Trust has placed the matter onto the agenda at the next JSOG (Joint Strategic Operational Group), where the Trust meet with the Police and other stakeholders on a regular basis. The next meeting is due to take place on 18th August 2022. The meeting will discuss how to share this information between agencies to ensure that the message is shared clearly and clarity is gained around what the Liaison and Diversion Service are responsible for.” Source location Response form Birmingham and Solihul Mental Health 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 Develop and publish a weekly bulletin explaining the Liaison and Diversion Service’s role and limitations.
Verbatim wording from the response “As stated in point 2 above the Trust intends to discuss this in more detail at the JSOG meeting in August. This meeting will address your concerns around cross-agency information. However, in order to address the internal issue around understanding the role of the Liaison and Diversion Service, the Manager of the team will be carrying out internal work with the Trust Communications Team to put a piece together as part of the weekly bulletin outlining what the team do. This will be completed in line with the outcome of the current tender for the new integrated offender health service, which will incorporate liaison and diversion in custody. This will ensure the greatest visibility, clarity and impact with the communication. We expect to be in a position to complete this in September 2022.” Source location Response form Birmingham and Solihul Mental Health 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 Present the respective PCHS and L&D responsibilities for mental health crises at the NPCC Custody Forum Conference.
Verbatim wording from the response “NHS England works collaboratively with all agencies and stakeholders to ensure a clear understanding of responsibilities for mentally unwell persons in custody. Recently, NHS England presented at the NPCC Custody Forum Conference (September 2022) and took the opportunity to emphasise the respective roles and reinforce the responsibilities of the PCHS and L&D service when responding to those in mental health crisis.” 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 Commission and publish a career and competency framework defining L&D roles and required competencies.
Verbatim wording from the response “NHS England commissioned Health Education England (HEE) and Skills for Health (SfH) to produce a career and competency framework for L&D services Career and Competence Framework | Info Hub | Skills for Health. This framework was published on 31 May 2018 and clearly sets out the respective job roles required within a multi-disciplinary L&D team, and the competencies required to discharge those roles. HEE and SfH are currently reviewing the content, as part of a wider piece of work to develop a career and competency framework across all of our Health & Justice non-custodial programmes of work.” 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 Discuss cross-agency information sharing and clarify Liaison and Diversion Service responsibilities at the Joint Strategic Operational Group meeting.
Verbatim wording from the response “The Trust has placed the matter onto the agenda at the next JSOG (Joint Strategic Operational Group), where the Trust meet with the Police and other stakeholders on a regular basis. The next meeting is due to take place on 18th August 2022. The meeting will discuss how to share this information between agencies to ensure that the message is shared clearly and clarity is gained around what the Liaison and Diversion Service are responsible for.” Source location Response from Birmingham and Solihull Mental Health
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 Publish a weekly bulletin explaining the Liaison and Diversion Service’s role and limitations to improve internal understanding.
Verbatim wording from the response “As stated in point 2 above the Trust intends to discuss this in more detail at the JSOG meeting in August. This meeting will address your concerns around cross-agency information. However, in order to address the internal issue around understanding the role of the Liaison and Diversion Service, the Manager of the team will be carrying out internal work with the Trust Communications Team to put a piece together as part of the weekly bulletin outlining what the team do. This will be completed in line with the outcome of the current tender for the new integrated offender health service, which will incorporate liaison and diversion in custody. This will ensure the greatest visibility, clarity and impact with the communication. We expect to be in a position to complete this in September 2022.” Source location Response from Birmingham and Solihull Mental Health
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 frontline staff with clear advice on the nature, scope and limitations of the current Liaison and Diversion function.
Verbatim wording from the response “For these reasons, in response to the second and third concerns identified by HM Area Coroner for Birmingham and Solihull, I have instructed that the following steps take place within six months of the date of this response:” Source location Response from West Midlands 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 Present the respective PCHS and L&D responsibilities for mental health crises at the NPCC Custody Forum Conference.
Verbatim wording from the response “NHS England works collaboratively with all agencies and stakeholders to ensure a clear understanding of responsibilities for mentally unwell persons in custody. Recently, NHS England presented at the NPCC Custody Forum Conference (September 2022) and took the opportunity to emphasise the respective roles and reinforce the responsibilities of the PCHS and L&D service when responding to those in mental health crisis.” 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 Continue collaborative work with Police and Crime Commissioner counterparts to align PCHS, Liaison and Diversion specifications, responsibilities and locally commissioned services.
Verbatim wording from the response “The Home Office’s position usually indicates that it is for each PCC to determine the level of healthcare provision required for their area, however, NHS England acknowledges that unless each PCHS is designed to fit with the L&D service specification and other locally commissioned services, then the potential for gaps in service provision will remain. It would not be practicable for NHS England to commission a service to take on the role of the PCHS, and instead the PCHS and L&D service should continue to work closely, ensuring that the service specifications and responsibilities are clear, aligned and understood. NHS England’s national Health & Justice team officials will continue to work collaboratively with their counterparts at the PCC in this regard.” 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 Provide all frontline staff with clear advice about the nature, scope and limitations of the current Liaison and Diversion function.
Verbatim wording from the response “For these reasons, in response to the second and third concerns identified by HM Area Coroner for Birmingham and Solihull, I have instructed that the following steps take place within six months of the date of this response:” Source location Response from West Midlands 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 Custody staff may rely on and defer to qualified healthcare practitioners for mental and physical health assessments.
Verbatim wording from the response “Turning to the third concern, following the evidence adduced at the inquest, it is acknowledged that the understanding of some WMP custody officers/staff in relation to the role and limitation of L&D requires improvement. Given that custody officers/staff are not medically trained, it is reasonable for them to be able to rely on, and defer to, the professional opinion of healthcare practitioners in relation to matters of mental and physical health. At the same time, it is accepted that custody officers/staff need to understand the differing levels of expertise of various clinicians and healthcare practitioners.” Source location Response from West Midlands 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 It would not be practicable for NHS England to commission a service to take on the Police Custody Healthcare Service role.
Verbatim wording from the response “The Home Office’s position usually indicates that it is for each PCC to determine the level of healthcare provision required for their area, however, NHS England acknowledges that unless each PCHS is designed to fit with the L&D service specification and other locally commissioned services, then the potential for gaps in service provision will remain. It would not be practicable for NHS England to commission a service to take on the role of the PCHS, and instead the PCHS and L&D service should continue to work closely, ensuring that the service specifications and responsibilities are clear, aligned and understood. NHS England’s national Health & Justice team officials will continue to work collaboratively with their counterparts at the PCC in this regard.” Source location Response from NHS England
Open published response
Concerns raised 1
Insufficient targeted training on drug and alcohol-related risks in custody View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Name not published · 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
The deceased was arrested on 2 October 2011 and held in custody, where he received prescribed methadone and medication for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on 3 October 2011; the recorded medical cause of death was methadone intoxication, with alcohol withdrawal in a chronic alcoholic also identified. Concerns included communication between medical practitioners and custody staff, inconsistent observation levels, joint training, and training on drug and alcohol-related risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient targeted training on drug and alcohol-related risks in custody
Wider context from the report “5. That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal , particularly if the detainee is likely to be in custody for upwards of 24 hours.
” Source location Name not published · 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 Secure force training on drug and alcohol risks, including methadone intoxication and alcohol withdrawal.
Verbatim wording from the response “5. Training will be secured by the Force regarding the risks and dangers of drug and alcohol abuse, including Methadone intoxication and alcohol withdrawal. This will be built into the aforementioned training programme.” Source location 2015-0138-Response-by-Staffordshire-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 mandatory first-aid induction training, including defibrillator, advanced airway, drug and alcohol risk training, with annual refresher training for detention officers.
Verbatim wording from the response “5. As per response three above, G4S have and continue to provide mandatory first aid training to each of its custody officers as part of an initial induction training programme. The first aid training is taught over three days and includes (but is not limited to); Defibrillator and Advanced Airway training; training on Alcohol and Drugs (including associated risks). In addition, each of the custody detention officers is required to undertake a refresher first aid training course annually. Again training on the risks and dangers of drug and alcohol abuse will be taught during that refresher course. G4S will also examine opportunities to provide additional guidance via an ‘on line’ Learning Management System.” Source location 2015-0138-Response-by-G4S1
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 Examine opportunities to provide additional drug and alcohol risk guidance through an online learning management system.
Verbatim wording from the response “5. As per response three above, G4S have and continue to provide mandatory first aid training to each of its custody officers as part of an initial induction training programme. The first aid training is taught over three days and includes (but is not limited to); Defibrillator and Advanced Airway training; training on Alcohol and Drugs (including associated risks). In addition, each of the custody detention officers is required to undertake a refresher first aid training course annually. Again training on the risks and dangers of drug and alcohol abuse will be taught during that refresher course. G4S will also examine opportunities to provide additional guidance via an ‘on line’ Learning Management System.” Source location 2015-0138-Response-by-G4S1
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 Existing guidance and training already address drug and alcohol risks, withdrawal, and referral for medical assessment where concerns arise.
Verbatim wording from the response “5. That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal, particularly if the detainee is likely to be in custody for upwards of 24 hours.” Source location 2015-0138-Response-by-College-of-Policing
Open published response
Concerns raised 2
Custody-suite training failing to provide adequate preparation View source Lack of training for custody-record reviewing inspectors View source
This report raised 27 other concerns. 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. 1
South Yorkshire Police
Review Acting Inspector custody-review training and develop a protocol, guidance pack and associated electronic review materials.
View source
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AI-generated summary
Neil Budziszewski · 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
Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.
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 Custody-suite training failing to provide adequate preparation
Wider context from the report “(15) The afternoon custody sergeant told the IPCC investigators that he did not think his custody suite training was fit for purpose . He claimed that this had already been raised by another custody sergeant but was not aware of anything happening about it .
” Source location Neil Budziszewski · 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 training for custody-record reviewing inspectors
Wider context from the report “(12) The reviewing inspector had no training in his task , he was simply given the job because he was an available shift inspector at the police station.
” Source location Neil Budziszewski · 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 Acting Inspector custody-review training and develop a protocol, guidance pack and associated electronic review materials.
Verbatim wording from the response “Following this error a review is being undertaken to review the training provided to Acting Inspectors required to carry out custody reviews. This will include a new protocol whereby the custody sergeant will be expected to confirm the Inspector’s familiarity with the process. The new custody digital log contains the legal requirements of the review with drop down menus and guidance. There is also a piece of work ongoing to collate a pack to be provided to Acting and Temporary Inspectors which will contain information and guidance on completing a custody review. It is hoped that the review and the pack will be completed by 31st May 2015, Appendix B shows a copy of the electronic form the Inspector will need to complete.” Source location 2015-0109-Response-by-South-Yorkshire-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 Existing custody training and practices comply with Home Office standards; the identified failures were attributed to individual officer error rather than deficient arrangements.
Verbatim wording from the response “Whilst Mr Budziszewski was at Bridge Street custody he was not cooperative with the risk assessment process. In any event this should have been reviewed upon his return to Ecclesfield. Custody staff are aware of the importance of the risk assessment and the requirement to regularly review where information is missing and therefore this failure on this occasion is down to officer error and not due to an issue with the training and practices. Appendix A refers to the new risk assessment which has been in force since October 2014.” Source location 2015-0109-Response-by-South-Yorkshire-Police
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.