Recurring concern

Failure to individualise bail conditions for vulnerable defendants

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First reported 6 Aug 2015•Latest report 8 Jan 2025

Definition

What this concern includes

Includes only assertions that directly instantiate the manually reviewed condition ‘Failure to individualise bail conditions for vulnerable defendants’ and satisfy this evidence boundary: Two distinct reports directly support failure to assess individual risk and balance a vulnerable defendant's acute needs when setting bail conditions. Excludes the separate assertions about failing to impose conditional bail at all and failing to follow pre-charge bail procedures; those are different threshold and procedural-compliance controls.

Not included

  • Excludes generic criminal-investigation delays, prosecution decisions or detention decisions where individualised bail-condition assessment is not the unsafe condition.
  • Excludes failures to notify victims or other recipients about bail release after conditions have been appropriately set; those concern notification rather than individualisation of bail conditions.
  • Excludes misunderstandings of a particular residence condition where no broader failure to assess and tailor bail conditions to individual risk is identified.
  • Excludes generic mental-health, safeguarding or risk-assessment deficiencies not specifically connected to setting or reviewing bail conditions for vulnerable defendants.
  • Excludes manifestations outside the manually reviewed boundary: Two distinct reports directly support failure to assess individual risk and balance a vulnerable defendant's acute needs when setting bail conditions. Excludes the separate assertions about failing to impose conditional bail at all and failing to follow pre-charge bail procedures; those are different threshold and procedural-compliance controls.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2015–2025

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

College of Policing1
Devon & Cornwall Police1
Metropolitan Police Service1
Ministry of Justice1
National Police Chiefs’ Council1

Concerns and responses across reports

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

  1. Cumbria

    AI-generated summary

    Matthew Brierley · 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 Brierley died in the car park of Buttermere Court Hotel on 24 April 2024, after being arrested, bailed and placed under conditions that prevented him from living at home or having unsupervised contact with his children and stepdaughter. The inquest concluded that his death was suicide. Concerns included the potentially prolonged period before decisions were made about his devices and case, the use of standard bail conditions without an apparent specific risk assessment, and the lack of proactive follow-up support after his release on bail.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to undertake detailed individual risk assessment when applying bail conditions

    Wider context from the report

    “(2) I was told that when released on bail Matthew was informed that examination of devices and a decision in his case might take up to 18 months. Being suspended from work and unable to live at home removed normality and stability from Matthew and likely impaired his ability to cope with his situation. The length of time taken to reach a decision seems excessive, prolonging the time Matthew would be at risk. I was told devices can be "triaged" within a matter of days or more quickly, surely ceases such as this should be dealt with more expeditiously? It seems that "standard" bail conditions are applied but I am not aware of any suggestion of a specific risk to Matthew's stepdaughter, might a more detailed individual assessment of risk be helpful? I should record that Matthew's phone was examined after his death and that images found were not of a grade that would have led to a prosecution. ”

    Source location

    Matthew Brierley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Request qualitative information from relevant police forces and analyse returned data to identify post-release suicide-risk factors.

    Verbatim wording from the response

    “The next phase of the research discussed today, will be for each force from which one of those deaths occurred, to answer further qualitative questions to identify commonalities. At present, we do not ask the key questions that identify the impact upon somebody’s life, following their arrest. Questions proposed include subjects such as:”

    Source location

    Response from National Police Chief's Council
    Page 2 · response
    Published 13 January 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Share the prevention report and recommendations with UK custody leads to strengthen suicide-risk consideration in investigative strategies and digital-device triage.

    Verbatim wording from the response

    “I have shared a copy of this prevention of future deaths report with all custody leads within the UK, with a recommendation to ensure that the risk of suicide within cohorts such as Matthew’s, are included within the investigative strategies and particularly the triage of digital devices, and that risk assessments are tailored to the individual circumstances of the investigation.”

    Source location

    Response from National Police Chief's Council
    Page 3 · response
    Published 13 January 2025

    Open published response

    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

    Investigating officers must apply individual circumstances to risk assessments and supervisors must ratify disposal decisions.

    Verbatim wording from the response

    “Assessments of risk should always be individualised. Whilst there will be a question set used to conduct a pre-release risk assessment, the responses should be applied to the individual circumstances of the investigation, by the OIC and ratified by their supervisor when making a disposal decision. Bail conditions should only be applied where it is necessary and proportionate to do so. There is a”

    Source location

    Response from National Police Chief's Council
    Page 2 · response
    Published 13 January 2025

    Open published response

    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 Home Office has no authority to intervene in operational policing matters or comment on police officers’ operational decisions.

    Verbatim wording from the response

    “How the APP is followed is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 13 January 2025

    Open published response

    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 decisions about following custody guidance are the responsibility of individual police forces and their chief officers.

    Verbatim wording from the response

    “How the APP is followed is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 13 January 2025

    Open published response

    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

    Individual police forces and case decision-makers determine device examinations, investigation scope and bail conditions according to operational context.

    Verbatim wording from the response

    “As operationally independent organisations, each police force will have provisions for the forensic examination of mobile phones and other digital devices. The context of each investigation will also shape the extent of both lines of enquiry and the depth or otherwise, of those examination processes, which will invariably have an impact on the time taken to complete those examinations. Similarly, the context of each case and presentation of risks would also help inform decision makers. Given the case specifics here, I would expect that officers appropriately recognise their responsibilities to safeguard children under Working Together 2023 and the Children Act 1989 and that this had a strong bearing on the bail conditions imposed.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 13 January 2025

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Darrell Sharples · 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

    Darrell Sharples died on 21 July 2018, aged 49. The inquest recorded the medical cause of death as asphyxia due to hanging and concluded that he died by suicide. Concerns included whether information about vulnerable individuals from ViST forms could be appropriately shared with partner agencies, and whether custody staff should access relevant CJLDT assessments before imposing bail conditions and releasing vulnerable individuals.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to consider the ramifications of bail conditions for vulnerable individuals

    Wider context from the report

    “Custody Access to CJLDT Assessments and Consideration of Ramifications of Imposing Bail Conditions on Vulnerable Individuals. At his assessment by CJLDT in May 2018, it had been recognised that ████████ was a strong protective factor keeping Darrell from harming himself. After his release from custody in July 2018, a bail condition was (correctly) imposed that he was not to contact his wife. This had the unintended consequence of removing that strong protective factor. In the event those in custody had known of the assessment in the CJLDT records, that may have had an influence on assessing Darrell’s risk to himself at the point of release. It may have led to a request to an HCP or CPFT to re-assess Darrell’s risk to himself. It may be that the standard questions completed by custody sergeants could be amended to require an Officer to review or have reviewed any assessment in CJLDT prior to the imposition of a bail condition on a vulnerable individual and his release from custody. ”

    Source location

    Darrell Sharples · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure custody access to and review of CJLDT assessments before bail conditions and release of vulnerable individuals

    Wider context from the report

    “Custody Access to CJLDT Assessments and Consideration of Ramifications of Imposing Bail Conditions on Vulnerable Individuals. At his assessment by CJLDT in May 2018, it had been recognised that ████████ was a strong protective factor keeping Darrell from harming himself. After his release from custody in July 2018, a bail condition was (correctly) imposed that he was not to contact his wife. This had the unintended consequence of removing that strong protective factor. In the event those in custody had known of the assessment in the CJLDT records, that may have had an influence on assessing Darrell’s risk to himself at the point of release. It may have led to a request to an HCP or CPFT to re-assess Darrell’s risk to himself. It may be that the standard questions completed by custody sergeants could be amended to require an Officer to review or have reviewed any assessment in CJLDT prior to the imposition of a bail condition on a vulnerable individual and his release from custody. ”

    Source location

    Darrell Sharples · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner South London

    AI-generated summary

    Darren Brown · 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

    Darren Brown died by suicide on 3 March 2014 at Lambeth Hospital; the medical cause of death was asphyxia due to ligature compression of the neck. The report described mental health issues, limited social support, family bereavements and an imminent court appearance as contributory factors. A principal concern was whether restricting his contact with his mother and sister properly balanced the risks and needs of a highly vulnerable adult against the reasons for restricting family contact.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to balance vulnerable prospective defendants’ needs and risks when setting bail conditions or restricting support

    Wider context from the report

    “During the course of the inquest the evidence revealed that he was prevented from contacting his mother or sister and that they were not even aware of the circumstances nor consulted about this decision. The evidence suggested that both the deceased and his relatives regretted the complete cessation of communications. Mr Brown was an extremely vulnerable adult and professional evidence was heard about his high risk of suicide and his incapacity to make friends and how crucial his reliance was on his mother and sister. The prevention of any communication was a factor which led to his taking his life. Whilst the details of the offences being investigated were not disclosed to the jury, but were known to the coroner, it is clear that there may have been good reason to restrict contact between members of the family. However the matter of concern is whether in making that decision, proper consideration was given to balancing those needs or risks with the very acute needs of and risks to the deceased. It is of great public concern that the needs and risks of prospective defendants, who are (not infrequently) suffering from mental health problems and are vulnerable are taken into account in setting bail conditions or making restrictions on support to them. The inquest did not permit exploration of the possible charges or the decisions of the police, mindful of the proper scope of enquiry and the need to respect Convention rights about what may enter the public domain. ”

    Source location

    Darren Brown · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026