Recurring concern

Inadequate pre-release risk assessment for people leaving custody

First to latest report 3 Mar 2016 — 12 Aug 2024

Reports that mention this concern
7
Times this concern has been raised
9
Stated actions linked to this concern
8

What this concern includes

Includes failures in pre-release risk assessments for people leaving custody, including missing or incomplete assessment, failure to ask or meaningfully consider wellbeing and suicide or self-harm risks, and failure to use relevant answers or information to inform release safeguards.

What is not included
  • Excludes general custody risk assessments or ongoing in-custody assessments where the release decision or pre-release period is not materially involved.
  • Excludes generic staff training, communication or documentation deficiencies unless they directly impair the pre-release risk-assessment process.
  • Excludes post-release supervision, accommodation or healthcare failures where the pre-release risk assessment was not itself deficient.
  • Excludes general release-planning or high-risk-offender management failures that do not concern assessment of the person's immediate wellbeing and safety risks before release.

Reports and published responses 7 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Black Country

    AI-generated summary

    Mr Parminder Singh Sanghera · 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

    Mr Parminder Singh Sanghera was arrested after displaying erratic behaviour, including running naked, and was taken to hospital before being held in police custody. He was released without charge on 13 February 2023 and was later found deceased in a canal near the custody suite. The principal concern was that, despite his behaviour and vulnerability, no full mental health assessment was undertaken before his release and risk assessments did not identify a risk of suicide or self-harm.

    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 of hospital and police custody risk assessments to identify suicide or self-harm risk before release

    Wider context from the report

    “1. During the course of the inquest, I heard evidence Mr Sanghera was deemed to be suffering from behavioural issues rather than a mental health crisis and no full Mental Health Act assessment took place either at New Cross Hospital or whilst in custody at Oldbury Police station. 2. The risk assessments performed in hospital and police custody identified no concerns of risk of suicide or self-harm from release. However, evidence at the inquest showed that he was suffering from a mental health crisis at the time. 3. My concern is that given the erratic behaviour he was displaying and his vulnerability, further consideration should have been given for a full mental health act assessment to take place before release. Therefore, you may wish to consider reviewing the arrangements and assessments required before discharge from hospital or being released from custody. ”

    Source location

    Mr Parminder Singh Sanghera · 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

    Audit pre-release risk assessments monthly to monitor and improve their quality.

    Verbatim wording from the response

    “(i) Over 90% of custody staff have completed the College of Policing vulnerability in custody training; (ii) Pre-release risk assessments are now subject to monthly audits to ensure quality; (iii) Detained persons now receive a leaflet signposting to support service pathways, a copy of which is enclosed with this response; (iv) The Health Care Provider specification now includes a requirement for their staff to have access to Summary Care Records (Mitie became the service provider on 1 September 2024 and have access to these records, whereas the previous provider did not). When the name, date of birth and address of the detained person is entered the Summary Care Records entry would provide an NHS number, GP details and potentially a pharmacy number.”

    Source location

    Response from West Midlands Police
    Page 3 · response
    Published 30 September 2024

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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

    Mental-health input for people in police custody is provided through the locally organised Liaison and Diversion Service between police and mental-health services.

    Verbatim wording from the response

    “Further, on the latter attendance the 12th February, the Trust does not provide any mental health “input” in relation to those in police custody. It is understood that this would be provided by the Liaison and Diversion Service – which will be organised at a local level between the police and mental health services and is subject to a Memorandum of Understanding between services. Again, this is not something that the Trust would have any involvement in.”

    Source location

    Response from Wolverhampton NHS Trust
    Page 2 · response
    Published 30 September 2024

    Open published response

  2. South Yorkshire (Eastern)

    AI-generated summary

    Peter Alfred Kelly · Prevention of Future Deaths report

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

    Report summary

    Peter Alfred Kelly was released from police custody on the morning of 26 April 2023 and was found hanged at 07:45 the following day, believed to have been dead for some time. The concerns included failures to complete the pre-release risk assessment properly, understand processes for involving the Liaison and Diversion team, and recognise potential mental health vulnerabilities at release.

    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 properly complete the pre-release risk assessment

    Wider context from the report

    “3. Failure to properly complete the Pre Release risk assessment and failure to understand the importance of the question asking an individual how they are feeling at the point of release. ”

    Source location

    Peter Alfred Kelly · Prevention of Future Deaths report
    Page 2 · concerns

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    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 understand the importance of the release wellbeing question in the pre-release risk assessment

    Wider context from the report

    “3. Failure to properly complete the Pre Release risk assessment and failure to understand the importance of the question asking an individual how they are feeling at the point of release. ”

    Source location

    Peter Alfred Kelly · 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

    Review the wording of Pre-Release Risk Assessment questions, including whether terms such as “appear” appropriately identify non-visible mental health issues.

    Verbatim wording from the response

    “Action:”

    Source location

    Response from South Yorkshire Police
    Page 6 · response
    Published 13 August 2025

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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

    Use the contrasting risk assessments and investigation lessons learned in continuing Custody Sergeant training and CPD on Pre-Release Risk Assessments.

    Verbatim wording from the response

    “Action:”

    Source location

    Response from South Yorkshire Police
    Page 6 · response
    Published 13 August 2025

    Open published response

  3. Manchester North

    AI-generated summary

    Vaughan Lee WHALLEY · 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

    Vaughan Lee WHALLEY was found unresponsive after being released on bail from police custody and died in hospital on 21 February 2023 despite surgery and supportive care. The principal concerns were that no assessment of his risk of suicide or self-harm on release took place, communication to police about any assessment was unclear, and the practitioner’s contact and subsequent review did not meet best practice or identify learning adequately.

    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 assess the risk of suicide or self-harm upon release

    Wider context from the report

    “(1) No assessment of the risk of suicide or self-harm upon release took place during the Deceased’s time in detention ”

    Source location

    Vaughan Lee WHALLEY · 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

    Implement a Health and Justice risk-assessment procedure covering suicide and self-harm assessment, information sharing, Police IT recording, verbal-feedback documentation, and recording declined assessments.

    Verbatim wording from the response

    “As a result of the concerns raised we have undertaken a review of the risk assessment processes across our Health and Justice Services. Some inconsistencies in the standards were identified which we have addressed by the development of a Standard Operating Procedure for risk assessment to be applied across Health and Justice Services. The SOP incorporates standards for conducting and sharing risk assessments for people in Police custody. Included in the SOP is a requirement for risk related information to be recorded in the appropriate place in Police IT systems.”

    Source location

    Response from Midlands Partnership University NHS Foundation Trust
    Page 2 · response
    Published 18 October 2023

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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

    Deliver mandatory three-level suicide-mitigation training to Health and Justice clinical staff through e-learning and taught sessions.

    Verbatim wording from the response

    “The revised standards will be supported and embedded by delivery of Suicide Mitigation Training to all clinical staff working in Health and Justice Services.”

    Source location

    Response from Midlands Partnership University NHS Foundation Trust
    Page 2 · response
    Published 18 October 2023

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Terance Alfred RADFORD · 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

    Terance Alfred Radford, aged 87, died at the scene on 19 April 2019 after being struck by a car driven at speed by a male driver. The report identified concerns about the Home Detention Curfew Policy, including the release of prisoners directly from segregation, insufficient assessment of risk to others, and a lack of multi-agency information sharing.

    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 of the Home Detention Curfew Policy to require assessment of prisoners’ risk of harm to others

    Wider context from the report

    “2. The national Home Detention Curfew Policy does not expressly require consideration or assessment of the prisoner’s risk of harm to others, beyond the suitability of the proposed release address. If a broader assessment of risk of harm to others is anticipated by the Policy, there is no guidance on who should complete the assessment (singular or multi-agency input), when it should be completed, and what factors ought to be considered as part of that assessment. ”

    Source location

    Terance Alfred RADFORD · 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

    Amend the HDC Policy Framework to require assessment of overall risks and confirmation that an adequate release risk-management plan is in place before HDC release.

    Verbatim wording from the response

    “address. If a broader assessment of risk of harm to others is anticipated by the Policy, there is no guidance on who should complete the assessment (singular or multi-agency input), when it should be completed, and what factors ought to be considered as part of that assessment. Response: The HDC Policy Framework will be amended to ensure that consideration for HDC takes into account the risks presented overall, and not just to those at the address.”

    Source location

    2022-0014-Response-from-Ministry-of-Justice_Published
    Page 2 · response
    Published 20 January 2022

    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

    Provide communications and training to embed the revised HDC risk-assessment and release-planning requirements.

    Verbatim wording from the response

    “What this means for HDC is that Offender Managers must assess, when completing the Address Checks form, whether there is already in place an adequate plan to manage the offender safely on release. If not, they must identify what steps are needed to put such a plan in place. No release should occur until the plan is in place. In some cases, the plan will exclude the proposed address as the offender cannot be managed safely there, and HDC will be refused. Changes to the HDC Policy Framework will make clear that this approach is required in every case and will be accompanied by communications and training to embed the message going forwards.”

    Source location

    2022-0014-Response-from-Ministry-of-Justice_Published
    Page 2 · response
    Published 20 January 2022

    Open published response

  5. 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

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    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

  6. Bedfordshire and Luton

    AI-generated summary

    David Bird · 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

    David Bird was arrested and held in police custody after concerns that he might take his own life, but was released without the medical assessment requested by police. He was found hanging in his bedroom on 21 August 2018. The principal concerns were the adequacy of custody officers’ training in interpreting detainee behaviour and in identifying when a detainee should see a healthcare practitioner before release.

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    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 formulate care plans that identify the need for pre-release health care assessment

    Wider context from the report

    “(2) Adequacy of Training of Custody Officers in formulating a suitable care-plan for a detainee; in particular, identifying the need in the Pre-Release Risk Assessment (PRRA) for Mr Bird to see a Health Care Practitioner (HCP) before release: Although both Custody Sergeants had received in their training (as evidenced by the Power-Point presentation exhibited as “EM02”) guidance on formulating a Care-Plan and page 28 of that presentation gave the following example: “DP has been returned from interview from OIC, became tearful during interview and made comments that indicated possible self-harm risk on release. Obs level changed to L/30mins obs. PRRA considerations – DP to see HCP before release, DP has been told to see his GP about how he feels, he lives with his partner so there is someone at home to give support”, Mr Bird was released without a being seen by the HCP even though: i. David had already been identified as a Vulnerable Adult (in term of a possible suicide risk) by Bedford Police on 18 August 2018 and a further concern for welfare had been raised in respect of him by Northamptonshire Police on 19 August 2018; ii. He had been very tearful and distressed during his interview describing himself as ‘one with no home, no life, no job’. iii. The IO and his colleague had requested a medical assessment for him prior to release 3 times ”

    Source location

    David Bird · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Worcestershire

    AI-generated summary

    STEWART AKINS · 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

    On 25 May 2015, Stewart Akins took his own life by placing himself in the path of a train after being released on conditional bail following his arrest. The report raised concerns that his repeated statements indicating a high risk of suicide or self-harm were not communicated to the prosecution or Magistrates’ Court, resulting in the risk being significantly downplayed and no objection to bail being made.

    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 raise suicide and self-harm risks with the prosecutor before bail decisions

    Wider context from the report

    “(1) Throughout Mr. Akins' time in custody, entries were made on the custody record which recorded his repeatedly stated intention to end his own life. Statements to that effect were recorded as having been made, inter alia, to the Custody Sergeant, ████████ to a nurse, to a Forensic Medical Examiner ████████ and to the officer in charge of the investigation ████████ at the end of his police interview. The view was taken that he presented a high risk of suicide/self-harm. (2) The officer in charge of the investigation into the offences with which Mr. Akins was eventually charged, ████████ submitted an MG7 remand application form for consideration by the Crown Prosecution Service, and with a view to bail being opposed in the Magistrates' Court. In that form, she set out of objections on a number of grounds including a remand for Mr. Akins' own protection. However, in giving details substantiating that particular ground for opposing bail she stated: "AKINS has a problem with alcohol and mental health, clearly a combination that does not mix well. AKINS spoke of his suffering with post traumatic stress disorder (PTSD) and there is a real concern that, being charged with offences and now being NFA, he may pose a significant risk to not only those he encounters, but also to himself. It is therefore requested that a remand in custody be sought for AKINS own protection." (3) ████████ evidence at the inquest was that those details substantiating that ground for opposing bail ( for Mr. Akins' own protection ) were based solely on her own dealings with Mr. Akins, and not on what was recorded in the Custody Record. In fact, she was not aware of any of the entries recorded on the Custody Record and was therefore not aware of the level of risk of suicide/self-harm which those in charge of his detention felt that Mr. Akins presented. She had not sought to check the Custody Record for any such entries, nor to speak to the Custody Sergeant, nor had the Custody Sergeant sought to make her aware of such entries. (4) Because ████████ was unaware of the contents of these entries in the Custody Record, the description in the MG7 of the risk of suicide/self-harm which Mr. Akins presented was significantly downplayed. (5) In addition to that under-reporting of risk, prior to the hearing in the Magistrates' Court ████████ was informed by the Senior Crown Prosecutor that she was considering agreeing to bail with certain conditions. Those conditions did not address the issue of risk of suicide/self-harm, but ████████ accepted that she had not sought to raise this with the prosecutor. (6) A direct result of that under-reporting of risk of suicide/self-harm, and of ████████ failure to raise it with the prosecutor, was that the prosecutor was minded to agree to conditional bail as proposed. No objections to bail were raised with the Magistrates, and conditional bail was duly granted. (7) I am therefore concerned that no chain of communication appeared to be in place whereby ████████ had made aware of the risks highlighted in the Custody Record, so that an MG7 could be properly and fully prepared. (8) The explanations for this appear to be either: (i) that provision does not exist generally for such a chain of communication to be in place; or (ii) that provision does exist, and that ████████ and/or the Custody Sergeant(s) failed to operate in accordance with such provision. ”

    Source location

    STEWART AKINS · Prevention of Future Deaths report
    Page 1 · 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

    Include in mandatory custody-sergeant training the requirement to highlight known risks and concerns to the officer in charge when considering an MG7 remand application.

    Verbatim wording from the response

    “West Mercia has also ensured that mandatory training for custody sergeants includes the awareness of highlighting known risks and concerns to the OIC upon consideration of a MG7 remand application. This will enable prosecutors and the courts to make fully informed decisions about a person’s vulnerabilities and needs.”

    Source location

    S-Akins-Response
    Page 1 · response
    Published 3 March 2016

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026