Recurring concern

Unclear healthcare and police responsibilities for safety-critical action

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First reported 14 Nov 2014•Latest report 7 Apr 2025

Definition

What this concern includes

Includes failures in explicitly healthcare–police operational arrangements where roles, responsibilities, required actions, escalation routes or coordination for safety-critical matters are unclear, undocumented or not understood by the relevant staff.

Not included

Excludes generic inter-agency communication or accountability failures without a specific healthcare–police operational interface.
Excludes failures confined to a named mental-health assessment, conveyance or liaison pathway where that pathway supplies the more specific supported boundary.
Excludes failures in police investigation, healthcare treatment or clinical assessment where the cross-service responsibility arrangement is not itself deficient.
Excludes generic staff training or policy deficiencies unless they directly cause unclear or misunderstood healthcare–police responsibilities.

Reports: 9
Individual concerns: 13
Date range: 2014–2025
Stated actions: 42

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Metropolitan Police Service3

NHS England2

South London and Maudsley NHS Foundation Trust2

Ashford and St Peter'S Hospitals NHS Foundation Trust1

British Transport Police1

Cheshire Constabulary1

Cleveland Police1

Cumbria Constabulary1

Department of Health and Social Care1

East London NHS Foundation Trust1

Epsom and St Helier University Hospitals NHS Trust1

Frimley Health NHS Foundation Trust1

General Medical Council1

Greater Manchester Police1

Hampshire and Isle of Wight Constabulary1

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.

7 Apr2025
South London
Concerns raised1
1. Failure to draw up a joint police and Trust staff action plan when police are likely to return a patient to hospital
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Cascade the AWOL safety measures through Trust-wide bulletins and briefings, obtaining formal directorate confirmation of implementation.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
2. Action
  Update the AWOL Policy to require a jointly agreed police and Trust action plan when police involvement in a hospital return is anticipated.
  Stated by South London and Maudsley NHS Foundation TrustStated completed
AI-generated summary

Christopher McDonald · 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

Christopher McDonald, who had been detained under section 3 of the Mental Health Act and was receiving care at Bethlem Royal Hospital, died by strangulation by a ligature he had applied around his neck. Concerns included shortcomings in the individualised assessment and management of his leave after he went AWOL, failure to follow the AWOL policy, inadequate review of observation levels, and avoidable delay in identifying the ligature and communicating his relevant medical history to ambulance staff.

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 draw up a joint police and Trust staff action plan when police are likely to return a patient to hospital
Wider context from the report
“The evidence heard at the inquest demonstrated that staff working on the NPU did not have knowledge or a clear understanding of the “AWOL - Missing & Absent Persons Policy” of South London and Maudsley NHS Foundation Trust (“SLAM”) Specifically: (1) Whilst there should be an individualised assessment of whether it is appropriate to suspend section 17 when a patient goes AWOL: (a) one member of staff at the inquest gave evidence that it was “standard practice” and “protocol” that leave would be suspended; and (b) there was no evidence of any individualised assessment in Mr McDonald’s case. (2) The policy provides that SLAM staff should always accompany the police if the patient is to be returned from their home. This was not done in this case, and there was no evidence that any member of NPU staff considered this once Mr McDonald was located at his mother’s address on 24 February 2023. (3) The policy provides that if the police are likely to be involved in returning the patient to hospital then an action plan – jointly drafted between the police and Trust staff - needs to be drawn up. This was not done in this case, and there was no evidence that this was considered or completed by SLAM staff. ”
Source location
Christopher McDonald · 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
Cascade the AWOL safety measures through Trust-wide bulletins and briefings, obtaining formal directorate confirmation of implementation.

Verbatim wording from the response
“• These actions will be shared and cascaded via Trust-wide through a blue light bulletin. Each directorate will be required to provide formal confirmation of full implementation to ensure accountability.”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 2 · response
Published 11 April 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
Update the AWOL Policy to require a jointly agreed police and Trust action plan when police involvement in a hospital return is anticipated.

Verbatim wording from the response
“3. Joint Action Planning with Police”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 2 · response
Published 11 April 2025
Open published response
8 Dec2023
Manchester South
Concerns raised1
1. Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 20
1. Action
  Implement and operate Joint Operating Protocols with four North West police forces covering information sharing, agency primacy, escalation, open lines, lead agency and clinical hub contact.
  Stated by NHS Cheshire and Merseyside ICBStated completed
2. Action
  Oversee progress updates on Joint Operating Protocol implementation through the Regional Clinical Quality Assurance Committee.
  Stated by NHS Cheshire and Merseyside ICBStated planned
3. Action
  Review the concerns with two other Northwest integrated care boards and coordinate steps to progress them.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
1. Action
  Implement the Joint Operating Protocol with Cheshire, Cumbria, Lancashire and Merseyside Police Forces.
  Stated by North West Ambulance Service NHS TrustStated completed
2. Action
  Complete sign-off and implement the updated Joint Operating Protocol with Greater Manchester Police across the North West.
  Stated by North West Ambulance Service NHS TrustStated planned
3. Action
  Review communication procedures and standards with blue-light partners, particularly North West Ambulance Service.
  Stated by Merseyside Fire and Rescue ServiceStated completed
4. Action
  Continue working with Northwest partners to agree and implement a Joint Operating Procedure aligned with Right Care, Right Person.
  Stated by Greater Manchester PoliceStated in progress
5. Action
  Develop a Greater Manchester partnership agreement defining police and ambulance roles and expectations for physical-health Concern for Welfare incidents.
  Stated by Greater Manchester PoliceStated in progress
6. Action
  Brief FCCO staff on the agreed Joint Operating Procedure before its implementation, including its purpose, relevance and required use.
  Stated by Greater Manchester PoliceStated planned
7. Action
  Continue adopting JESIP principles and operational guidance to promote collaborative working between blue-light partners.
  Stated by Lancashire Fire and Rescue ServiceStated completed
8. Action
  Apply JESIP principles and clear speech when coordinating with other emergency services.
  Stated by North West Fire ControlStated completed
9. Action
  Embed and assess compliance with NFCC National Operational Guidance and JESIP inter-agency operating standards.
  Stated by North West Fire ControlStated in progress
10. Action
  Operate the Multi-Agency Tactical Control Communications Group to improve interoperability through shared lessons, training and exercises.
  Stated by North West Fire ControlStated completed
11. Action
  Operate under a Joint Operating Procedure defining agency responsibilities, information sharing and incident escalation.
  Stated by Cumbria ConstabularyStated completed
12. Action
  Sign and endorse the revised joint operating protocol.
  Stated by Cheshire ConstabularyStated completed
13. Action
  Maintain direct inter-control-room communications with police, ambulance and fire services through ESICTRL talk groups.
  Stated by British Transport PoliceStated completed
14. Action
  Implement the regional Standard Operating Procedure on information sharing in relation to incident logs (Version 1.0).
  Stated by Lancashire ConstabularyStated completed
15. Action
  Brief Force Control Room Supervisors and Force Incident Managers on the Joint Operating Protocol.
  Stated by Lancashire ConstabularyStated completed
16. Action
  Continue monthly meetings with regional forces and ambulance services to agree the Joint Operating Protocol.
  Stated by Lancashire ConstabularyStated in progress
17. Action
  Sign off Lancashire Police’s version 1.3 Joint Operating Protocol document.
  Stated by Lancashire ConstabularyStated completed
Respondent positions 3
1. Position
  Ambiguous lead-agency wording prevents agreement to the Joint Operating Procedure until responsibilities and deployment expectations are clarified.
  Stated by Greater Manchester PoliceUnable to act
1. Position
  Existing LFRS guidance and processes are considered sufficient to address the recommendations.
  Stated by Lancashire Fire and Rescue ServiceExisting arrangements considered sufficient
2. Position
  Confirmation of the Joint Operating Protocol’s go-live rests with North-West Ambulance Service, pending sign-off from GMP and Fire and Rescue.
  Stated by Lancashire ConstabularyRedirects responsibility
AI-generated summary

Claire Nicole Briggs · 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

Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
Wider context from the report
“The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022. Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved. Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses. ”
Source location
Claire Nicole Briggs · 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 and operate Joint Operating Protocols with four North West police forces covering information sharing, agency primacy, escalation, open lines, lead agency and clinical hub contact.

Verbatim wording from the response
“As mentioned in your concern during the time of the inquest NWAS had engaged with all the North West Police Forces and were advanced in the development of a Joint Operating Protocol (JOP) for the opening, updates, and closures of logs between NWAS and Police Forces. I can now confirm that four of the North West forces including Cheshire Constabulary and Merseyside Police and have now agreed and gone live with their JOPs.”

Source location
Response from Cheshire and Merseyside ICB
Page 1 · response
Published 12 December 2023
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
Oversee progress updates on Joint Operating Protocol implementation through the Regional Clinical Quality Assurance Committee.

Verbatim wording from the response
“The JOP should mitigate the gap in process that you highlighted and the learning from Claire’s tragic death and progress updates on the implementation of the Joint Operating Protocol will be overseen by the NWAS Regional Clinical Quality Assurance Committee which has representation from the Lancashire and South Cumbria Integrated Care Board (LSC ICB) as a commissioner of ambulance services.”

Source location
Response from Cheshire and Merseyside ICB
Page 1 · response
Published 12 December 2023
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
Review the concerns with two other Northwest integrated care boards and coordinate steps to progress them.

Verbatim wording from the response
“Following the inquest, you raised concerns in your Regulation 28 Report that there is a risk a future death will occur unless action is taken. We have worked with the 2 other ICBs in the Northwest who also use North West Ambulance Service particularly Lancashire ICB who act as a lead commissioner for the provider to review the concerns and ensure steps are taken to progress the concerns raised.”

Source location
Response from Greater Manchester ICB
Page 1 · response
Published 12 December 2023
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
Implement the Joint Operating Protocol with Cheshire, Cumbria, Lancashire and Merseyside Police Forces.

Verbatim wording from the response
“As confirmed in the evidence provided by the Trust during the inquest, the JOP implementation process was recommenced with all Police partners on 6 July 2023 and involved fortnightly meetings with all parties. The aim of those meetings was to agree a standard format and wording for the JOP to be used across the North West.”

Source location
Response from NWAS
Page 2 · response
Published 12 December 2023
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
Complete sign-off and implement the updated Joint Operating Protocol with Greater Manchester Police across the North West.

Verbatim wording from the response
“We have continued to work closely with Greater Manchester Police to overcome any remaining barriers and an updated version of the JOP has now been agreed with Greater Manchester Police who are in the final stages of sign off. It is anticipated the updated version of the JOP will be implemented and “go live” across the whole North West following the next meeting with police partners, scheduled for the latter part of February 2024.”

Source location
Response from NWAS
Page 2 · response
Published 12 December 2023
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
Review communication procedures and standards with blue-light partners, particularly North West Ambulance Service.

Verbatim wording from the response
“Upon receipt of the Regulation 28 referred to above Merseyside Fire and Rescue Service reviewed its current procedures and standards of communication with its blue light partners, in particular with North West Ambulance (‘NWAS’).”

Source location
Response from Merseyside Fire and Rescue Service
Page 1 · response
Published 12 December 2023
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
Continue working with Northwest partners to agree and implement a Joint Operating Procedure aligned with Right Care, Right Person.

Verbatim wording from the response
“Further progress has been made to finalise, agree, and implement the JOP since the inquest touching upon the death of Claire Briggs concluded. Version 1.0 of the JOP went live on 12 October 2023 with four of the five North West police forces, namely Cheshire Constabulary, Cumbria Constabulary, Lancashire Constabulary and Merseyside Police.”

Source location
Response from GMP
Page 2 · response
Published 12 December 2023
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
Develop a Greater Manchester partnership agreement defining police and ambulance roles and expectations for physical-health Concern for Welfare incidents.

Verbatim wording from the response
“GMP is currently working closely with NWAS in respect of the RCRP project. Work is ongoing in relation to the response to be provided by police and ambulance resources to incidents of a physical health concern. To ensure an appropriate response is provided by both blue light services, a partnership agreement specific to Greater Manchester is currently in development. This partnership agreement will formally outline each organisation’s roles and expectations at incidents of Concern for Welfare (‘CFW’) where the primary or sole nature of the incident relates to a physical health concern, and will ensure that GMP’s response to matters of physical health concern, in conjunction with NWAS, is aligned to the principles of RCRP and the regional JOP and that organisations meet their legal obligations under ECHR legislation.”

Source location
Response from GMP
Page 2 · response
Published 12 December 2023
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
Brief FCCO staff on the agreed Joint Operating Procedure before its implementation, including its purpose, relevance and required use.

Verbatim wording from the response
“Once the JOP has been agreed for launch in Greater Manchester, and before the implementation stage, there will be a process within the FCCO to ensure that all staff are made aware of the document and that they understand its purpose and aims, its relevance to GMP, and how it should be used by them. This message will be distributed by the senior leadership team within the FCCO to all supervisors within the branch for further cascading to all staff members.”

Source location
Response from GMP
Page 3 · response
Published 12 December 2023
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
Continue adopting JESIP principles and operational guidance to promote collaborative working between blue-light partners.

Verbatim wording from the response
“LFRS were not involved in this tragic incident but we are committed to a culture of improvement and learning from lessons identified. LFRS actively supports and works to the Joint Emergency Services Interoperability Programme (JESIP) doctrine, promoting effective interagency working through its principles of Co-Location, Communication, Co-ordination, Joint Understanding of Risk and Shared Situational Awareness. LFRS regularly review policies, procedures and training in line with JESIP. LFRS has adopted the National Fire Chiefs (NFCC) National Operational Guidance, which is considered good practice; this guidance has been incorporated into LFRS Standard Operating Procedures (SOP).”

Source location
Response from Lancashire Fire and Rescue Service
Page 1 · response
Published 12 December 2023
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
Apply JESIP principles and clear speech when coordinating with other emergency services.

Verbatim wording from the response
“2.1. NWFC supports the consistent and robust embedding of the Joint Emergency Services Interoperability Programme (JESIP), which promotes effective inter-agency working through its principles of Co-Location, Communication, Co-ordination, Joint Understanding of Risk, and Shared Situational Awareness. We ensure we follow the JESIP doctrine and use clear speech when liaising with other agencies and avoid using fire service terminology.”

Source location
Response from North West Fire Control
Page 2 · response
Published 12 December 2023
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
Embed and assess compliance with NFCC National Operational Guidance and JESIP inter-agency operating standards.

Verbatim wording from the response
“2.13. To ensure that operating standards set out in NFCC endorsed National Operational Guidance and JESIP related to inter-agency working are embedded and being met.”

Source location
Response from North West Fire Control
Page 4 · response
Published 12 December 2023
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
Operate the Multi-Agency Tactical Control Communications Group to improve interoperability through shared lessons, training and exercises.

Verbatim wording from the response
“2.16. The Inter-Agency Lead has successfully established the Multi-Agency Tactical Control Communications Group which has control room representation at senior level from NWFC, Merseyside Fire Control, all North West regional Police Services, NWAS, British Transport Police and the Coastguard.”

Source location
Response from North West Fire Control
Page 4 · response
Published 12 December 2023
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
Operate under a Joint Operating Procedure defining agency responsibilities, information sharing and incident escalation.

Verbatim wording from the response
“We have been working under this Joint Operating Procedure (JOP) since the 12th October 2023. The JOP outlines the roles and responsibilities of each agency, how we share information and how to escalate any incidents through the command structure.”

Source location
Response from Cumbria Constabulary
Page 1 · response
Published 12 December 2023
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
Sign and endorse the revised joint operating protocol.

Verbatim wording from the response
“1. Cheshire Constabulary has been in liaison with NWAS and throughout the development of the JOP has been supportive and keen to move this forward.”

Source location
Response from Cheshire Constabulary
Page 1 · response
Published 12 December 2023
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
Maintain direct inter-control-room communications with police, ambulance and fire services through ESICTRL talk groups.

Verbatim wording from the response
“Following the major incidents of MAI and Grenfell Tower, a recommendation was made to improve communications directly between the three Emergency Service Control Rooms (3ES -Police, Fire, Ambulance). This resulted in the creation of ESICTRL (Emergency Service Inter-Control) radio talk groups that provide 24/7, uninterrupted, radio communications directly between the 3ES control rooms.”

Source location
Response from BTP
Page 2 · response
Published 12 December 2023
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
Implement the regional Standard Operating Procedure on information sharing in relation to incident logs (Version 1.0).

Verbatim wording from the response
“Lancashire Police have been working with North-West Regional Forces and NWAS to finalise, agree and implement a Joint Operating Protocol (JOP). This was initially agreed and the final version V1.0 of the Regional Standard Operating Procedure – Information Sharing in Relation to Incident Logs went live on Thursday 12th October 2023. It was also agreed with the regional Forces and NWAS that monthly meetings will continue until North-West Fire and GMP were able to proceed with the agreement.”

Source location
Response from Lancashire Constabulary
Page 1 · response
Published 12 December 2023
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
Brief Force Control Room Supervisors and Force Incident Managers on the Joint Operating Protocol.

Verbatim wording from the response
“Lancashire Police are already working closely with North-West Regional Forces and North-West Ambulance Service in relation to agreed processes in the Joint Operating Protocol. The document will provide clarity and guidance to Control Room staff regarding escalation of incidents due to delays. It will also give operational officers at the scene of an incident guidance and information to obtain direct clinical advice from North-west Ambulance Service prior to them arriving on the scene of an incident. Implementation was initially via email/briefing to all Force Control Room Supervisors and Force Incident Managers.”

Source location
Response from Lancashire Constabulary
Page 1 · response
Published 12 December 2023
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
Continue monthly meetings with regional forces and ambulance services to agree the Joint Operating Protocol.

Verbatim wording from the response
“Lancashire Police have been working with North-West Regional Forces and NWAS to finalise, agree and implement a Joint Operating Protocol (JOP). This was initially agreed and the final version V1.0 of the Regional Standard Operating Procedure – Information Sharing in Relation to Incident Logs went live on Thursday 12th October 2023. It was also agreed with the regional Forces and NWAS that monthly meetings will continue until North-West Fire and GMP were able to proceed with the agreement.”

Source location
Response from Lancashire Constabulary
Page 1 · response
Published 12 December 2023
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
Sign off Lancashire Police’s version 1.3 Joint Operating Protocol document.

Verbatim wording from the response
“Rollout via email briefing was due to take place to operational officers and Control Room staff to be made aware of the purpose and aims of the JOP, how it applies to that agency and how it should be used by staff. However, this has been delayed due to GMP having issues with the wording in the document about the responsibilities of the lead agency. Further meetings have now taken place with all regional forces to agree the wording. Version 1.3 was due to go live on 31/01/2024, however this is still waiting sign off from GMP and Fire and Rescue. Lancashire Police are happy and have signed off with the Version 1.3 document, and we are just waiting for confirmation of go live from North-west Ambulance Service who are leading on the document.”

Source location
Response from Lancashire Constabulary
Page 1 · response
Published 12 December 2023
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
Ambiguous lead-agency wording prevents agreement to the Joint Operating Procedure until responsibilities and deployment expectations are clarified.

Verbatim wording from the response
“Other partner organisations, including GMP, have yet to agree to the JOP. GMP considers the wording contained within the section on ‘Identifying the Lead Agency’ creates ambiguity and could cause confusion. The current wording is not clear as to which organisation would be the lead agency in certain circumstances, particularly in instances when there may be scene safety concerns, and what such a designation would mean in practical terms. This section of the JOP also suggests that two organisations could be considered the lead agency at the same incident for different purposes (“the lead for the policing purpose would be the Police, NWAS would remain the Lead Agency for the health matter”).”

Source location
Response from GMP
Page 2 · response
Published 12 December 2023
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
Existing LFRS guidance and processes are considered sufficient to address the recommendations.

Verbatim wording from the response
“In response to the recommendations made, LFRS believes that appropriate guidance and processes are available and in place, and I trust this response addresses the matters raised. LFRS will continue to adopt existing JESIP principles and operational guidance, promoting collaborative working between blue-light partners, whilst striving to develop guidance and process to ensure the most effective response is delivered.”

Source location
Response from Lancashire Fire and Rescue Service
Page 2 · response
Published 12 December 2023
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
Confirmation of the Joint Operating Protocol’s go-live rests with North-West Ambulance Service, pending sign-off from GMP and Fire and Rescue.

Verbatim wording from the response
“Rollout via email briefing was due to take place to operational officers and Control Room staff to be made aware of the purpose and aims of the JOP, how it applies to that agency and how it should be used by staff. However, this has been delayed due to GMP having issues with the wording in the document about the responsibilities of the lead agency. Further meetings have now taken place with all regional forces to agree the wording. Version 1.3 was due to go live on 31/01/2024, however this is still waiting sign off from GMP and Fire and Rescue. Lancashire Police are happy and have signed off with the Version 1.3 document, and we are just waiting for confirmation of go live from North-west Ambulance Service who are leading on the document.”

Source location
Response from Lancashire Constabulary
Page 1 · response
Published 12 December 2023
Open published response
12 Jun2023
Inner North London
Concerns raised2
1. Confusion about police contact when a patient is missing
2. Failure of police and health-trust partnership working to allocate responsibility for patient retrieval
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Implement the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.
  Stated by Metropolitan Police ServiceStated in progress
2. Action
  Review the Trust’s responses and related reports to determine whether further action is needed.
  Stated by NHS EnglandStated planned
3. Action
  Revise the Missing and AWOL Policy to clarify safe responses when patients abscond from escorted leave.
  Stated by East London NHS Foundation TrustStated in progress
1. Action
  Establish an external partner delivery group with health and social care partners to clarify responsibilities and support Right Care, Right Person implementation.
  Stated by Metropolitan Police ServiceStated planned
2. Action
  Continue joint discussions with the MPS and local health stakeholders on AWOL responses and respective organisational roles.
  Stated by East London NHS Foundation TrustStated in progress
Respondent positions 7
1. Position
  Operational decisions about missing-person investigations are outside the Home Office’s authority.
  Stated by Home OfficeOutside remit
1. Position
  Responsibility for operational missing-person decisions rests with individual police forces and their Chief Officers.
  Stated by Home OfficeRedirects responsibility
2. Position
  The MPS Affinity Protocol is considered sufficient because it reflects the NPCC framework for missing persons from healthcare settings.
  Stated by Home OfficeExisting arrangements considered sufficient
3. Position
  Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
  Stated by NHS EnglandOutside remit
4. Position
  Existing Affinity Protocols, Joint Responsibility Agreements and national frameworks sufficiently define police and health partners’ roles for absconded patients.
  Stated by Metropolitan Police ServiceExisting arrangements considered sufficient
5. Position
  Retrieving sectioned patients who leave medical settings is generally a healthcare responsibility unless locating or detaining them engages core policing duties.
  Stated by Metropolitan Police ServiceRedirects responsibility
6. Position
  Health partners generally remain responsible for transporting located patients back to hospital, rather than police providing transport.
  Stated by Metropolitan Police ServiceRedirects responsibility
AI-generated summary

Heather FINDLAY · 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

Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.

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
Confusion about police contact when a patient is missing
Wider context from the report
“6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident. At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself. It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future. However, • the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and • any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection. So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff. I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020. This position seems lacking the necessary reflection. I draw your attention to earlier prevention of future deaths reports (PFDs) as follows: • Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing. • Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation. • Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT. ”
Source location
Heather FINDLAY · Prevention of Future Deaths report
Page 6 · 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 of police and health-trust partnership working to allocate responsibility for patient retrieval
Wider context from the report
“4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government. I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts. I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried. I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital. However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task. I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward. From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety. Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what. ”
Source location
Heather FINDLAY · 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 the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.

Verbatim wording from the response
“The Commissioner of the Metropolitan Police, ████████, wrote to Health and Social Care Partners on 24th May 2023, to set out the Met Police’s intention to implement the national Right Care, Right Person approach. Under Assistant Commissioner ████████ a team is now working to put this in place, and an initial senior board has taken place with senior health and social care providers to work towards RCRP implementation. This is also in parallel with the work being done by health care providers on the London mental health concordat. A key aspect of this is working with all of the”

Source location
Response from Metropolitan Police
Page 5 · response
Published 22 June 2023
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
Review the Trust’s responses and related reports to determine whether further action is needed.

Verbatim wording from the response
“I do however take the concerns raised seriously, and I thank you for bringing them to my attention, together with the other Reports to Prevent Future Deaths you highlight concerning the care of other patients at the Trust. I have asked that NHS England is sighted on the Trust’s response to your Report, as well as the responses to the other cases and we will consider these carefully, to include whether any further action needs to be taken. I have already been sighted on the Trust’s Patient Safety Serious Incident Review Report on this matter and note that they have taken a learning to ensure that the police are provided with a direct dial number whenever reporting a patient absconding, which did not happen in this case.”

Source location
Response from NHS England
Page 1 · response
Published 22 June 2023
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
Revise the Missing and AWOL Policy to clarify safe responses when patients abscond from escorted leave.

Verbatim wording from the response
“Although this was the practice in operation at the time, the Trust has taken action to review the relevant part of its Missing and Absent Without Leave (AWOL) Policy to reflect this practice. The updated version will read as below:”

Source location
Response from East London NHS Foundation Trust
Page 1 · response
Published 22 June 2023
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
Establish an external partner delivery group with health and social care partners to clarify responsibilities and support Right Care, Right Person implementation.

Verbatim wording from the response
“The preparatory work being done on implementing Right Care, Right Person provides the Mental Health Trusts with the opportunity to refresh their policies and training to allow them to meet their legal obligations under s18 Mental Health Act and Article 2 and 3 ECHR, in respect of someone who has absconded. In many cases this will be about asking trusts to implement in practise policies that currently exist. The MPS will be meeting with Health and Social Care partners from July to establish a RCRP External Partner Delivery Group to allow all parties to be clear on roles and responsibilities and for health and social care partners to develop their contingency plans to respond to patients who are Absent Without Leave from Mental Health facilities and the other pillars of Right Care, Right Person.”

Source location
Response from Metropolitan Police
Page 6 · response
Published 22 June 2023
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
Continue joint discussions with the MPS and local health stakeholders on AWOL responses and respective organisational roles.

Verbatim wording from the response
“The Trust notes that you are aware of the Affinity protocol which is already in place between the Metropolitan Police Service (MPS) and the Trust.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 22 June 2023
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 missing-person investigations are outside the Home Office’s authority.

Verbatim wording from the response
“With regards to the response to the missing person report made by the East London Foundation Trust (ELFT) to the Metropolitan Police Service (MPS), the police investigation of a missing person report 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. However, my officials have consulted the MPS to gain assurance that the correct protocols are in place in order to prevent future incidents of this nature.”

Source location
Response from Home Office
Page 2 · response
Published 22 June 2023
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
Responsibility for operational missing-person decisions rests with individual police forces and their Chief Officers.

Verbatim wording from the response
“With regards to the response to the missing person report made by the East London Foundation Trust (ELFT) to the Metropolitan Police Service (MPS), the police investigation of a missing person report 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. However, my officials have consulted the MPS to gain assurance that the correct protocols are in place in order to prevent future incidents of this nature.”

Source location
Response from Home Office
Page 2 · response
Published 22 June 2023
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 MPS Affinity Protocol is considered sufficient because it reflects the NPCC framework for missing persons from healthcare settings.

Verbatim wording from the response
“The MPS response will set out details of its Affinity Protocol, a joint agreement between the MPS and ELFT, which aligns with the NPCC’s framework, published in October 2020, and accessible at https://www.gov.uk/government/publications/the-multi-agency-response-for-adults-missing-from-health-and-care-settings-a-national-framework-for-england.”

Source location
Response from Home Office
Page 2 · response
Published 22 June 2023
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
Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.

Verbatim wording from the response
“The concerns in your Report relate to organisational policy at East London Foundation Trust as well as policy within the Metropolitan Police Service. NHS England is not therefore the appropriate organisation to respond to many of the concerns raised.”

Source location
Response from NHS England
Page 1 · response
Published 22 June 2023
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
Existing Affinity Protocols, Joint Responsibility Agreements and national frameworks sufficiently define police and health partners’ roles for absconded patients.

Verbatim wording from the response
“The MPS and medical agency partners already work to an existing framework which sets out roles and responsibilities. They are:”

Source location
Response from Metropolitan Police
Page 3 · response
Published 22 June 2023
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
Retrieving sectioned patients who leave medical settings is generally a healthcare responsibility unless locating or detaining them engages core policing duties.

Verbatim wording from the response
“The core responsibilities of the police are to prevent and detect crime, protect life and property and maintain the Kings Peace. The retrieval of persons sectioned under the Mental Health Act, who have left the medical setting in which they reside, is a health care responsibility unless the need to locate them and/or take them into police custody, falls into one of the core policing duties. Involving the police in mental health issues where there is no crime or threat to life risks criminalisation of patients, and in London in particular, where there is a higher percentage of mental illness within some minority communities, has a disproportionate criminalising effect on them.”

Source location
Response from Metropolitan Police
Page 3 · response
Published 22 June 2023
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
Health partners generally remain responsible for transporting located patients back to hospital, rather than police providing transport.

Verbatim wording from the response
“In instances where police do respond, unless the patient is subject to criminal proceedings (e.g. Part III MHA 1983), or S18 MHA applies, then police will generally not provide transport for the purpose of returning patients from the location they are found. This is clearly set out in the National Missing Adult Framework and is therefore a position which makes clear with which partner the responsibility sits. The National Missing Adult Framework also highlights that for many patients, being transported in a police vehicle is a traumatic experience and the most appropriate professional should return the patient.”

Source location
Response from Metropolitan Police
Page 5 · response
Published 22 June 2023
Open published response
20 Nov2019
Inner North London
Concerns raised3
1. Lack of ward staff understanding of actions required to prompt police progression
2. Lack of ward staff understanding of key information required by the MPS
3. Lack of ward staff understanding of MPS actions in response to absent-without-leave reports
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Nimo Younis · 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

Nimo Younis was detained in a psychiatric intensive care unit and was granted unescorted leave on 24 January 2019, but did not return. She was found at a friend's home the following day after hanging herself. The concerns included shortcomings in communication and understanding between ward staff and the police, the escalation and handling of the missing-person enquiry, the information provided to police decision-makers, and the use of the patient's friends in searching for her.

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 ward staff understanding of actions required to prompt police progression
Wider context from the report
“2. C&I ward staff did not have a proper understanding of what action the MPS required others to take in order to prompt the police to progress the matter further. ”
Source location
Nimo Younis · 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
Lack of ward staff understanding of key information required by the MPS
Wider context from the report
“4. C&I ward staff did not have a proper understanding of what key information they needed to provide the MPS in order to trigger a police missing person enquiry, or to escalate an existing enquiry. ”
Source location
Nimo Younis · 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
Lack of ward staff understanding of MPS actions in response to absent-without-leave reports
Wider context from the report
“1. C&I ward staff did not have a proper understanding of what action the MPS would take in what circumstances, following the report of a patient absent without leave. ”
Source location
Nimo Younis · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 May2019
Central Hampshire
Concerns raised1
1. Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review mental health training for emergency services, emergency departments, police and Trust staff to include proportionate coverage of Mental Health Act sections 17 and 18.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated planned
2. Action
  Draft a shared systemwide protocol for managing complex AWOL cases and work towards its finalisation.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progress
3. Action
  Hold a further stakeholder meeting to review achievements and identify additional actions or training needs, including dissemination of learning.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated planned
AI-generated summary

Sasha Sabrina FORSTER · 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

Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.

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 shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report
“Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances. As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not. ”
Source location
Sasha Sabrina FORSTER · 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 mental health training for emergency services, emergency departments, police and Trust staff to include proportionate coverage of Mental Health Act sections 17 and 18.

Verbatim wording from the response
“The mental health training provided to emergency services, emergency department, police and SABP staff will be reviewed to include an overview of section 17 and 18 of the MHA. This should be proportionate to the frequency that each organisation is expected to come across these cases and this will be determined by each organisation.”

Source location
Sasha-Forster-R2019-01692
Page 4 · response
Published 2 August 2019
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
Draft a shared systemwide protocol for managing complex AWOL cases and work towards its finalisation.

Verbatim wording from the response
“The PFD stated that clarification was required as to the actions that would be taken to achieve the goals set out in a letter dated 22 May 2019 from the Deputy Chief Executive of Surrey and Borders Partnership NHS Foundation Trust (SABP). This letter committed to the development of joint working protocols across the system for the management of complex absent without leave (AWOL) cases (cases where section 17 has been revoked and a person is AWOL).”

Source location
Sasha-Forster-R2019-01692
Page 2 · response
Published 2 August 2019
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
Hold a further stakeholder meeting to review achievements and identify additional actions or training needs, including dissemination of learning.

Verbatim wording from the response
“To respond to the PFD, a meeting was held on the 01 July 2019 between a number of the key stakeholders named in the PFD. Below is a summary of the discussions and actions that were agreed moving forwards. A further meeting will be held to discuss and evidence dissemination of learning and training.”

Source location
Sasha-Forster-R2019-01692
Page 2 · response
Published 2 August 2019
Open published response
16 Nov2018
Southampton and New Forest
Concerns raised1
1. Unclear staff responsibility to report patient crimes to the police regardless of consent
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Eleanor Valerie Fyfe BRABANT · 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 2 November 2017, Eleanor Brabant hanged herself while alone in a room at Trinity Ward, Antelope House, Southampton. She had a history of mental illness, and her behaviour and mental state had deteriorated after her compulsory detention was rescinded without a clear care plan in place. Concerns included the application and staff training relating to patient observations, safeguarding and reporting crimes involving vulnerable patients, use of Mental Health Act powers for informal patients, and involving families in care planning when consent had been withdrawn.

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
Unclear staff responsibility to report patient crimes to the police regardless of consent
Wider context from the report
“5.2 Witnesses who gave testimony on the subject were unclear about the need for safeguarding of vulnerable patients who are the victim of crime, such as Eleanor Brabant and their responsibility to report those crimes to the police, whether or not the patient consented. ”
Source location
Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report
Page 1 · concerns
Open source report
11 Jul2017
Central Hampshire
Concerns raised1
1. Failure to make timely and procedurally clear police notifications in appropriate deaths
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mark William Berry · 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 William Berry suffered a cardiac arrest after apparently taking morphine or heroin and pregabalin, and was declared dead in hospital. The medical cause of death was recorded as morphine toxicity. Concerns included delays in notifying police, incomplete handover information about the address where he was found, and communication of information from a private ambulance service to the control room.

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 make timely and procedurally clear police notifications in appropriate deaths
Wider context from the report
“1. Hospital staff did not contact police in what appeared to be a suspicious and unnatural death for several hours. Further, I was told there appeared to be confusion about the correct procedure with regards to notifying police. This suggests a possible need to revisit who, when and how hospital staff contact the police both before and after death in appropriate cases. ”
Source location
Mark William Berry · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Jun2017
South London
Concerns raised1
1. Lack of defined and understood respective roles and responsibilities between healthcare and police staff
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Continue the Mental Health Team’s work supporting development of the national police-healthcare memorandum of understanding.
  Stated by Metropolitan Police ServiceStated in progress
2. Action
  Agree and implement a joint police-healthcare protocol covering police support in relevant mental-health settings.
  Stated by Metropolitan Police ServiceStated completed
3. Action
  Implement formal Operation Metallah protocols for police responses to hospital emergencies.
  Stated by South London and Maudsley NHS Foundation TrustStated completed
1. Action
  Deliver Trust-wide training on Operation Metallah, multi-agency emergency roles, and responsibilities for police assistance.
  Stated by South London and Maudsley NHS Foundation TrustStated completed
2. Action
  Conduct recurring police liaison meetings to discuss interface issues, review incidents, monitor trends, and undertake thematic section 136 reviews.
  Stated by South London and Maudsley NHS Foundation TrustStated completed
3. Action
  Formally discuss and sign off the Memorandum of Understanding with the Metropolitan Police at the scheduled 5 September 2017 meeting.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
AI-generated summary

Olaseni Lewis · 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

Olaseni Lewis developed an acute psychotic illness, was admitted to hospital, and was later restrained by police and healthcare staff after becoming agitated. He became unconscious and suffered a cardiac arrest. The concerns included prolonged and disproportionate restraint, inadequate police and healthcare training and communication, unclear responsibilities, and failures to respond appropriately to the medical emergency.

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 defined and understood respective roles and responsibilities between healthcare and police staff
Wider context from the report
“(5) There was no training or understanding about the respective roles and responsibilities of healthcare and police staff. There was (and still is) no Memorandum of Understanding. ”
Source location
Olaseni Lewis · 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
Continue the Mental Health Team’s work supporting development of the national police-healthcare memorandum of understanding.

Verbatim wording from the response
“The potential confusion this term may cause when working with other mental health service providers highlighted in your report is however acknowledged. This barrier can be reduced through improved working relations with the police and health care professionals. Work in this area includes the production of the ‘Safer Restraint’ DVD by the MPS in partnership with South London and Maudsley NHS Trust (SLaM) and the ongoing work of the MPS Mental Health Team in support of the national Memorandum of Understanding (MOU) announced by the College of Policing in January 2017 (College of Policing, 2017). The MOU was provided to you as an appendix to ████████ statement dated 26/01/2017.”

Source location
2017-0205-Response-by-Metropolitan-Police
Page 3 · response
Published 28 July 2017
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
Agree and implement a joint police-healthcare protocol covering police support in relevant mental-health settings.

Verbatim wording from the response
“5. The service level agreement (SLA) that had been in place since 6 September 2000 between SLaM/BRH and the MPS had fallen out of use by 2010 (C170, Holmes ref D20, pages 7563 – 7576). Although SLAs were agreed between SLaM and various MPS policing boroughs in 2004 - 6, one was not in place with Bromley. Following Mr. Lewis’ death, a new Joint Protocol was agreed between SLaM and relevant MPS policing boroughs (including Bromley), which came into effect in September 2012 (C280, Holmes ref D50, pages 8093 – 8134).”

Source location
2017-0205-Response-by-Metropolitan-Police
Page 4 · response
Published 28 July 2017
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
Implement formal Operation Metallah protocols for police responses to hospital emergencies.

Verbatim wording from the response
“Following the death of Olaseni Lewis, the Trust and police have worked very closely together to develop formal working protocols when the police are called. This is currently called Operation Metallah and was described in my witness statement for the inquest dated 1 February 2017. Any emergency call received by the Central Control Centre ('CCC') originating from the Bethlem Royal Hospital, Maudsley Hospital, or Lambeth Hospital sites is”

Source location
2017-0205-Response-by-South-London-and-Maudsley-NHS-Trust
Page 1 · response
Published 28 July 2017
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
Deliver Trust-wide training on Operation Metallah, multi-agency emergency roles, and responsibilities for police assistance.

Verbatim wording from the response
“Training has been implemented across the Trust which teaches staff about the protocols of Operation Metallah. In addition, a training DVD called "Safety in Mind" has been and is being shown to staff. The film aims to demonstrate successful ways of working together, the roles, relationships and expectations that should feature when working in a multi-agency mental health emergency. Staff have also been and are continuing to be trained in their respective roles and responsibilities relating to police assistance at one of the Trust's hospital sites as a matter of routine.”

Source location
2017-0205-Response-by-South-London-and-Maudsley-NHS-Trust
Page 3 · response
Published 28 July 2017
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
Conduct recurring police liaison meetings to discuss interface issues, review incidents, monitor trends, and undertake thematic section 136 reviews.

Verbatim wording from the response
“Local police liaison meetings, chaired by local clinical service managers with local police representation present, occur every 2 months. In these meetings any local interface issues are discussed and all Operation Metallah incidents for that specific borough are reviewed. In addition, there is a Trust-wide police liaison meeting which is chaired by one of our service directors which brings the four borough representatives from both the police and the Trust together to discuss issues that cut across the four boroughs. Monitoring of all Operation Metallah incidents and relevant trends takes place at this meeting and they also undertake thematic reviews of section 136 use. This meeting occurs every three months.”

Source location
2017-0205-Response-by-South-London-and-Maudsley-NHS-Trust
Page 3 · response
Published 28 July 2017
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
Formally discuss and sign off the Memorandum of Understanding with the Metropolitan Police at the scheduled 5 September 2017 meeting.

Verbatim wording from the response
“There is also a quarterly meeting with borough commanders which is chaired by our Chief Operating Officer where any significant issues are raised. The Memorandum of Understanding will be formally discussed and signed off at the next quarterly meeting on 5 September 2017, as issues have been clarified between the two organisations in the intervening period since the release of the draft document for comment in the early part of this year.”

Source location
2017-0205-Response-by-South-London-and-Maudsley-NHS-Trust
Page 3 · response
Published 28 July 2017
Open published response
14 Nov2014
Teesside
Concerns raised2
1. Lack of memorandum of understanding or guideline for taking aggressive detainees to A&E departments
2. Insufficient police understanding of A&E treatment for detainees
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Establish joint guidance for assessing, treating, discharging and communicating information about aggressive or medically unwell detainees attending emergency departments.
  Stated by NHS Durham Dales, Easington and Sedgefield CCG and NHS Hartlepool and Stockton on Tees CCG and NHS North Durham CCG and NHS South Tees Clinical Commissioning GroupStated completed
2. Action
  Inform relevant NHS and police staff about the agreed detainee-management guidance.
  Stated by NHS Durham Dales, Easington and Sedgefield CCG and NHS Hartlepool and Stockton on Tees CCG and NHS North Durham CCG and NHS South Tees Clinical Commissioning GroupStated planned
3. Action
  Issue Cleveland Police guidance for managing aggressive detainees transferred to emergency or mental-health services, incorporating agreed police and NHS arrangements.
  Stated by Cleveland PoliceStated planned
1. Action
  Brief custody staff, medical staff and frontline officers on the new detainee-transfer guidance.
  Stated by Cleveland PoliceStated in progress
2. Action
  Review the effectiveness of the guidance after six months.
  Stated by Cleveland PoliceStated planned
3. Action
  Hold discussions with Durham Constabulary to ensure officers know that patients should be taken to the emergency department.
  Stated by NHS Durham Dales, Easington and Sedgefield CCG and NHS Hartlepool and Stockton on Tees CCG and NHS North Durham CCG and NHS South Tees Clinical Commissioning GroupStated completed
AI-generated summary

Kirk William Williams · 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

Kirk William Williams ingested several drugs and displayed highly agitated and aberrant behaviour before being restrained by police. Although one officer considered that he should be taken to hospital, he was taken to a police station and later suffered cardiac arrest and died in hospital. The concerns included differing understandings between police and A&E staff about treating aggressive detainees, and the absence of clear dialogue or guidance for managing such medical emergencies.

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 memorandum of understanding or guideline for taking aggressive detainees to A&E departments
Wider context from the report
“(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients. (3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff. (4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff. (5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments. (6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments. (7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions. (8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments. (9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others. ”
Source location
Kirk William Williams · 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
Insufficient police understanding of A&E treatment for detainees
Wider context from the report
“(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients. (3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff. (4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff. (5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments. (6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments. (7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions. (8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments. (9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others. ”
Source location
Kirk William Williams · 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
Establish joint guidance for assessing, treating, discharging and communicating information about aggressive or medically unwell detainees attending emergency departments.

Verbatim wording from the response
“A meeting was held between the Medical Directors and senior A&E medical staff of both Foundation Trusts and Detective Chief Superintendent ████████ from Cleveland Police.”

Source location
2014-0499-Response-by-South-Tees-Clinical-Commissioning-Group
Page 1 · response
Published 14 November 2014
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
Inform relevant NHS and police staff about the agreed detainee-management guidance.

Verbatim wording from the response
“• All relevant staff, both NHS and Police, to be informed of the guidelines agreed for future reference.”

Source location
2014-0499-Response-by-South-Tees-Clinical-Commissioning-Group
Page 2 · response
Published 14 November 2014
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
Issue Cleveland Police guidance for managing aggressive detainees transferred to emergency or mental-health services, incorporating agreed police and NHS arrangements.

Verbatim wording from the response
“At point 8 in your report you identified that there did not appear to be a Memorandum of Understanding or guidance to cover aggressive detainees in Custody being taken to A&E Departments.”

Source location
2014-0499-Response-by-Cleveland-Police
Page 1 · response
Published 14 November 2014
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
Brief custody staff, medical staff and frontline officers on the new detainee-transfer guidance.

Verbatim wording from the response
“• All staff both NHS and Police to be informed of the guidelines agreed for future reference.”

Source location
2014-0499-Response-by-Cleveland-Police
Page 2 · response
Published 14 November 2014
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
Review the effectiveness of the guidance after six months.

Verbatim wording from the response
“It is my intention to review the effectiveness of the guidance in six months’ time and to take any appropriate action where necessary, whether that is amendments to the guidance in conjunction with the two Trusts, or further training to ensure staff are aware of and are implementing the guidance.”

Source location
2014-0499-Response-by-Cleveland-Police
Page 2 · response
Published 14 November 2014
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
Hold discussions with Durham Constabulary to ensure officers know that patients should be taken to the emergency department.

Verbatim wording from the response
“County Durham and Darlington NHS Foundation Trust have confirmed that the lead Security Officer for the Trust has held discussions with Durham Constabulary lead officers to ensure that all police officers know that patients should be taken to the Emergency Department.”

Source location
2014-0499-Response-by-South-Tees-Clinical-Commissioning-Group
Page 2 · response
Published 14 November 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to draw up a joint police and Trust staff action plan when police are likely to return a patient to hospital

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.20

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised2

Confusion about police contact when a patient is missing

Failure of police and health-trust partnership working to allocate responsibility for patient retrieval

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7

Actions described in response 2

Actions described in response 20

Respondent positions 3

Actions described in response 5

Respondent positions 7