Recurring concern

Unreliable medical assessments in police custody

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First reported 23 Mar 2015•Latest report 20 Feb 2026

Definition

What this concern includes

Includes failures in custody medical-assessment arrangements, including timely assessment, completion of required examinations, accurate recording of incomplete or non-performed assessments, fitness decisions and escalation for detainees requiring medical attention.

Not included

  • Excludes general custody records, risk assessments or handovers where no custody medical-assessment deficiency is identified.
  • Excludes failures in clinical treatment after a complete and accurate custody medical assessment has been provided.
  • Excludes generic healthcare staffing, training or documentation deficiencies unless they directly impair medical assessment in police custody.
  • Excludes ambulance, hospital or community medical assessments outside the police-custody setting.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
5

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Crown Prosecution Service1
Department of Health and Social Care1
Greater Manchester Combined Authority1
Greater Manchester Police1
Home Office1
Lancashire County Council1
Medacs Healthcare Limited1
Metropolitan Police Service1
Ministry of Housing, Communities and Local Government1
National Police Chiefs’ Council1
Pennine Care NHS Foundation Trust1
Police and Crime Commissioner for West Midlands1
Serco Group plc1
South Yorkshire Police1
Tameside Borough Council1

Concerns and responses across reports

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

  1. Inner North London

    AI-generated summary

    Sean Perry 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

    Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.

    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

    Delays in custody nurse assessment after detention

    Wider context from the report

    “For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

    Source location

    Sean Perry 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

    Issue operational reminders requiring custody officers to make timely medical requests for detainees needing assessment.

    Verbatim wording from the response

    “MPS Custody Teams (Police Sergeant Custody Officer and Designated Detention Officers) complete a risk assessment and identify detainees who require medical assessment. They inform the Healthcare Practitioner (HCP) on duty (Nurse, Doctor or Paramedic). The communication takes the form of a ‘medical request’ on the MPS CONNECT¹ system, in addition, a verbal handover is sometimes included direct to the HCP.”

    Source location

    Response from Metropolitan Police Service
    Page 1 · response
    Published 24 February 2026

    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 a daily case-finding protocol requiring healthcare practitioners and Grip Sergeants to identify detainees with unmet medical needs.

    Verbatim wording from the response

    “A new protocol for ‘case finding’ was implemented in November 2025, where the HCP on duty runs through the custody whiteboard with the Grip Sergeant² at around 05:30hrs and checks if there are any detainees who may have unmet medical needs (i.e. they do not have a medical request on CONNECT).”

    Source location

    Response from Metropolitan Police Service
    Page 2 · response
    Published 24 February 2026

    Open published response

  2. Coventry

    AI-generated summary

    Mark Adam Yafai · 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 Adam Yafai was arrested in the early hours of 1 July 2015 after disclosing recent cocaine use, and was found convulsing and frothing at the mouth in his cell. He suffered cardiac arrest and died at hospital; the stated cause of death was acute cocaine toxicity. The report raised concerns that custody policies used unclear terminology and gave too much discretion over healthcare assessment, risk assessment and observation for detainees who had disclosed drug use.

    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 require Health Care Professional assessment after disclosed recent drug consumption

    Wider context from the report

    “i. The Safer Detention Policy and Handling of Person in Custody Composite Policy as updated August 2014 was replaced by the WMP Detention and Custody Policy Inc. Standard Operating Procedure with effect from the 22nd December 2015. The earlier policy was in operation at the time Mark Yafai died. The earlier policy lacked clarity or guidance in how the phrase “under the influence” must be interpreted. The phrase is unsuitable since it confers a very broad discretion upon a custody officer to not have the detainee examined by a Health Care Professional, despite a detainee has disclosed recently consuming drugs. The impact upon risk assessment and levels of observation is clear and significant. A broad discretion of an officer when determining risk concerning medical matters including drug use is inadequate. The jury made a determination in similar terms. ii. The evidence was the policy is accessible. Accordingly, it is paramount that the policy must provide clear unambiguous guidance/ direction to custody officers particularly in relation to drugs which can have serious consequences for an individual who has consumed. The circumstances of this inquest touching upon the death of Mark Yafai accentuated this point. The evidence was that cocaine can have toxic effects even from small quantities (as little as 0.03g). Consumption can be via a number of means and the effects delayed depending upon the method of ingestion. There is no antidote to cocaine toxicity. The evidence was custody officers range of knowledge about drugs and the effects can and do differ and this can have a bearing upon risk assessment given the terminology in the policy and broad discretion officers have. iii. The 2015 policy retains that same unclear terminology i.e. “believed to be under the influence of drugs or withdrawing from drugs” and “will be seen by a Health Care Professional (HCP) as a matter of course”. iv. It does not deal with the instances in which a detainee irrespective of presentation (which is not itself any easy assessment when a detainee is being observed by an officer most likely for the first time with no information against which a comparison may be made as whether their current presentation is indeed “normal”) has disclosed the recent consumption of drugs. What is “a line” or any quantitative opinion on drugs consumed is a very subjective assessment by the detainee and/ or the custody officer. v. An assessment as to the effect of any drugs is best assessed a by a Heath Care Professional. That was the evidence and information that emerged in the inquest. Standard medical observations can be undertaken ranging from a check as body temperature to elevated heart rate or blood pressure which may be indicators that drugs are having an adverse effect upon the body. vi. Earlier identification of these matters may prevent death particularly since treatment for many drugs, particularly cocaine, is symptomatic. Close observation of a detainee is clearly significant since early treatment of symptoms can have an impact upon an individual’s survivability. vii. The policy in other respects does use directional/ non discretion type terminology in some respects when dealing with drug issues. It is thus currently inconsistent in this respect on this topic and in interrelation with Risk assessment and appropriate observation levels which are a focus of custody personnel. ”

    Source location

    Mark Adam Yafai · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Kesia Lena Mary Leatherbarrow · 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

    Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

    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 record and explain incomplete medical assessments

    Wider context from the report

    “It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred. ”

    Source location

    Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

  4. South Yorkshire (Western)

    AI-generated summary

    Neil Budziszewski · Prevention of Future Deaths report

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

    Report summary

    Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to arrange direct doctor engagement with a non-cooperative detainee

    Wider context from the report

    “(21) It is accepted that Mr Budziszewski was asked at this stage if he wanted to see a doctor and admitted. However, expert evidence was given that this was unwise and the doctor should have been asked to engage with the prisoner as this was likely to have resulted in co-operation. ”

    Source location

    Neil Budziszewski · Prevention of Future Deaths report
    Page 4 · 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

    Address healthcare-provider arrangements concerning medical assessment of alcohol-related detainees.

    Verbatim wording from the response

    “Healthcare provision to South Yorkshire Police is provided by a private company. The practice of that company is that they will not routinely see a detainee where that detainee is under the influence of alcohol and they have been in custody for less than six hours. The only exception is where the factors referred to in paragraph five are present:-”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 4 · response
    Published 23 March 2015

    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

    Include medical-referral responsibilities in the Inspector guidance pack and remind substantive Inspectors of the referral requirement.

    Verbatim wording from the response

    “Although the medical referral would be the responsibility of the custody staff, the Inspector has a role to play in requesting the medical referral where, upon review, he or she believes it is necessary. This will all be included within the pack that will be provided to Acting and Temporary Inspectors. Substantive Inspectors will be reminded of this requirement by 31 May 2015.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 5 · response
    Published 23 March 2015

    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

    Remind custody staff of the obligation to seek medical attention when detainees present possible medical concerns, including when they decline an offer.

    Verbatim wording from the response

    “The custody sergeant would be expected to have requested a medical review for the detainee following this action. PACE Code C is clear and note 9C is clear that if there is any doubt over the condition of a detainee then medical attention should be sought. As discussed at paragraph 17, custody staff will be reminded of this in writing by 31 May 2015 and also in subsequent training. It is also anticipated that the new electronic risk assessment will trigger the requirement for a medical review when it is completed. The electronic custody log will have to be updated regularly and the time the log is updated will be recorded which will provide for greater accountability.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 6 · response
    Published 23 March 2015

    Open published response
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Data last updated 7 September 2026