First reported 29 May 2014•Latest report 25 Nov 2025
Definition
What this concern includes
Includes failures in dedicated sudden-death response or investigation processes, including officer training, policy and categorisation guidance, scene handling, information gathering, notification and escalation to relevant investigative or statutory bodies.
Not included
Excludes generic police training or investigation deficiencies where sudden death is not the identified process.
Excludes clinical management, resuscitation or treatment failures unrelated to the police or statutory response to a sudden death.
Excludes ordinary death registration, coronial disclosure or post-mortem-process failures where the sudden-death response or investigation itself is not deficient.
Excludes factual sudden-death outcomes without an identified failure in a dedicated response or investigation control.
Reports
6
Distinct published reports
Individual concerns
10
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
21
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
College of Policing2
Greater Manchester Police2
Metropolitan Police Service2
National Police Chiefs’ Council2
Cambridgeshire Constabulary1
Care Quality Commission1
Department for Digital, Culture, Media & Sport (2017 to 2023)1
Department of Health and Social Care1
Home Office1
Independent Office for Police Conduct1
National Crime Agency1
NHS England1
NHS South Yorkshire Integrated Care Board1
Royal College of Pathologists1
Serious Organised Crime Agency1
Police force5
Ministerial department3
National policing body3
Executive non-departmental public body2
Health and social care service regulator1
Health professional body1
Integrated care board1
Non-ministerial department1
Police oversight body1
Registered charity1
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.
Cambridgeshire and Peterborough
Concerns raised1
Failure to seize and retain relevant scene samples and evidence for later investigation
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Establish SOCO liaison and incorporate assessment and seizure of potentially evidential biological samples into child-death forensic strategies.
Stated by Cambridgeshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 2 December 2025.
Action
Amend, reissue and widely circulate procedural guidance and aide-memoires for child-death investigations, covering evidence preservation, medical liaison and anaphylaxis considerations.
Stated by Cambridgeshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 2 December 2025.
Action
Include revised child-death investigation processes in ongoing training cycles for frontline and investigative staff.
Stated by Cambridgeshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 2 December 2025.
Manchester South
Concerns raised1
Failure to provide adequate classroom-based or on-the-job training on sudden death response
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Review student-officer training on the Dealing with Death Procedure.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Present Dealing with Death learning at the monthly Tutor Constable Forum and quality-assure delivery through periodic classroom observations.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
There is nothing to suggest that online training created a broader force-wide issue, although learning from the inquest was disseminated.
Stated by Greater Manchester PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised4
Failure to fully inform forensic pathology experts about relevant equipment involvement in a death
Failure to preserve the scene and fully inform police and coronial investigators after a death
Failure to undertake prompt internal enquiries after sudden unexpected deaths
Failure to inform relevant statutory bodies of concerns after sudden unexpected deaths
This report raised 9 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2022.
Action
Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Establish the Patient Safety Incident Response Framework to support effective investigation and learning from patient safety incidents.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Add unexpected-death procedures to mandatory basic-life-support induction and annual-update training.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Expand simulation training to cover unexpected deaths in addition to medical emergencies and basic life support.
Stated by The Children's TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The police were informed of the cot bumper’s position and the relevant timing and circumstances of death were recorded in investigative materials.
Stated by The Children's TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Connor’s equipment and room remained sealed after staff repositioned him for clinical assessment, contrary to the concern that the scene was not preserved.
Stated by The Children's TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised2
Use of “unexplained” death categorisation distracting officers from treating sudden deaths as suspicious until investigation establishes otherwise
Lack of ownership and responsibility among officers leading unexplained-death investigations
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Finalise a four-category national classification system for death investigations.
Stated by College of Policing and National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2022.
Action
Remove and replace references to “unexplained deaths” in national policing curricula and publications.
Stated by College of Policing and National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2022.
Action
Review and update national guidance and publications following finalisation of the death-investigation classification system.
Stated by College of Policing and National Police Chiefs’ CouncilStated plannedThe respondent said that this action was planned when they made their response on 25 January 2022.
Action
Obtain approval for four death classifications, amend policy, and embed the classifications across the MPS.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 25 January 2022.
Action
Amend and publish the Death Investigation Policy to require recording post-mortem recommendations, rationale for non-compliance, structured death-investigation definitions, supervisor actions and ADR use.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2022.
Action
Review and amend the national curriculum, Investigative Supervisor/Manager Programme and APP to clarify responsibilities for leading death investigations.
Stated by College of Policing and National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2022.
Action
Share learning with Chief Constables and request action to ensure force arrangements clarify responsibilities for those leading death investigations.
Stated by College of Policing and National Police Chiefs’ CouncilStated plannedThe respondent said that this action was planned when they made their response on 25 January 2022.
Action
Add death-investigation leadership responsibilities to the DS and DI course curriculum.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 25 January 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Introducing an “N” CRIS classification is subject to a national paper submitted to the NPCC Homicide Lead.
Stated by Metropolitan Police ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure of Detective Inspector attendance at this type of death scene
This report raised 6 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.
London (North)
Concerns raised1
Lack of fully independent control over fatal shooting scenes during investigation
This report raised 9 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Increase IPCC resources to enable it to handle all serious and sensitive police-related cases.
Stated by Home OfficeStated plannedThe respondent said that this action was planned when they made their response on 29 May 2014.
Action
Review command and control at critical-incident scenes through a Directorate of Professional Standards-led working group with IPCC input.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2014.
Action
Work with the IPCC to formally record a protocol requiring strategic scene-coordination meetings for parallel investigations.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The Chief Officer, not the IPCC, is responsible for preserving evidence and securing scenes of deaths or serious injury.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A formal transfer of scene responsibility to the IPCC is constrained because it lacks crime scene managers and relies on police expertise and coverage.
Stated by Home OfficeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The IPCC could not deploy all necessary scene-management and forensic staff because it lacked resources and additional funding was restricted.
Stated by Independent Office for Police ConductUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
A formal transfer of scene responsibility was not considered practical because police involvement remained necessary for other investigations and evidence preservation.
Stated by Independent Office for Police ConductUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures in dedicated sudden-death response or investigation processes, including officer training, policy and categorisation guidance, scene handling, information gathering, notification and escalation to relevant investigative or statutory bodies.
