8 May 2026 SHAY MIDDLETON-PIERCE · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Lack of safeguards preventing erroneous removal of priority logs from the dispatch queue View source Failure to deploy a unit or add a significant update before removing a priority incident from the dispatch queue View source Failure to ensure senior-officer endorsement and supervisory oversight of immediate and priority grade logs View source
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AI-generated summary
SHAY MIDDLETON-PIERCE · 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
Shay Middleton-Pierce, aged 15, died on 29 March 2025 from multiple traumatic injuries following suicide near the Nutfield train line crossing in Redhill, Surrey. British Transport Police failed to establish whether officers could meet him at Redhill Station and did not inform Surrey Police that they were not attending after the incident log was moved from the dispatch queue to a sub queue in error. The report raises concerns about human error, insufficient supervisory oversight, and the lack of computer checks to prevent priority logs being removed from dispatch attention.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguards preventing erroneous removal of priority logs from the dispatch queue
Wider context from the report “The Dispatcher in the Control Room at British Transport Police was unable to explain why he had moved the log from the dispatch queue to the sub queue, other than due to human error. This meant that the log was not treated as a priority and there was a missed opportunity to consider deploying officers to attend Redhill Station to locate Shay, or to update Surrey Police that they would not be attending to see if they were able to deploy officers.
The Court heard evidence from the communications officer who had moved the log to the dispatch queue and from the dispatch officer who had moved the log to the sub queue. The Team Manager and Service Delivery Manager for BTP’s Force Control Room also gave evidence regarding expectations for dispatchers to deploy a unit or add a significant update before removing the incident from the dispatch queue. These actions did not take place.
Following conclusion of the inquest, the Court has heard and received further evidence from a Chief Inspector at BTP that, following an incident in March 2023, where issues were identified concerning lack of command and control where there was a threat to life identified, the Operations Manual was implemented in which it is documented that supervisory oversight is required for all immediate and priority grade calls, and the “CW log must be endorsed by a Force Incident Manager/Deputy Force Incident Manager/Team Manager to confirm their review and supervisory oversight”. Further the Court heard that this was subject to a recent review and updated and training was being undertaken to ensure all relevant staff were aware of this.
None of the BTP witnesses gave evidence that there was an expectation that Shay’s log had to be endorsed in this way by a senior officer and this did not take place despite the learning from the March 2023 incident.
The Court has received further evidence from BTP surrounding ongoing training and compliance monitoring in this regard, but given that this incident repeated concerns from the 2023 incident, it appears that further action is required to ensure that a priority log cannot be removed from the dispatch queue to the sub queue as a result of human error by a single dispatcher.
A dispatcher at BTP can move the log from the dispatch queue to a sub queue in error and this has been documented to have occurred on at least two occasions where a person’s life was considered to be at risk. This effectively removes the log from the dispatcher’s attention for action. There are no computer checks to prevent this from happening and a system to prevent this when senior officers having oversight of such cases was not referred to in evidence by BTP staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to deploy a unit or add a significant update before removing a priority incident from the dispatch queue
Wider context from the report “The Dispatcher in the Control Room at British Transport Police was unable to explain why he had moved the log from the dispatch queue to the sub queue, other than due to human error. This meant that the log was not treated as a priority and there was a missed opportunity to consider deploying officers to attend Redhill Station to locate Shay, or to update Surrey Police that they would not be attending to see if they were able to deploy officers.
The Court heard evidence from the communications officer who had moved the log to the dispatch queue and from the dispatch officer who had moved the log to the sub queue. The Team Manager and Service Delivery Manager for BTP’s Force Control Room also gave evidence regarding expectations for dispatchers to deploy a unit or add a significant update before removing the incident from the dispatch queue. These actions did not take place.
Following conclusion of the inquest, the Court has heard and received further evidence from a Chief Inspector at BTP that, following an incident in March 2023, where issues were identified concerning lack of command and control where there was a threat to life identified, the Operations Manual was implemented in which it is documented that supervisory oversight is required for all immediate and priority grade calls, and the “CW log must be endorsed by a Force Incident Manager/Deputy Force Incident Manager/Team Manager to confirm their review and supervisory oversight”. Further the Court heard that this was subject to a recent review and updated and training was being undertaken to ensure all relevant staff were aware of this.
None of the BTP witnesses gave evidence that there was an expectation that Shay’s log had to be endorsed in this way by a senior officer and this did not take place despite the learning from the March 2023 incident.
The Court has received further evidence from BTP surrounding ongoing training and compliance monitoring in this regard, but given that this incident repeated concerns from the 2023 incident, it appears that further action is required to ensure that a priority log cannot be removed from the dispatch queue to the sub queue as a result of human error by a single dispatcher.
A dispatcher at BTP can move the log from the dispatch queue to a sub queue in error and this has been documented to have occurred on at least two occasions where a person’s life was considered to be at risk. This effectively removes the log from the dispatcher’s attention for action. There are no computer checks to prevent this from happening and a system to prevent this when senior officers having oversight of such cases was not referred to in evidence by BTP staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure senior-officer endorsement and supervisory oversight of immediate and priority grade logs
Wider context from the report “The Dispatcher in the Control Room at British Transport Police was unable to explain why he had moved the log from the dispatch queue to the sub queue, other than due to human error. This meant that the log was not treated as a priority and there was a missed opportunity to consider deploying officers to attend Redhill Station to locate Shay, or to update Surrey Police that they would not be attending to see if they were able to deploy officers.
The Court heard evidence from the communications officer who had moved the log to the dispatch queue and from the dispatch officer who had moved the log to the sub queue. The Team Manager and Service Delivery Manager for BTP’s Force Control Room also gave evidence regarding expectations for dispatchers to deploy a unit or add a significant update before removing the incident from the dispatch queue. These actions did not take place.
Following conclusion of the inquest, the Court has heard and received further evidence from a Chief Inspector at BTP that, following an incident in March 2023, where issues were identified concerning lack of command and control where there was a threat to life identified, the Operations Manual was implemented in which it is documented that supervisory oversight is required for all immediate and priority grade calls , and the “CW log must be endorsed by a Force Incident Manager/Deputy Force Incident Manager/Team Manager to confirm their review and supervisory oversight” . Further the Court heard that this was subject to a recent review and updated and training was being undertaken to ensure all relevant staff were aware of this.
None of the BTP witnesses gave evidence that there was an expectation that Shay’s log had to be endorsed in this way by a senior officer and this did not take place despite the learning from the March 2023 incident.
The Court has received further evidence from BTP surrounding ongoing training and compliance monitoring in this regard, but given that this incident repeated concerns from the 2023 incident, it appears that further action is required to ensure that a priority log cannot be removed from the dispatch queue to the sub queue as a result of human error by a single dispatcher.
A dispatcher at BTP can move the log from the dispatch queue to a sub queue in error and this has been documented to have occurred on at least two occasions where a person’s life was considered to be at risk. This effectively removes the log from the dispatcher’s attention for action. There are no computer checks to prevent this from happening and a system to prevent this when senior officers having oversight of such cases was not referred to in evidence by BTP staff.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore with the information-system provider a software safeguard or prompt adding prevention or supervisory control before logs leave sub-queues.
Verbatim wording from the response “Technology Opportunities” Source location Response from British Transport Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require supervisory review and endorsement of control-room logs before progression, deprioritisation or release from active management.
Verbatim wording from the response “Recognising that supervision by the FIM/DFIM and Team Managers is a critical safeguard, BTP has implemented a comprehensive set of procedural and supervisory controls:” Source location Response from British Transport Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Logs cannot be prevented from moving between queues because such movement is operationally necessary; strengthened supervision is used instead.
Verbatim wording from the response “As part of a cohesive approach, BTP is exploring with the provider of its FCR Information Technology system whether a technological software safeguard or prompt could be developed to either reduce the potential for this user error, or to add an additional supervisory control on the computer system before a log is released from a sub-queue dispatch control group. This will be examined to accompany the controls of the current command and control system, balanced against the overall significant daily service demand and other operational requirements.” Source location Response from British Transport Police
Open published response
5 Jun 2024 Mohammed AKRAMUZZAMAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to form an independent assessment of a person's condition View source Lack of organisational learning and procedural change after a serious incident View source Failure to properly assess a person's condition before leaving them View source Failure to conduct a later welfare check on a person left in potential medical distress View source Premature attribution of a person's condition to drug or alcohol effects View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mohammed AKRAMUZZAMAN · 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
Mohammed Akramuzzaman, aged 39, was found in cardiac arrest beside Euston Station on 8 December 2023 after spending the night outside. His death involved alcohol-related ketoacidosis and hypothermia. Concerns included the adequacy of the British Transport Police assessment, the decision not to return to check on him despite the cold conditions, and the lack of identified organisational learning after his death.
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. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to form an independent assessment of a person's condition
Wider context from the report “2. The three station officers (one PC and two PCSOs) who attended Mr Akramuzzaman told me that they had placed great reliance on hearing a BTP response officer (one of three who had arrived just moments before the station officers) give an opinion over the radio that Mr Akramuzzaman was “coming round” after having taken drugs or alcohol. However, the station officers were themselves very experienced, and should have formed their own view .
3. The officers also eventually accepted at inquest that it was impossible to decide so quickly that this was a drug comedown.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Lack of organisational learning and procedural change after a serious incident
Wider context from the report “5. I was told that the BTP officers had reflected a lot about this incident in the time since, and had learnt a lot. However, when giving their evidence they struck me as defensive, and they were unable to point to any specific learning or any changes in their procedures following Mr Akramuzzaman’s death.
Whilst I readily accepted that the officers had talked about Mr Akramuzzaman since his death, I did not gain the impression of a culture of learning .
The sergeant told me that before the inquest, he had not known about the existence of ketoacidosis. The officers reminded me that they are not healthcare professionals. However, as I explained in court, I was not suggesting that they should have a particular understanding of ketoacidosis.
Mr Akramuzzaman could have been suffering from any number of medical conditions. He could have sustained a subtle head injury. He could have had diabetes (which, as it happens, can also result in ketoacidosis). He could have had epilepsy. The list goes on.
Mr Akramuzzaman did not need the BTP officers to be doctors in order to survive this episode, but he was probably already confused when officers dealt with him, and he needed them to make an appropriate assessment and to take appropriate action as BTP officers.
The sergeant told me that he thought learning should be undertaken by BTP at an organisational level .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to properly assess a person's condition before leaving them
Wider context from the report “1. However, the officers left Mr Akramuzzaman after he had simply nodded that he was alright and shaken his head that he did not want medical treatment. They never actually heard him speak.
They did not attempt to stand him up to see if he was able to support himself.
I appreciate that if Mr Akramuzzaman had mental capacity then he could not be forced to go to hospital, but it is difficult to see how he could have been assessed properly following just a nod and a shake of the head.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a later welfare check on a person left in potential medical distress
Wider context from the report “4. It must have been a very cold night (it was minus 4°C when he was found in the morning), but nobody went back to check on Mr Akramuzzaman later .
I appreciate that a decision had to be made about what action to take there and then. But when I asked, BTP witnesses agreed that it would have been an easy matter for an officer on patrol later to check on a person in that situation .
No consideration was given to that by either of the PCSOs, by the PC, or by the sergeant who then took the decision to cancel the ambulance called earlier.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Premature attribution of a person's condition to drug or alcohol effects
Wider context from the report “2. The three station officers (one PC and two PCSOs) who attended Mr Akramuzzaman told me that they had placed great reliance on hearing a BTP response officer (one of three who had arrived just moments before the station officers) give an opinion over the radio that Mr Akramuzzaman was “coming round” after having taken drugs or alcohol. However, the station officers were themselves very experienced, and should have formed their own view.
3. The officers also eventually accepted at inquest that it was impossible to decide so quickly that this was a drug comedown .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate a force-wide bulletin highlighting learning from the incident.
Verbatim wording from the response “In response to the IOPC recommendations, a force wide bulletin was circulated on 19 July 2024 to highlight the learnings identified as a result of this incident. This bulletin is exhibited to this response [EXHIBIT 1].” Source location Response from British Transport Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide reflective practice to involved officers, including review of safeguarding policies, legal powers, welfare checks and body-worn-video use.
Verbatim wording from the response “Reflective practice has been provided to the officers involved in the incident. The officers have reviewed their understanding of BTP's safeguarding policy and legal powers under the Mental Capacity Act and Mental Health Act, and they have reflected on the comments made by the Coroner around making further checks on the male's welfare, which in hindsight would have required the ControlWorks log to have been left open. They have also reflected on their use of BWV and the importance of capturing everything. They have commented that they would look to be more persuasive in convincing subjects to get medical attention in future incidents.” Source location Response from British Transport Police
Open published response
28 Mar 2024 Daniela Vitalia PANI · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Lack of Samaritan signs at the train station View source Failure to implement identified suicide-risk mitigation measures at the train station View source Training and guidance failing to address service users declining a visit or meeting View source Inability of staff to carry out face-to-face assessments in all possible cases View source Car park line-side fencing being too low View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Daniela Vitalia PANI · 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
Daniela Vitalia PANI died on 29 June 2023 after entering a train station, jumping onto the tracks and being struck by a train. Concerns were raised that potential suicide-risk mitigation measures at the station had not been implemented, and that mental-health staff lacked specific guidance and training for situations where service users declined face-to-face 72-hour reviews.
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. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Lack of Samaritan signs at the train station
Wider context from the report “1. A lack of Samaritan signs on the platforms or within the stations.
The mitigation proposed was conspicuously placed posters and/or additional signage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to implement identified suicide-risk mitigation measures at the train station
Wider context from the report “The report was submitted on the 25th July 2023. Despite the passage of nearly 9 months from submission of the report to the date of the inquest the BTP officer giving evidence could not inform me whether these changes had been actioned. I was advised that this information had been requested from South Western Railways but had not been provided.
On the 18th March 2024 I requested an update from BTP about the actions taken and invited them to attend the final hearing on the 25th March 2024. No information was submitted and no-one from BTP attended the final hearing.
I am therefore concerned that measures to mitigate the risk of future suicides at the train station have not been implemented .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Training and guidance failing to address service users declining a visit or meeting
Wider context from the report “I heard evidence from a number of members of the CMHT regarding the policies, procedures and training around the completion of this important review meeting.
During the course of this I heard that training and guidance did not specifically address how to deal with service users declining a visit or meeting.
This is a complex area with competing demands of the duty of care, mental capacity and the autonomy of an individual to make decisions about their own care and treatment. The evidence from the CMHT Joint Service Manager was that guidance and/or training would be important for staff seeking to deal with this challenging area .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Inability of staff to carry out face-to-face assessments in all possible cases
Wider context from the report “I am concerned that the staff not being able to carry out face to face assessments in all possible cases gives rise to the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Car park line-side fencing being too low
Wider context from the report “2. Car park line side fencing being too low.
The proposed mitigation was replacement of the fencing.
” Open source report
19 Dec 2023 Amanda Hitch · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Failure to use structured risk management tools alongside clinical experience and judgment View source Failure to conduct multidisciplinary discussion of changes in presentation View source Failure of the clinical record to present information as a continuous chronological running record View source Failure of the multi-agency support plan to clearly state limitations on information from unstaffed station attendances View source Unavailability of resources to identify and provide information about all unstaffed railway station attendances View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Amanda Hitch · 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
Amanda Hitch died on 12 February 2022 after deliberately jumping in front of a train intending to die. She was receiving community mental health treatment. Concerns included important clinical information not being visible to the care team, structured risk-management tools not being specifically considered, and railway-station attendances not being reliably passed to her care coordinator under a multi-agency support plan.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to use structured risk management tools alongside clinical experience and judgment
Wider context from the report “(2) The evidence was such that neither the care co- Ordinator nor the consultant psychiatrist as the medical lead of the service specifically considered the structured risk management tools that the Trust operates , preferring to rely on clinical experience and judgment alone. There may be a risk that not using such risk management tools in combination with clinical experience and judgment , particularly if this is being done by one clinician at an appointment rather than multidisciplinary discussion of changes in presentation, may lead to information being missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct multidisciplinary discussion of changes in presentation
Wider context from the report “(2) The evidence was such that neither the care co- Ordinator nor the consultant psychiatrist as the medical lead of the service specifically considered the structured risk management tools that the Trust operates, preferring to rely on clinical experience and judgment alone. There may be a risk that not using such risk management tools in combination with clinical experience and judgment, particularly if this is being done by one clinician at an appointment rather than multidisciplinary discussion of changes in presentation , may lead to information being missed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the clinical record to present information as a continuous chronological running record
Wider context from the report “(1) During the inquest, it became clear that one significant entry in the clinical notes made by someone in a separate service commissioned by the Essex Partnership University Trust, and which expressed a very specific and imminent intention from the deceased to end her life, was not seen by others in the clinical team. This was almost certainly because the clinical record does not present on computer screens as a continuous chronological running record, but is instead viewed thematically . That means that readers are likely to look at entries made within their particular clinical team, rather than see what others have recorded more recently. There is an obvious risk that critical and important information garnered by others and put into the medical records will not be seen , and that those making clinical decisions on risk management will thus be unaware of potentially very significant information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the multi-agency support plan to clearly state limitations on information from unstaffed station attendances
Wider context from the report “(3) There was also evidence about the measures that the British Transport Police had taken, seeking to provide additional support by setting up multi- agency support plan, which provided a system for alerting a number of people including the deceased’s care co-ordinator, when she attended at railway stations. In fact, for various reasons, although there are several known attendances at railway stations, none were passed on to the care co- Ordinator. The evidence at the inquest was that British Transport Police does not have the resources always to provide information about attendance at unstaffed stations (although in fact, one such attendance had been known about but was not passed on). The plan as presented does not make it entirely clear what the limitations in relation to information from attendances at unstaffed stations may be , and should it remain the position that BTP lacks the resources to identify all such attendances at railway stations by persons at specific risk of suicide on the railway, there is a risk that those expecting to receive information under such a plan may not realise that the plan will often not assist where its subject is attending unmanned stations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of resources to identify and provide information about all unstaffed railway station attendances
Wider context from the report “(3) There was also evidence about the measures that the British Transport Police had taken, seeking to provide additional support by setting up multi- agency support plan, which provided a system for alerting a number of people including the deceased’s care co-ordinator, when she attended at railway stations. In fact, for various reasons, although there are several known attendances at railway stations, none were passed on to the care co- Ordinator. The evidence at the inquest was that British Transport Police does not have the resources always to provide information about attendance at unstaffed stations (although in fact, one such attendance had been known about but was not passed on). The plan as presented does not make it entirely clear what the limitations in relation to information from attendances at unstaffed stations may be, and should it remain the position that BTP lacks the resources to identify all such attendances at railway stations by persons at specific risk of suicide on the railway , there is a risk that those expecting to receive information under such a plan may not realise that the plan will often not assist where its subject is attending unmanned stations.
” Open source report
19 Dec 2023 Chloe Elizabeth MACDERMOTT · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Lack of prominent signposting to organisations providing suicide-prevention help View source Internet availability and delivery of an unspecified item to individual users in the UK View source Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide View source Failure of effective border and customs controls for delivery of an unspecified item to UK users View source Lack of age or other access restrictions for children, vulnerable teenagers and vulnerable adults View source Failure to effectively remove posts containing details of suicide methods View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Chloe Elizabeth MACDERMOTT · 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
Chloe Elizabeth MACDERMOTT died at home in the early hours of 23 May 2021 after ingesting a substance purchased through Amazon US. The report identifies concerns about online forums encouraging, assisting and counselling suicide, inadequate age restrictions and signposting to help, harmful content not being effectively removed, and the availability and delivery of the product to UK users without effective border or customs controls.
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. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Lack of prominent signposting to organisations providing suicide-prevention help
Wider context from the report “(6) No prominent signposting is in place to organisations from whom help is available to prevent suicide .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Internet availability and delivery of an unspecified item to individual users in the UK
Wider context from the report “(9) The availability of ████████ through the internet and its delivery to individual users in the UK with a non-commercial or agricultural use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide
Wider context from the report “(3) ████████ is a forum that permits material to be exchanged and reviewed within its open chatrooms whereby suicide is encouraged, assisted, counselled and procured through the provision and exchange of information and methods .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure of effective border and customs controls for delivery of an unspecified item to UK users
Wider context from the report “(10) The ability for UK users to purchase ████████ through Amazon in the United States and to take delivery in the United Kingdom without effective border and/or custom controls .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Lack of age or other access restrictions for children, vulnerable teenagers and vulnerable adults
Wider context from the report “(5) No age or other restrictions are in place to prevent access to children, vulnerable teenagers and vulnerable adults .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively remove posts containing details of suicide methods
Wider context from the report “(7) Posts are made by users containing details of methods of suicide without any effective administration to remove such harmful content .
” Open source report
8 Dec 2023 Claire Nicole Briggs · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses View source Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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. The report was sent to British Transport Police; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
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 .
” 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 Provide control-room briefings to support exchange of initial triage information with partner responder agencies.
Verbatim wording from the response “BTP are also adopting this model that improves the identification of incidents/ patients requiring escalation. Actions currently underway to ensure BTP officers and staff are adequately aware of this approach include:” Source location Response from BTP
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
Open published response
Concerns raised 4 Lack of public announcements directing people to obtain assistance View source Failure to fully implement identified station security recommendations View source Insufficient CCTV surveillance and platform visibility View source Limited staffing at the railway station View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alun John Davies · 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
Alun John Davies died instantly after jumping from the platform at Portchester railway station into the path of a non-stopping train on 4 May 2021. The evidence described acute anxiety and chronic depression, following recent personal difficulties. Concerns included limited staffing, CCTV coverage and platform visibility at the station, as well as insufficient public security and welfare announcements and information about obtaining assistance.
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. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Lack of public announcements directing people to obtain assistance
Wider context from the report “(3) The post-incident site report further identified the lack of public security and welfare announcements at the station (and within the station concourse) aimed at providing direction in the event of illness or of assistance being required . There is a lack of information/announcements to other members of the public as to how to obtain assistance if they are concerned by someone else’s condition or actions . It is not clear to what extent this has been further considered or addressed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to fully implement identified station security recommendations
Wider context from the report “(2) The post-incident site report further identified that Portchester Railway station is an impending ‘escalated’ location. Since 2017 there have been 2 previous fatalities in similar circumstances at the station – which is now recognised as having lower levels of surveillance – with Mr Davies’ death being the third. Although recommendations were made after the first incident, the above recommendations and identified risks (at 1) have not yet been (fully) addressed or implemented .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient CCTV surveillance and platform visibility
Wider context from the report “(1) The post-incident site report presented by British Transport Police (in conjunction with the Design Out Crime Unit) and completed on 22 July 2021 identified that there was (and remains) limited staffing and CCTV surveillance at Portchester Railway Station and limited visibility of the platforms - requiring a security risk assessment with a view to increasing staffing (at the ticket office and on the platform) with increased RCO Patrols and platform surveillance and that additional CCTV installation and coverage was required (of the platforms and public areas) with real time capability .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Limited staffing at the railway station
Wider context from the report “(1) The post-incident site report presented by British Transport Police (in conjunction with the Design Out Crime Unit) and completed on 22 July 2021 identified that there was (and remains) limited staffing and CCTV surveillance at Portchester Railway Station and limited visibility of the platforms - requiring a security risk assessment with a view to increasing staffing (at the ticket office and on the platform) with increased RCO Patrols and platform surveillance and that additional CCTV installation and coverage was required (of the platforms and public areas) with real time capability.
” Open source report
Concerns raised 1 Failure to consider credible alternative routes of access in post-death railway investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christine Elizabeth GOULD (Chris) · 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
Christine Elizabeth Gould, aged 17, died by suicide on 26 January 2019 after deliberately stepping in front of a passing train near the Cherry Hinton Bypass Level Crossing. The report raised concerns that BTP and Network Rail had too readily assumed a single route of access to the railway and had not sufficiently considered the boundary fence as a credible alternative route, potentially missing opportunities for earlier mitigation.
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. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to consider credible alternative routes of access in post-death railway investigations
Wider context from the report “(1) Following completed suicides on the railway network BTP and Network Rail are both involved in considering further mitigating measures that may be appropriate at the location to guard against further fatalities.
(2) In Chris’ case, earlier consideration to the fence boundary being a credible route of access may have led to the fence boundary being improved more quickly after her death.
(3) I am concerned that your investigation into, and consideration of, Chris’ death did not keep a sufficiently open mind that she may have climbed the boundary fence to access the railway line . If similar assumptions are made in other investigations, there is a risk of future fatalities: there is a risk that mitigating measures will be missed if BTP and Network Rail too readily assume that one point of access to the railway was used when the evidence permits of credible alternative routes of access .
Accordingly, I am concerned that action should be taken in the sphere of guidance in keeping an open mind in post-death investigations but the nature of any appropriate action to be taken is for your organisations to consider.
” 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 Apply revised post-incident site-visit procedures requiring incident-log review, pre-deployment liaison, assessment of multiple access points and repeat visits where necessary.
Verbatim wording from the response “BTP has now implemented a procedural change for PISV whereby the DOCO will ensure the full incident log is read prior to a site visit, and liaison will take place prior to deployment with the Fatality Investigator (or SIO if unexplained or a child fatality) assigned to the investigation team when the access point isn’t immediately clear. This is to ensure the location subject to the PISV is the one established to have been used, or potentially include multiple points if entirely unknown. If at any point following completion of a PISV report, a location(s) other than that visited and referenced in the report is established to have been the point of entry, a second site visit to the correct location will be made and a new report is issued.” Source location 2021-0185-Response-from-BTP_Published
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 ongoing continuous professional development training on railway fatality scene assessments, rationale documentation, access-point evidence and geolocation tools.
Verbatim wording from the response “The BTP Disruption Team review the Force’s frontline response to non-suspicious fatalities, through their assessments the identify areas of improvement and good practice. The Disruption Team have commenced a programme of regular “bite-sized” continuous professional development training sessions for police officers, one of these specifically targets scene assessments at railway fatality locations. Following the prevention of future deaths report, this training now incorporates renewed focus on attending officers comprehensively documenting their rationale following a scene assessment. The training also seeks to remind staff of how to use static railway infrastructure and modern technology such as the geolocation application What3Words, to provide precise positional locations for key evidential material (i.e. possible access points/recovered property from scenes).” Source location 2021-0185-Response-from-BTP_Published
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 Network Rail is responsible for deciding whether appropriate and proportionate action is needed to implement BTP’s proposed access-point improvements.
Verbatim wording from the response “Through the changes that have been implemented to the structure of non-suspicious fatalities, the ongoing training of frontline staff around scene assessment and the preparing, production and submission of PISV reports, BTP has implemented robust procedures which significantly reduce the risk of mitigating measures being missed by the BTP during post-incident site visits. There is a structured process for the PISV reports to be passed on to Network Rail, whose responsibility it is to decide on any appropriate and proportionate action around the proposed improvement considerations highlighted by BTP.” Source location 2021-0185-Response-from-BTP_Published
Open published response
10 Jul 2018 Bartholomew Patrick Coleman · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Easy public access to the railway track from the bridge View source Lack of warnings about the dangers of accessing the railway track View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Bartholomew Patrick Coleman · 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
Bartholomew Patrick Coleman accessed a railway track near his home, lay on the track as a train approached, and died after being struck. Concerns included that the track was easily accessible from a bridge used by schoolchildren and that there appeared to be no warning about the dangers of accessing the area.
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. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Easy public access to the railway track from the bridge
Wider context from the report “i. I understand children of school age cross the bridge to and from school. There is evidence to suggest that the area has been used by either groups or individuals to consume alcohol: there are discarded drinks containers in the area beyond the bridge and close to the train track. I am concerned that the railway track is easily accessible to members of the public from this bridge. In addition, there appears to be no warning as to the dangers presented by accessing this area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Lack of warnings about the dangers of accessing the railway track
Wider context from the report “i. I understand children of school age cross the bridge to and from school. There is evidence to suggest that the area has been used by either groups or individuals to consume alcohol: there are discarded drinks containers in the area beyond the bridge and close to the train track. I am concerned that the railway track is easily accessible to members of the public from this bridge. In addition, there appears to be no warning as to the dangers presented by accessing this area .
” Open source report
23 Jul 2015 Mr Ashley Aaron Matthews · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Absence of warning signs about high voltage cabling dangers View source Failure to maintain secure perimeter fencing and prevent unauthorised site access View source Failure of security patrols to remain alert and effective View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Ashley Aaron Matthews · 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
Ashley Matthews accessed Bescot Traction Maintenance Depot, climbed over a railway bridge and was electrocuted after contacting a high-voltage cable. He died in hospital from extensive full-thickness burns. Concerns included insecure perimeter fencing, inadequate security patrols and a lack of warning signs about the high-voltage cabling.
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. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Absence of warning signs about high voltage cabling dangers
Wider context from the report “(1) During the course of the inquest, evidence suggested that access to the site was gained by insecure fencing.
(2) After the death of Ashley Matthews, the family were able to gain access to the site unchallenged by security.
(3) The family witnessed the security guard asleep in his car.
(4) Others had gained access and placed flowers on Bridge 26.
(5) The family witnessed someone on the site walking with their dog and placing flowers on bridge 26.
(6) Evidence suggested that some parts of the perimeter fencing were secured with cable ties.
(7) Evidence suggested there were no warning signs on Bridge 26 warning of the dangers posed by high voltage cabling .
(8) In light of the inquest findings, you may wish to consider the physical security of the site including fencing as well as the security patrols in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain secure perimeter fencing and prevent unauthorised site access
Wider context from the report “(1) During the course of the inquest, evidence suggested that access to the site was gained by insecure fencing .
(2) After the death of Ashley Matthews, the family were able to gain access to the site unchallenged by security .
(3) The family witnessed the security guard asleep in his car.
(4) Others had gained access and placed flowers on Bridge 26 .
(5) The family witnessed someone on the site walking with their dog and placing flowers on bridge 26 .
(6) Evidence suggested that some parts of the perimeter fencing were secured with cable ties .
(7) Evidence suggested there were no warning signs on Bridge 26 warning of the dangers posed by high voltage cabling.
(8) In light of the inquest findings, you may wish to consider the physical security of the site including fencing as well as the security patrols in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Failure of security patrols to remain alert and effective
Wider context from the report “(1) During the course of the inquest, evidence suggested that access to the site was gained by insecure fencing.
(2) After the death of Ashley Matthews, the family were able to gain access to the site unchallenged by security.
(3) The family witnessed the security guard asleep in his car .
(4) Others had gained access and placed flowers on Bridge 26.
(5) The family witnessed someone on the site walking with their dog and placing flowers on bridge 26.
(6) Evidence suggested that some parts of the perimeter fencing were secured with cable ties.
(7) Evidence suggested there were no warning signs on Bridge 26 warning of the dangers posed by high voltage cabling.
(8) In light of the inquest findings, you may wish to consider the physical security of the site including fencing as well as the security patrols in place.
” 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 Discuss with Network Rail whether employing a security officer would be cost-effective.
Verbatim wording from the response “Point 8. Network rail have never employed a security officer at the depot. It is currently used as a marshalling yard for trucks carrying low value railway ballast. I have discussed point 8 with ████████ who will be speaking with Network Rail to see if a security officer would be cost effective. He has mentioned that the site where this fatality took place is not actually within the area of the marshalling yard but is on the access line that runs towards it.” Source location 2015-0297-Response-by-BTP
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 security officer reportedly seen at the site was employed by a nearby haulage or construction site, not Network Rail.
Verbatim wording from the response “The construction site for the adjacent distribution depot was well underway, it has been established that the security officer mentioned by the family was for this site and not associated in any way with Network Rail. No cable ties were found on Network Rail fencing, visit, however there are some cable ties securing temporary fencing that sounds the construction site.” Source location 2015-0297-Response-by-BTP
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 family did not access the rail yard, so the reported security failure there did not relate to their access route.
Verbatim wording from the response “Finally, the liaison officer for this case has spoken with the family about the points that they raised. He has supplied a statement of their conversation and in this he confirms that the family did not access the rail yard at any time. They have also clarified that the security guard found asleep was from a nearby haulage yard and was nothing to do with Network Rail.” Source location 2015-0297-Response-by-BTP
Open published response
17 Jul 2015 Adam Lee Connelly · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Inadequate restriction of public access to the railway track from the steps accessing footbridge 57 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Adam Lee Connelly · 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
Adam Lee Connelly was found deceased beside railway tracks near footbridge 57 between Walkden and Atherton after sustaining injuries consistent with being struck by a train. The principal concern was that the approximately five-foot walls of the steps leading to the footbridge could allow a person of reasonable athletic ability to access the railway track, creating a risk of future fatalities.
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. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate restriction of public access to the railway track from the steps accessing footbridge 57
Wider context from the report “i. Due to the height of the walls of the steps which are used to access footbridge 57 on the railway line between Walkden and Atherton train stations, a person of reasonable athletic ability could gain access to the railway track , which could lead to future fatalities at this location on the railway
” Open source report
15 Jul 2014 Stephen Peter Church · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 4 Lack of joint working to address high self-harm risk promptly View source Insufficient knowledge and understanding of the interagency mental health working protocol View source Breakdown of the British Transport Police chain of command for detention responsibilities View source Lack of appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Peter Church · 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
Stephen Church was found dead at the entrance to the multi-storey car park at Royal Berkshire Hospital on 13 May 2011 after absconding while detained under section 136 of the Mental Health Act 1983. The concerns included a broken chain of command resulting in only one police officer being responsible for his detention, insufficient understanding of an interagency working protocol, inadequate joint working to keep him safe, and delay in contacting an approved mental health professional to arrange a Mental Health Act assessment.
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. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Lack of joint working to address high self-harm risk promptly
Wider context from the report “(3) There was a lack of joint working amongst the British Transport Police, Royal Berkshire Hospital and psychiatric liaison service staff members to ensure that Stephen Church was safe and the high risk of him self-harming addressed promptly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient knowledge and understanding of the interagency mental health working protocol
Wider context from the report “(2) There was insufficient knowledge and understanding amongst members of the psychiatric liaison service and the Royal Berkshire Hospital as regards the "Interagency joint Working Protocol for the Management of Mental Health Thames Valley Area"
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Breakdown of the British Transport Police chain of command for detention responsibilities
Wider context from the report “(1) The chain of command within the British Transport Police was broken unacceptably leading to only one police officer responsible for detaining Mr Church .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Transport Police; that does not assign responsibility.
PFD Monitor interpretation Lack of appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment
Wider context from the report “There was a lack of appreciation amongst the psychiatric liaison service, Royal Berkshire Hospital staff and British Transport Police as to the importance of contacting an approved mental health professional promptly to arrange a Mental Health Act assessment .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include proactive interagency dialogue requirements in relevant BTP training.
Verbatim wording from the response “I acknowledge that regular and detailed communication with the other agencies involved in Mr Church’s case could have led to his greater care whilst at the hospital. Further, that additional care staff may have been provided had they been aware that he was with only one officer. This issue of ‘proactively maintaining dialogue’ is covered in the ‘Briefing Note – New Policy for London Section 136, (page 60) under the heading ‘Triage Risk Assessment/Triage Psychiatric Assessment’. This element of that briefing note is now included in all relevant BTP training.” Source location 2014-0331-Response-by-British-Transport-Police
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 Add requirements to keep detainees supervised until formal handover and ensure mental-health professionals and AMHPs are informed.
Verbatim wording from the response “In summary, the break down in the chain of command is being addressed as a conduct issue and I am confident that there is no systemic failing in this area. With regards to the other concern highlighted, the BTP Manual of Guidance now includes the following:” Source location 2014-0331-Response-by-British-Transport-Police
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 any Independent Police Complaints Commission recommendations concerning the officers’ actions and promulgate resulting lessons throughout the force.
Verbatim wording from the response “I recognise that this breakdown in the chain of command ultimately had implications for the care of Mr Church but I do not believe that this is a systematic failing in BTP processes. Rather, this was an isolated incidence of misconduct. My Professional Standards Department referred this incident to the Independent Police Complaints Commission in 2011 and we currently await the outcome of that investigation. I will ensure that any recommendations in relation to the actions of ████████ and ████████ are implemented and that any lessons learned are appropriately promulgated throughout the force.” Source location 2014-0331-Response-by-British-Transport-Police
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 chain-of-command breakdown was an isolated misconduct incident, not evidence of a systemic failing in British Transport Police processes.
Verbatim wording from the response “I recognise that this breakdown in the chain of command ultimately had implications for the care of Mr Church but I do not believe that this is a systematic failing in BTP processes. Rather, this was an isolated incidence of misconduct. My Professional Standards Department referred this incident to the Independent Police Complaints Commission in 2011 and we currently await the outcome of that investigation. I will ensure that any recommendations in relation to the actions of ████████ and ████████ are implemented and that any lessons learned are appropriately promulgated throughout the force.” Source location 2014-0331-Response-by-British-Transport-Police
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 professionals, through the place-of-safety coordinator, are responsible for contacting the AMHP and arranging necessary mental-health assessment arrangements.
Verbatim wording from the response “My view is supported by reference to a recent meeting of the Mental Health Partnership Board for London, which includes CEOs of the London Mental Health Trusts. At that meeting the question of whose role it was to call the AMHP following a S136 detention delivered a unanimous response; that it was the role of the health professionals as the police would not have access to up to date information. The Board has recently launched a new policy for S136 and S135 arrangements in” Source location 2014-0331-Response-by-British-Transport-Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation British Transport Police cannot reliably contact AMHPs before arrival because it lacks current on-call contact lists and maintaining them nationally is impractical.
Verbatim wording from the response “It was acknowledged at the Inquest that British Transport Police was not a signatory to the joint interagency protocol, but officers giving evidence accepted that they would try to work to the aims where possible. I endorse this aspiration but must highlight the impracticalities of British Transport Police being able to achieve this in every case.” Source location 2014-0331-Response-by-British-Transport-Police
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations