19 May 2026 Catherine Mary MORGAN · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 10 Failure to use a viable welfare-check pathway when the resident is not known to be at the address View source Overly rigid application of deployment policy and affinity protocol View source Failure to inform the nurse in charge about leave decisions and circumstances View source Failure to include a patient photograph in the grab pack View source Inadequate monitoring and escalation of patients on leave who do not return View source Lack of a voluntary-patient checklist for measures taken to locate the patient View source Failure to conduct leave risk assessments consistently with NICE Guidelines View source Inadequate communication and recording of leave decisions View source Training that restricts professional judgement in deployment decisions View source Inconsistent approach to leave and return for detained and voluntary patients View source See 7 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
Catherine Mary MORGAN · 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
Catherine Mary Morgan, who was receiving mental health care, left hospital on unescorted leave and was later located near Dover Castle. She jumped to her death at 20.16 on 4 September 2024. Concerns included delays in the police response to reports that she was missing, and inadequate systems for assessing, authorising, communicating and monitoring voluntary patients’ leave.
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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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to use a viable welfare-check pathway when the resident is not known to be at the address
Wider context from the report “2. A call handler informed SLAM to call London Ambulance Service to do a welfare check at
the home address of the patient in circumstances where the ambulance service will only
attend an address if the resident is known to be there ;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Overly rigid application of deployment policy and affinity protocol
Wider context from the report “1. An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted
in a delayed deployment . Even where call handlers have real concerns that someone not
returning to a mental health unit is a high risk missing person, the outcome of the toolkit not to
deploy is the same if the individual's address has not been visited, even when told that they
would not go there. The way in which the policy was applied removed any discretion by call
handlers and dispatchers to deploy whilst checks at the address were being conducted .
Evidence was given at the inquest that the call handler in the second call to MPS attempted to
convey her concerns that there should be immediate deployment to her supervisors in
despatch and was advised the police would not deploy;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the nurse in charge about leave decisions and circumstances
Wider context from the report “2. The systems in place for safeguarding voluntary patients in respect of leave and recording
the decisions was inadequate and decisions were largely communicated by word of mouth
which led to differences of understanding what had been agreed, the basis on which it had
been agreed and by whom it was agreed. Documentation in respect of leave was incomplete
and did not comply with policy. The nurse in charge was not informed of the decision for leave
or the circumstances in which leave was granted ;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to include a patient photograph in the grab pack
Wider context from the report “5. A photograph of the patient was not included in the grab pack . Unlike detained patients there
was no checklist for voluntary patients as to the measures taken to locate the patient
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring and escalation of patients on leave who do not return
Wider context from the report “3. The system for monitoring leave was inadequate , reliance being placed on hourly checks.
The nurse conducting the hourly check at 12.00 when Catherine was due to return was not
aware that she was on unescorted leave and did not escalate the matter to the nurse in charge
with the result that the ward only became aware that she had not returned when her mother
arrived at 12.50. Consideration was not given to the appropriate amount of leeway to be given
to the patient before escalating the fact of them not having returned , with patients being given
30 minutes or more;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a voluntary-patient checklist for measures taken to locate the patient
Wider context from the report “5. A photograph of the patient was not included in the grab pack. Unlike detained patients there
was no checklist for voluntary patients as to the measures taken to locate the patient
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct leave risk assessments consistently with NICE Guidelines
Wider context from the report “1. Evidence was given at the inquest that although dynamic risk assessments were undertaken
in advance of leave being authorised, risk assessments were not consistent with NICE
Guidelines ;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication and recording of leave decisions
Wider context from the report “2. The systems in place for safeguarding voluntary patients in respect of leave and recording
the decisions was inadequate and decisions were largely communicated by word of mouth
which led to differences of understanding what had been agreed, the basis on which it had
been agreed and by whom it was agreed . Documentation in respect of leave was incomplete
and did not comply with policy . The nurse in charge was not informed of the decision for leave
or the circumstances in which leave was granted;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Training that restricts professional judgement in deployment decisions
Wider context from the report “It was recognised by MPS at the inquest that there was an overly rigid approach to the Right
Care Right Person policy and Affinity Protocol resulting from the robust application of the
policy and protocol (see above). Some changes have been made within MPS within the
parameters allowed given national guidance and standards, but evidence was given to the
effect that training as to the application of the policy, protocol and toolkit could result in the
professional judgement of call handlers/despatchers/supervisors being restricted resulting in
delays to deployment
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Inconsistent approach to leave and return for detained and voluntary patients
Wider context from the report “4. Ward staff appeared to take a different approach to leave and return depending upon the
status of the patient as a detained or voluntary patient ;
” 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 Disseminate updated guidance to all forces and support implementation through communications, practitioner briefings and national Tactical Delivery Board input.
Verbatim wording from the response “3. Dissemination and implementation support” Source location Response from College of Policing
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 Engage forces to understand how guidance is interpreted regarding professional judgement and deployment thresholds.
Verbatim wording from the response “3. Engagement with operational stakeholders” Source location Response from College of Policing
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 Publish the revised guidance after completing the ongoing review.
Verbatim wording from the response “The College will publish the revised guidance following the completion of the review of existing guidance which is currently underway. Updated materials will then be disseminated to forces, supported by clear communications and practitioner briefings to promote understanding, consistency and effective implementation of the revised guidance.” Source location Response from College of Policing
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 Revise the national Right Care Right Person toolkit to reinforce professional judgement, prioritise vulnerability and life-threatening risk, and prevent undue deployment delays.
Verbatim wording from the response “The College will implement the following actions to directly address the concern raised and strengthen national consistency:” Source location Response from College of Policing
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 Review Right Care Right Person and Missing Persons guidance jointly to identify clarifications supporting operational decision-making.
Verbatim wording from the response “The College has already commenced work to address this issue through the following activity:” Source location Response from College of Policing
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 Produce interoperability guidance for ambiguous Right Care Right Person and Missing Persons cases, including escalation to appropriately trained specialist teams.
Verbatim wording from the response “2. Development of interoperability guidance between RCRP and Missing Persons frameworks” Source location Response from College of Policing
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 Identify emerging risk-based operational practice, including escalation routes to specialist missing person teams for uncertain incident classifications.
Verbatim wording from the response “2. Identification of emerging operational practice” Source location Response from College of Policing
Open published response
24 Apr 2026 Edward Muwanga · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation View source Lack of awareness of the section 135 MHA 1980 process View source Fragmented healthcare record systems limiting the visibility and communication of important patient safety information View source Failure to locate and identify information about a section 135 MHA 1980 warrant View source Failure to make a detailed and measured assessment of a person’s situation View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edward Muwanga · 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
Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation
Wider context from the report “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the section 135 MHA 1980 process
Wider context from the report “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980 , and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Fragmented healthcare record systems limiting the visibility and communication of important patient safety information
Wider context from the report “(3) The sharing and visibility of important health care records between medical agencies, (held on multiple platforms by multiple health care agencies) in particular here between the treating Trust (SLAM) and NHS 111, and between the Ambulance Service (not NHS 111) and the treating Trust (SLAM). ████████ from London Ambulance Service NHS Trust writes to me in her PFD statement that “it is recognised that there remain challenges with the visibility of information from healthcare settings across London. While advances have been made, the visibility of pertinent information depends on technological developments and the coordination of a complex healthcare system.” In her written evidence to me dated 19th March 2026 ████████ Chief Medical Officer of LAS NHS Trust, writes that “..there is currently no single, comprehensive system that provides universal access to all patient records across NHS organisations. Access is influenced by information governance requirements, system interoperability, commissioning arrangements, and the extent to which partner organisations upload information to shared platforms." Whilst this fragmented situation persists with a multiplicity of systems, platforms, screens, and process in which important patient safety information is embedded the risk such information is not identified or communicated to practitioners making healthcare decisions remains and as such gives rise to a risk of death due to decisions being made on incomplete information where more complete information exists .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to locate and identify information about a section 135 MHA 1980 warrant
Wider context from the report “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant , together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to make a detailed and measured assessment of a person’s situation
Wider context from the report “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Authorised Professional Practice guidance and consider the report’s concerns in resulting amendments.
Verbatim wording from the response “The College of Policing recognises the risks associated with mental health incidents and we understand the critical importance of decisions about the appropriate response to such calls. The police response to mental health incidents is covered within the guidance produced by the College under the Authorised Professional Practice (APP). The APP is currently going through a formal review and we will ensure that the points highlighted within your report are fully considered within any amendments made within the review process.” Source location Response from College of Policing
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 The Metropolitan Police Service is responsible for addressing operational elements and decision-making processes and is providing the substantive response.
Verbatim wording from the response “In relation to the operational elements and decision-making processes, we have been in contact with the Metropolitan Police Service (MPS) and understand that a full response to these points is being provided.” Source location Response from College of Policing
Open published response
30 Mar 2026 Oliver John Roberts · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Lack of practical guidance on making communications data applications View source Lack of practical guidance on authorising communications data applications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver John Roberts · 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
Oliver John Roberts was found suspended by a ligature in a wooded area on 28 January 2024, after being reported missing and after communications data had been requested by police. The principal concern was a lack of practical national guidance for police officers on when and how to make communications data requests, including urgent Grade 2 applications; in this case, the Grade 2 request was submitted almost 24 hours after he was reported missing.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of practical guidance on making communications data applications
Wider context from the report “(1) There is a lack of guidance to assist Police Officers in the practical application of their powers to obtain communications data, whether that be under a Grade 1, 2 or 3 application.
(2) Communications data can be obtained by Police forces in England and Wales pursuant to the Investigatory Powers Act 2016 (the Act). In November 2018 the Home Office issued the Communication Data Codes of Practice (the Codes of Practice) which is a document that extends to 144 pages and relates to the exercise of functions conferred by virtue of Parts 3 & 4 of the Act.
(3) Requests are submitted by police representatives to their Communication Data Investigation Teams to access data, and this will be done in different ways depending on the grading of the request.
(4) Grade 1 requests are made when there is an immediate risk to life. Grade 2 requests are made when there is an exceptionally urgent requirement for the prevention or detection of serious crime; a credible and immediate threat to national security; or a serious concern for the welfare of a vulnerable person where urgent provision of the communications data will have an immediate and positive impact on the investigation or operation. Grade 3 requests are made when matters that are not urgent but, where appropriate, will include specific or time-critical issues such as bail dates; court dates; where persons are in custody; or where there is a specific line of investigation into a serious crime and early disclosure by the telecommunications operator or postal operator will directly assist in the prevention or detection of that crime.
(5) Section 5 of Codes of Practice refers to the application process and Section 6 deals with the authorisation of the application, however there is no practical guidance, such as Authorised Professional Practice Guidance, to assist Forces and their officers, as to how and when applications should be made and authorisations should be given.
(6) In this case a Grade 2 application was submitted almost 24 hours after Ollie was reported missing. Once submitted, Ollie was found within 2 hours and 9 minutes. This application was submitted in writing, however evidence was given that in some circumstances a verbal application for a Grade 2 request can be made if the Grade 2 application is urgent. There is a lack of guidance to police officers nationally as to what would constitute a Grade 2 urgent application and what should be done in writing and what should be done verbally.
(7) I am concerned the circumstances of Ollie’s death could occur again as a result of the lack of practical guidance to Police Forces and their staff as to when and how to make data communication requests pursuant to the Investigatory Powers Act 2016 .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of practical guidance on authorising communications data applications
Wider context from the report “(1) There is a lack of guidance to assist Police Officers in the practical application of their powers to obtain communications data, whether that be under a Grade 1, 2 or 3 application.
(2) Communications data can be obtained by Police forces in England and Wales pursuant to the Investigatory Powers Act 2016 (the Act). In November 2018 the Home Office issued the Communication Data Codes of Practice (the Codes of Practice) which is a document that extends to 144 pages and relates to the exercise of functions conferred by virtue of Parts 3 & 4 of the Act.
(3) Requests are submitted by police representatives to their Communication Data Investigation Teams to access data, and this will be done in different ways depending on the grading of the request.
(4) Grade 1 requests are made when there is an immediate risk to life. Grade 2 requests are made when there is an exceptionally urgent requirement for the prevention or detection of serious crime; a credible and immediate threat to national security; or a serious concern for the welfare of a vulnerable person where urgent provision of the communications data will have an immediate and positive impact on the investigation or operation. Grade 3 requests are made when matters that are not urgent but, where appropriate, will include specific or time-critical issues such as bail dates; court dates; where persons are in custody; or where there is a specific line of investigation into a serious crime and early disclosure by the telecommunications operator or postal operator will directly assist in the prevention or detection of that crime.
(5) Section 5 of Codes of Practice refers to the application process and Section 6 deals with the authorisation of the application, however there is no practical guidance, such as Authorised Professional Practice Guidance, to assist Forces and their officers, as to how and when applications should be made and authorisations should be given .
(6) In this case a Grade 2 application was submitted almost 24 hours after Ollie was reported missing. Once submitted, Ollie was found within 2 hours and 9 minutes. This application was submitted in writing, however evidence was given that in some circumstances a verbal application for a Grade 2 request can be made if the Grade 2 application is urgent. There is a lack of guidance to police officers nationally as to what would constitute a Grade 2 urgent application and what should be done in writing and what should be done verbally.
(7) I am concerned the circumstances of Ollie’s death could occur again as a result of the lack of practical guidance to Police Forces and their staff as to when and how to make data communication requests pursuant to the Investigatory Powers Act 2016.
” 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 Provide the “Standardising Communications Data Applications” training product through the NCDS website.
Verbatim wording from the response “In addition to the referenced College training, in collaboration with the National Action Fraud Network, IPCO-A, HMRS and Home Office, we have produced a further training product, “Standardising Communications Data Applications,” which is available on the NCDS website. Some organisations have taken the decision to mandate this training for staff.” Source location Response from College of Policing
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 national eLearning on communications data applications, including Grade 1 and Grade 2 criteria, to police officers and staff.
Verbatim wording from the response “There is eLearning training that is available for investigators on our national ‘College Learn,’ platform. These learning packages “Introduction to Communications Data,” sit within the Digital Media Investigators (DMI) modules. Within this training there is emphasis on Grade 1’s requiring an ‘immediate threat to life, and Grade 2’s requiring …’ a serious concern for the welfare of a vulnerable person where urgent provision of the communications data will have an immediate and positive impact on the investigation or operations.” This training is available for all police officers and staff across England and Wales. (Please also see my response to point five, for additional available training).” Source location Response from College of Policing
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 Examine how Missing Persons Authorised Professional Practice can be strengthened to clarify communications data and tracking.
Verbatim wording from the response “I have tasked my team with examining where the Missing Persons Authorised Professional Practice could be further strengthened in this area to provide greater clarity and direction around communications data and tracking, during the current review process.” Source location Response from College of Policing
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 Develop further communications data training for the SPoC community, including a Hydra immersive exercise for fast-time decision-making, and pilot it in summer 2026.
Verbatim wording from the response “Acknowledging the grading criteria, and the available training (referenced in my response to point 1 and 5 below), we are also in the process of developing further training for the ‘CD Single Point of Contact (SPoC) community; particularly with the development of a Hydra (immersive learning) exercise around fast-time decision making in this space. We anticipate that this will be piloted in Summer 2026.” Source location Response from College of Policing
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 The concern may relate to the initial risk assessment and application speed rather than communications-data grading or guidance.
Verbatim wording from the response “While I am not privy to any further detail of the investigation, (and cede to any new information that could cast light on the following) the concern here may be around the initial risk assessment and speed of application submission, rather than the grading or guidance. According to the IPCO Service Level Agreement, Priority two data, has a six-hour turnaround, for example.” Source location Response from College of Policing
Open published response
25 Mar 2026 Name not published · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 7 Failure to routinely seize feeding bottles and equipment pending toxicology results View source Insufficient police consideration of poisoning in unexpected child deaths View source Warning information for chlorpheniramine-containing products omitting their association with sudden unexpected death in children View source Perfunctory scene examinations in child death investigations View source Police training and guidelines requiring updating View source A person who illicitly administered chlorpheniramine to a child continuing to work as a nanny View source Absence of a national regulation system for nannies View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Name not published · 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
A baby died unexpectedly at home on 15 January 2024, after being found unresponsive in a bassinet; chlorpheniramine was present in his blood and had probably been administered by the night nanny. The coroner reached an open conclusion, with expert evidence that the drug could possibly have caused or contributed to the death. Concerns included an inadequate scene examination, failure to seize feeding equipment or search relevant property, insufficient consideration of poisoning, and the lack of specific nanny regulation and guidance about chlorpheniramine.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely seize feeding bottles and equipment pending toxicology results
Wider context from the report “2. That feeding bottles and equipment are not routinely seized pending toxicology results .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient police consideration of poisoning in unexpected child deaths
Wider context from the report “3. That insufficient consideration is given the potential role of poisoning in such deaths by the police .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Warning information for chlorpheniramine-containing products omitting their association with sudden unexpected death in children
Wider context from the report “9. That the warning information on products containing chlorpheniramine, such as piriton may need to be updated to include the association between administration of the substance and sudden unexpected death in children .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Perfunctory scene examinations in child death investigations
Wider context from the report “1. That child death investigation teams are too easily reassured when they attend deaths and find a well-presented home environment with no overt signs of neglect or injury to the deceased child, such that the scene examination becomes perfunctory and forensic opportunities are lost .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Police training and guidelines requiring updating
Wider context from the report “4. That police training and guidelines may need to be updated .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation A person who illicitly administered chlorpheniramine to a child continuing to work as a nanny
Wider context from the report “7. That a person whom the court found administered chlorpheniramine illicitly to a child and that administration possibly contributed to that child’s death is still working as a nanny .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Absence of a national regulation system for nannies
Wider context from the report “8. That there is no national regulation system for nannies .
” 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 Revise Child Abuse Authorised Professional Practice through a launched consultative process.
Verbatim wording from the response “The College of Policing has recently also launched a consultative period for our revision of Child Abuse Authorised Professional Practice (APP). I will ensure that the team proactively considers whether greater alignment between the practice advice on child death investigations and the APP on child abuse is required.” Source location Response from College of Policing
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 Work with NPCC colleagues to consider whether further strengthening and alignment of child death investigation practice advice and training is required.
Verbatim wording from the response “While I am satisfied that current police training and practice advice do cover the crucial issues kindly raised. I would also like to reassure you that we will work closely with NPCC colleagues, to consider whether further strengthening of the approach advocated is required. This includes ensuring that both the practice advice and training are aligned in all areas.” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and relaunch the national Investigating Sudden Death in Childhood Course.
Verbatim wording from the response “The College of Policing offers a national, Investigating Sudden Death in Childhood Course, which was reviewed and re-launched in 2025, and which is available to all Home Office forces. The programme has been developed for Lead Investigators who have the responsibility for conducting investigations following the sudden, unexpected death of a child. Those who attending the course should have previously completed Professionalising Investigation Programme (PIP) level 2 or level 3 learning and registration. The course reflects the 2024 National Police Chief’s Council (NPCC) Practice advice on child death investigation and provides delegates with the knowledge to conduct thorough and impartial investigations.” Source location Response from College of Policing
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 Current police training and practice advice already cover the concerns about child death investigations, so updating them is not currently considered necessary.
Verbatim wording from the response “While I am satisfied that current police training and practice advice do cover the crucial issues kindly raised. I would also like to reassure you that we will work closely with NPCC colleagues, to consider whether further strengthening of the approach advocated is required. This includes ensuring that both the practice advice and training are aligned in all areas.” Source location Response from College of Policing
Open published response
15 Oct 2025 Katie Overd · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Failure to undertake proactive public communications about the implementation of Right Care Right Person 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
Katie Overd · 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
Katie Overd, aged 46, died at home on 20 March 2025. The inquest concluded that she died from an unintended overdose of prescribed medication against a background of longstanding inappropriate prescribing and delayed medication reduction. The report raised concern that the lack of proactive public communication about the Right Care Right Person process could delay families seeking assistance in emergencies.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake proactive public communications about the implementation of Right Care Right Person
Wider context from the report “1. There has been a decision made not to undertake any proactive public communications in relation to the implementation of Right Care Right Person . The court heard evidence this was both on a national and regional basis . As a result, the public who have significant concerns for the life of their family members may not seek assistance as quickly as they could do, labouring under the misapprehension that there will be a timely response from emergency services.
” Open source report
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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 National public-facing communications are unnecessary because local inter-agency pathways triage calls and determine the appropriate responding service.
Verbatim wording from the response “When the NPA was originally developed and agreed by all the signatories, a discussion took place regarding whether there should be national public facing communications in respect of which agency should deliver specific services. However, it was agreed and remains the position that when the public make calls for service, they will not necessarily know which service is the most appropriate to be responding to a call as the nature of an incident and the associated risks can vary significantly. It is for” Source location Response from College of Policing
Open published response
7 Oct 2025 Ann Sabrina LASKOWSKY · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 4 Lack of dissemination and promotion of the Partner Triage Line to operational police officers View source Lack of clear training on assessing whether a person is responsive or unresponsive View source Lack of specific policy, guidance or training on using the Partner Triage Line View source Lack of clear training on assessing whether a person is breathing normally View source See 1 more concern
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
Ann Sabrina LASKOWSKY · 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
Ann Sabrina Laskowsky was found unresponsive at home on 5 October 2024 after police attended when an inactivity alarm was triggered. She was taken to hospital later that day and died on 6 October 2024 from naturally occurring disease contributed to by self-neglect and exacerbated by longstanding alcohol dependence. The principal concerns were the adequacy and clarity of police first-aid training, including recognising abnormal breathing and unresponsiveness, and officers’ knowledge, use and training regarding the Partner Triage Line.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of dissemination and promotion of the Partner Triage Line to operational police officers
Wider context from the report “2. The knowledge, use and training in respect of available resources
In the course of the Inquest, I heard evidence in respect of a resource or service, known as the ’Partner Triage Line’. This is a service which has been provided for a number of years by the Yorkshire Ambulance Service which provides a direct line for police officers to speak to a medical practitioner at the emergency operations centre, to seek advice, with the facility for the Officer to send photographs to the practitioner to help inform their advice and an ability for the practitioner to conduct a live video assessment.
Differing evidence was heard at inquest in terms of the knowledge of individual officers in respect of that service, with one officer being unaware that there was a service or resource.
In the course of my investigation, I received further evidence confirming that the telephone number for the ‘Partner Triage Line’ is visible and accessible in the contact environment and is then sent to officers on request, but that it is not known or promoted to those officers carrying out operational duties , who are those who are likely to need it the most.
I have significant concerns in relation to the knowledge of this valuable resource and its overall lack of use and promotion amongst those Officer who might need it the most. In particular my concerns relate to the following:-
a. The lack of knowledge and use of the service throughout West Yorkshire Police given the lack of dissemination and promotion amongst all of the officers to whom it would be of benefit , providing them with the tools to enable them to properly and effectively carry out their duties; and
b. The lack of specific policy, guidance or training for Officers in respect of how the service can be used to support them in carrying out their duties, enabling them to keep members of the public safe. This is of particular concern, given that the service has now been available for a number of years.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of clear training on assessing whether a person is responsive or unresponsive
Wider context from the report “1. The adequacy of First Aid Training provided by West Yorkshire Police
The body worn camera footage which was played during the course of the inquest, clearly shows that when the Officers arrived, they found Ann lying slumped on the sofa, appearing pale with an increased respiratory rate. Ann was profoundly unwell and required urgent medical attention.
The attending Officers did not recognise the severity of Ann's condition and instead considered that Ann was asleep but could not be woken. This of itself, raises significant concerns in respect of the nature and adequacy of the training that had been provided to the officers at the time.
Expert evidence received during the course of the Inquest concluded that even if the Officers had sought medical attention when they attended, given the severity of her condition, such treatment would not have prevented her death.
During the course of the Inquest, evidence was received from a variety of sources, in respect of nature and quality of the First Aid Training provided to Officers, in both their initial training and their annual refresher training.
This evidence demonstrated an overwhelming lack of clarity in terms of the way in which officers are trained to assess whether an individual is alive, breathing and conscious , something which it is expected that Officers can assess, in line with their authorised professional practice. The very nature of this evidence was such as to raise significant concerns as to the impact of this training upon the preservation of life.
There were two main areas in which the lack of clarity and consequent inadequacy of training were of particular concern:-
a. The assessment of whether a person is breathing normally and how this is to be assessed; and
b. Whether an individual is responsive or unresponsive, particularly in cases where there may be some involuntary movements from the individuals concerned .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of specific policy, guidance or training on using the Partner Triage Line
Wider context from the report “2. The knowledge, use and training in respect of available resources
In the course of the Inquest, I heard evidence in respect of a resource or service, known as the ’Partner Triage Line’. This is a service which has been provided for a number of years by the Yorkshire Ambulance Service which provides a direct line for police officers to speak to a medical practitioner at the emergency operations centre, to seek advice, with the facility for the Officer to send photographs to the practitioner to help inform their advice and an ability for the practitioner to conduct a live video assessment.
Differing evidence was heard at inquest in terms of the knowledge of individual officers in respect of that service, with one officer being unaware that there was a service or resource.
In the course of my investigation, I received further evidence confirming that the telephone number for the ‘Partner Triage Line’ is visible and accessible in the contact environment and is then sent to officers on request, but that it is not known or promoted to those officers carrying out operational duties, who are those who are likely to need it the most.
I have significant concerns in relation to the knowledge of this valuable resource and its overall lack of use and promotion amongst those Officer who might need it the most. In particular my concerns relate to the following:-
a. The lack of knowledge and use of the service throughout West Yorkshire Police given the lack of dissemination and promotion amongst all of the officers to whom it would be of benefit, providing them with the tools to enable them to properly and effectively carry out their duties; and
b. The lack of specific policy, guidance or training for Officers in respect of how the service can be used to support them in carrying out their duties , enabling them to keep members of the public safe. This is of particular concern, given that the service has now been available for a number of years.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of clear training on assessing whether a person is breathing normally
Wider context from the report “1. The adequacy of First Aid Training provided by West Yorkshire Police
The body worn camera footage which was played during the course of the inquest, clearly shows that when the Officers arrived, they found Ann lying slumped on the sofa, appearing pale with an increased respiratory rate. Ann was profoundly unwell and required urgent medical attention.
The attending Officers did not recognise the severity of Ann's condition and instead considered that Ann was asleep but could not be woken. This of itself, raises significant concerns in respect of the nature and adequacy of the training that had been provided to the officers at the time.
Expert evidence received during the course of the Inquest concluded that even if the Officers had sought medical attention when they attended, given the severity of her condition, such treatment would not have prevented her death.
During the course of the Inquest, evidence was received from a variety of sources, in respect of nature and quality of the First Aid Training provided to Officers, in both their initial training and their annual refresher training.
This evidence demonstrated an overwhelming lack of clarity in terms of the way in which officers are trained to assess whether an individual is alive, breathing and conscious , something which it is expected that Officers can assess, in line with their authorised professional practice. The very nature of this evidence was such as to raise significant concerns as to the impact of this training upon the preservation of life.
There were two main areas in which the lack of clarity and consequent inadequacy of training were of particular concern:-
a. The assessment of whether a person is breathing normally and how this is to be assessed ; and
b. Whether an individual is responsive or unresponsive, particularly in cases where there may be some involuntary movements from the individuals concerned.
” 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 Review Regulation 28 reports and relevant inquest findings as standing agenda items of the NPCC First Aid Forum.
Verbatim wording from the response “The operational deployment of local clinical support tools, such as the Partner Triage Line, is determined by individual forces in collaboration with local healthcare providers and falls outside the scope of the FALP licensing framework. Nonetheless, the College recognises the critical importance of ensuring that learning from incidents involving first aid provision is captured and shared across the policing community.” Source location Response from College of Policing
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 Produce and circulate national learning summaries and practice notes to all police forces.
Verbatim wording from the response “To ensure that national learning identified through the Forum is effectively disseminated and embedded, the College works closely with NPCC strategic and clinical leads to:” Source location Response from College of Policing
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 Engage force training leads and clinical governance advisers to support local implementation of national learning.
Verbatim wording from the response “To ensure that national learning identified through the Forum is effectively disseminated and embedded, the College works closely with NPCC strategic and clinical leads to:” Source location Response from College of Policing
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 Embed casualty assessment, primary survey, breathing checks and acute alcohol intoxication recognition in initial and annual refresher first-aid training.
Verbatim wording from the response “In 2023, the College undertook a comprehensive review of the FALP, which was subsequently endorsed by the NPCC. This review expanded both the learning content and the associated training time. The programme now includes high-level learning outcomes covering casualty assessment, primary survey techniques including responsiveness and breathing checks, and recognition of acute alcohol intoxication. These outcomes are embedded in both initial and annual refresher training for all public-facing officers. While the College sets the learning outcomes, individual forces retain discretion over delivery methods, in line with their local clinical governance arrangements.” Source location Response from College of Policing
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 Individual forces are responsible for delivering FALP training in accordance with their local clinical governance arrangements.
Verbatim wording from the response “In 2023, the College undertook a comprehensive review of the FALP, which was subsequently endorsed by the NPCC. This review expanded both the learning content and the associated training time. The programme now includes high-level learning outcomes covering casualty assessment, primary survey techniques including responsiveness and breathing checks, and recognition of acute alcohol intoxication. These outcomes are embedded in both initial and annual refresher training for all public-facing officers. While the College sets the learning outcomes, individual forces retain discretion over delivery methods, in line with their local clinical governance arrangements.” Source location Response from College of Policing
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 Individual forces, working with local healthcare providers, determine the operational deployment of local clinical support tools.
Verbatim wording from the response “The operational deployment of local clinical support tools, such as the Partner Triage Line, is determined by individual forces in collaboration with local healthcare providers and falls outside the scope of the FALP licensing framework. Nonetheless, the College recognises the critical importance of ensuring that learning from incidents involving first aid provision is captured and shared across the policing community.” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational deployment of local clinical support tools falls outside the FALP licensing framework.
Verbatim wording from the response “The operational deployment of local clinical support tools, such as the Partner Triage Line, is determined by individual forces in collaboration with local healthcare providers and falls outside the scope of the FALP licensing framework. Nonetheless, the College recognises the critical importance of ensuring that learning from incidents involving first aid provision is captured and shared across the policing community.” Source location Response from College of Policing
Open published response
Concerns raised 11 Lack of police training for mental health-related incidents involving illicit substance use View source Lack of cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance View source Delays and non-attendance in EMAS ambulance response to s.136 conveyance requests View source Unavailability of mental health management, monitoring and treatment for people with co-occurring substance misuse who cannot abstain View source Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy View source Failure of police training on ambulance conveyance for s.136 detainees View source Lack of police training on communicating s.136 detention decisions and reasons View source Lack of an out-of-hours local protocol for police access to mental health advice View source Lack of joined-up agency policy for s.136 detention and conveyance View source Reliance on unrealistic self-referral for people requiring mental health and substance misuse support View source Failure to align Street Triage Team capacity with current demand View source See 8 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
Kaine Regan FLETCHER · 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
Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of police training for mental health-related incidents involving illicit substance use
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee. Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances . I am concerned that training in the area of mental health generally is lacking , which is impacting upon the approach of the police officers dealing with mental health related incidents.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance
Wider context from the report “1. Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance
In September 2022, the Royal College of Psychiatrists issued a position statement on Acute Behavioural Disturbance and Excited Delirium. The RCP recommend that:
• A cross-sector working group should be convened to develop an interim consensus on ‘ABD’, with active involvement of patients and carers, to agree terminology, key principles for professional guidance, and priorities for further research.
• This group should include representatives from police, custodial, ambulance, emergency medicine, mental health, and the judicial and coronial system. Support from relevant government departments would help ensure consistency across services.
• Further research should be urgently commissioned, including detailed investigation into how racial bias plays into the application of terminology such as ‘ABD’.
• Members of the cross-sector working group should collaborate on the development and delivery of training materials for staff working across public services
• All services should seek to improve standardised collection of disaggregated data on presentations and outcomes, and to conduct regular multi-disciplinary reviews to support high-quality research on this topic.
I have heard evidence that in Nottingham and Nottinghamshire, no such cross-sector working is in place or joint agency policy is in place . I have also heard evidence that there is no knowledge of such cross-sector working or joint agency policy in place within the East Midlands generally, or nationally. The consequence of this is that there is no joined up thinking, procedure or policy, between front-line services who are regularly dealing with cases of ABD . That lack of collaborative working between services gives rise to a risk of future death for persons who develop ABD both in the community or in custody. People at risk of developing ABD often also fall into categories of vulnerability, such as suffering with a mental health disorder or using illicit substances. To my mind, this increases the risk of future death in the absence of any collaboration. I am concerned that this appears to be a national issue.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Delays and non-attendance in EMAS ambulance response to s.136 conveyance requests
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee.
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all .
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance. Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS . This may, in part, be explained by the policy/service level agreement confusion within EMAS.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health management, monitoring and treatment for people with co-occurring substance misuse who cannot abstain
Wider context from the report “6. Mental Health Services – ‘the gap’
I am concerned that there is a ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis . Clinically, I understand that substance misuse can provide a barrier to effective treatment of any mental health condition. However, I have heard evidence that there is no service available to patients for management, monitoring and treatment in circumstances where they are unable to abstain from substances but require care for the residual mental health condition . In circumstances where it is clinically recognised that substance misuse can exacerbate the symptoms of many mental health conditions, this gives risk to a clear risk of future death. The evidence that I have heard is that once treatment or referral options for these patients have been exhausted, they are discharged from the Local Mental Health Team with signposting to other services e.g. substance misuse services/charities or CRISIS. These services often required self-referral, which is not realistic for many people in these circumstances. Kaine fell into this gap, and I am concerned that there is a risk of future death for other patients if this gap is not filled. Again, it seems to me that this is an issue of national concern.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation . They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy , rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance. For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of police training on ambulance conveyance for s.136 detainees
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee .
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all.
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance . Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS. This may, in part, be explained by the policy/service level agreement confusion within EMAS.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of police training on communicating s.136 detention decisions and reasons
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee . Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances. I am concerned that training in the area of mental health generally is lacking, which is impacting upon the approach of the police officers dealing with mental health related incidents.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of an out-of-hours local protocol for police access to mental health advice
Wider context from the report “5. The availability of the Street Triage Team
I heard evidence that Nottinghamshire is pioneering in its provision of a Street Triage Team, a service that has been available since 2014. This team is comprised of one police officer and one community psychiatric nurse who can travel to mental health incidents to provide assessment and advice to the response officers, particularly in relation to exercising s.136 powers.
I heard that this service is available between 8am and 1am, and that the resourcing of the service (both in terms of the shift patterns and the available cars) was determined by analysis of a data set in 2017.
At the time that the incident arose with Kaine on 3 July 2022, no STT was available as it was out of hours.
I am concerned that there is a need to review the data to ensure that the demand for the service in 2025 is still reflected in the shift patterns. I am concerned, based on the evidence that I heard from EMAS in relation to an increase of ~60% in mental health related calls, that the demand for service may have changed since 2017.
I note that the Mental Health Code of Practice includes the following guidance at [16.23] in relation to triage and s.136: “When deciding that detention may be necessary, the police may also benefit from seeking advice before using section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours”. I am concerned that I have not seen any local protocol as to who the police should contact out of hours , and I note that EMAS do have available mental health nurses between the hours of 1am and 8am. This again appears to be a local policy and communication issue.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of joined-up agency policy for s.136 detention and conveyance
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation. They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy, rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance . For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Reliance on unrealistic self-referral for people requiring mental health and substance misuse support
Wider context from the report “6. Mental Health Services – ‘the gap’
I am concerned that there is a ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis. Clinically, I understand that substance misuse can provide a barrier to effective treatment of any mental health condition. However, I have heard evidence that there is no service available to patients for management, monitoring and treatment in circumstances where they are unable to abstain from substances but require care for the residual mental health condition. In circumstances where it is clinically recognised that substance misuse can exacerbate the symptoms of many mental health conditions, this gives risk to a clear risk of future death. The evidence that I have heard is that once treatment or referral options for these patients have been exhausted, they are discharged from the Local Mental Health Team with signposting to other services e.g. substance misuse services/charities or CRISIS. These services often required self-referral, which is not realistic for many people in these circumstances . Kaine fell into this gap, and I am concerned that there is a risk of future death for other patients if this gap is not filled. Again, it seems to me that this is an issue of national concern.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to align Street Triage Team capacity with current demand
Wider context from the report “5. The availability of the Street Triage Team
I heard evidence that Nottinghamshire is pioneering in its provision of a Street Triage Team, a service that has been available since 2014. This team is comprised of one police officer and one community psychiatric nurse who can travel to mental health incidents to provide assessment and advice to the response officers, particularly in relation to exercising s.136 powers.
I heard that this service is available between 8am and 1am, and that the resourcing of the service (both in terms of the shift patterns and the available cars) was determined by analysis of a data set in 2017 .
At the time that the incident arose with Kaine on 3 July 2022, no STT was available as it was out of hours.
I am concerned that there is a need to review the data to ensure that the demand for the service in 2025 is still reflected in the shift patterns . I am concerned, based on the evidence that I heard from EMAS in relation to an increase of ~60% in mental health related calls, that the demand for service may have changed since 2017 .
I note that the Mental Health Code of Practice includes the following guidance at [16.23] in relation to triage and s.136: “When deciding that detention may be necessary, the police may also benefit from seeking advice before using section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours”. I am concerned that I have not seen any local protocol as to who the police should contact out of hours, and I note that EMAS do have available mental health nurses between the hours of 1am and 8am. This again appears to be a local policy and communication issue.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the mental health Approved Professional Practice to align ABD guidance with updated health policy.
Verbatim wording from the response “The College is currently undertaking a review of the mental health Approved Professional Practice (APP), which will ensure that any development in the published guidelines in relation to ABD are updated to ensure consistency with updated health policy.” Source location Response from College of Policing
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 Support forces to develop local protocols with partner agencies.
Verbatim wording from the response “• Support forces in developing local protocols with partner agencies” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational and local partnership concerns are being addressed by Nottinghamshire Police, which is providing the full response.
Verbatim wording from the response “We have carefully considered the matters of concern raised in your Regulation 28 report. This response outlines the College of Policing’s position on Acute Behavioural Disturbance, and police training in respect of the Mental Health Act. In relation to the operational elements and local partnership working, we have been in contact with Nottinghamshire Police and understand that a number of measures are being implemented and a full response to the concerns you have raised is being provided.” Source location Response from College of Policing
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 National health-related policy on ABD should be led by health partners, with policing informed by agreed health guidance.
Verbatim wording from the response “This is an area that requires further research and an evidence base to inform national policy. The police’s role in responding to ABD, particularly as a medical risk, needs to be informed and based on agreed guidance from our partners in Health – it is imperative that health should lead on areas of national health-related policy.” Source location Response from College of Policing
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 Further research and an evidence base are required before national policy on ABD can be developed.
Verbatim wording from the response “This is an area that requires further research and an evidence base to inform national policy. The police’s role in responding to ABD, particularly as a medical risk, needs to be informed and based on agreed guidance from our partners in Health – it is imperative that health should lead on areas of national health-related policy.” Source location Response from College of Policing
Open published response
Concerns raised 3 Failure to provide specific briefing discussion or direction on when to announce “armed police” View source Insufficient training and guidance on positioning firearms officers close to property entrances View source Lack of clear and consistent guidance and training on timing and factors for announcing “armed police” during containment and call-out operations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
SEAN FITZGERALD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 4 January 2019 in Coventry, Sean Fitzgerald emerged from the rear door of a house during a West Midlands Police firearms operation and was shot in the chest by a police firearms officer. He died at 6.55pm despite first aid and medical treatment. The report identifies concerns about inconsistent guidance and training on when to announce “armed police” and how firearms officers should position themselves near property entrances, including the risks associated with close proximity.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide specific briefing discussion or direction on when to announce “armed police”
Wider context from the report “(1) Training and practice in relation to timing of any announcement of “armed police” in police firearms operations involving containment of properties
In the police operation in which Mr Fitzgerald was killed, the officers employed the tactic of “contain and call out with limited entry.” This involves firearms officers “containing” a property by surrounding it and providing firearms cover with their weapons; creating a breach by forcing entry; and “calling out” the subjects inside (directing them to leave through the point of breach), without the officers themselves entering. In evidence, it was explained that this is a very common tactic, which is used in a range of scenarios.
████████ a former senior firearms officer and armed policing lead within the College of Policing, gave evidence in the inquest. He explained that an integral part of the tactic is for officers to announce their presence by loud shouts of “armed police.” This warns those inside the property that it is the police forcing entry and informs them that the officers are armed. It was explained that this warning helps to avoid confusion and encourage compliance, thereby reducing the risk of harm to officers and occupants. The timing of the announcement is plainly important, and any potential for confusion or for making the announcement at the wrong time risks fatal consequences.
████████ said that the timing of any such announcement is not prescribed by national training or guidance, and that there is no “template” for when it should be done, although he understood that it would usually be made after achieving a breach (e.g. breaking down a door). The procedural and training documents (both national and from WMP) which were put in evidence in the inquest gave no detailed guidance on the subject. The Chief Firearms Instructor at WMP, ████████, gave evidence that WMP trains its officers to make the announcement after achieving a breach.
The evidence of the officers involved in the operation as to the recommended or standard practice was inconsistent. The Strategic Firearms Commander said that he expected officers to announce themselves as armed police as soon as they were in position. The Operational Firearms Commander said that the shout should first be made as soon as the chainsaw was being applied to the door and again as the breach was made. One further member of the team said that he thought best practice was to give the shout as the chainsaw was being applied, but acknowledged that he had not done so on this occasion. Several other members of the team thought that proper practice was only to make the announcement after the door had been breached.
The firearms briefing told the officers that method of entry would be conducted and “[o]nce breached, challenges will be made at the threshold and suspects will be handcuffed”. There was no further discussion or direction about when the officers should first announce their presence .
In the event, the officers at the front of the property did not shout “armed police” before breaking down the two doors at the front of the property. Before any announcement was made, Mr Fitzgerald left through the rear door of the premises and was shot by Officer K, who was providing rear containment.
In these circumstances, I am concerned that the guidance and training given to firearms officers on tactics of containing and entering properties (and specifically in relation to the containment and call out with limited entry tactic) does not ensure a clear and consistent understanding of when they should announce their presence, or what factors to consider in deciding when to make the announcement. I am also concerned that the topic was not the subject of more specific discussion or direction in the briefing .
It is important that officers conducting these kinds of highly challenging firearms operation should have proper guidance on this subject. If the approach of different officers is inconsistent, there is the clear potential for mistakes to be made and for the lives of officers and others to be put at risk. I appreciate that expert firearms training officers are best placed to produce any further guidance, and that it may not be possible to have a hard and fast rule. However, the inconsistent views of highly trained officers which were given in this inquest indicate that the subject ought to be further addressed in training and in formal guidance.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and guidance on positioning firearms officers close to property entrances
Wider context from the report “(2) Training and practice in relation to positioning of firearms officers in operations against properties (including consideration of the reactionary gap)
As set out above, in this case, Officer K was standing between 7 and 8 feet from the rear door of the property as Mr Fitzgerald left. He discharged his firearm within just over half a second of the door beginning to open. The jury found that he had acted lawfully, meaning that he had perceived a threat and had used force commensurate with the threat he perceived. They also found that he had acted reasonably in taking up the position which he took, given the briefing he had received. Nevertheless, the evidence at the inquest gave cause for concern in relation to the training and guidance given to firearms officers on how they should position themselves in operations against properties.
In the inquest, two experts in cognition and perception, ████████ and ████████, explained that close proximity to a potential source of danger can have a psychological impact, significantly elevating a person’s perception of threat and potentially increasing the likelihood that they will respond with force. The experts considered that, in this case, such proximity was likely to have heightened Officer K’s perception of threat.
The inquest heard evidence about the concept of the “reactionary gap”, a distance which officers are often trained to maintain between themselves and a subject who presents a threat. In evidence, ████████ discussed this concept, explaining that distance gives officers more time to assimilate information and respond to an approaching threat. ████████ explained that maintaining a reactionary gap prevents officers from being “closed down” by subjects. He said that officers are trained on the importance of distance in the context of containment tactics.
The firearms training and guidance materials considered in evidence made limited reference to positioning and the reactionary gap. The WMP training materials required students to demonstrate an appropriate reactionary gap in one training exercise and to explain its importance in another. The College of Policing’s Authorised Professional Practice on Armed Containment described the benefit of distance, but in terms of reducing stress, tension and the likelihood of a close quarter confrontation. None of the materials gave any detailed consideration to the risks presented by close proximity (including close proximity to entrances rather than subjects) in the context of armed containment of properties . None explained the potential impact of proximity on threat perception and the likelihood that an officer will respond with potentially lethal force .
I am concerned that the training and guidance given to firearms officers on how to position themselves, especially in operations against properties, does not include detailed consideration of the risks of taking up position in close proximity to entrances. It does not appear to address the effects of proximity on threat perception and the use of force .
As with the first matter of concern, I recognise that it should be for expert firearms training officers to decide how to deal with this subject in training and guidance, and that there will inevitably be situations where a firearms officer has to take up position very close to a doorway or other entrance when containing a property. However, there appears to be a need for further consideration of this issue in the interest of minimising the risks of mistake of fact shootings in the future.
Finally, I should stress that in raising this matter of concern, I am not detracting from the jury’s conclusions that Officer K’s use of force was lawful and that his decision on where to position himself was reasonable in light of the briefing and intelligence.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and consistent guidance and training on timing and factors for announcing “armed police” during containment and call-out operations
Wider context from the report “(1) Training and practice in relation to timing of any announcement of “armed police” in police firearms operations involving containment of properties
In the police operation in which Mr Fitzgerald was killed, the officers employed the tactic of “contain and call out with limited entry.” This involves firearms officers “containing” a property by surrounding it and providing firearms cover with their weapons; creating a breach by forcing entry; and “calling out” the subjects inside (directing them to leave through the point of breach), without the officers themselves entering. In evidence, it was explained that this is a very common tactic, which is used in a range of scenarios.
████████ a former senior firearms officer and armed policing lead within the College of Policing, gave evidence in the inquest. He explained that an integral part of the tactic is for officers to announce their presence by loud shouts of “armed police.” This warns those inside the property that it is the police forcing entry and informs them that the officers are armed. It was explained that this warning helps to avoid confusion and encourage compliance, thereby reducing the risk of harm to officers and occupants. The timing of the announcement is plainly important, and any potential for confusion or for making the announcement at the wrong time risks fatal consequences.
████████ said that the timing of any such announcement is not prescribed by national training or guidance, and that there is no “template” for when it should be done , although he understood that it would usually be made after achieving a breach (e.g. breaking down a door). The procedural and training documents (both national and from WMP) which were put in evidence in the inquest gave no detailed guidance on the subject . The Chief Firearms Instructor at WMP, ████████, gave evidence that WMP trains its officers to make the announcement after achieving a breach.
The evidence of the officers involved in the operation as to the recommended or standard practice was inconsistent. The Strategic Firearms Commander said that he expected officers to announce themselves as armed police as soon as they were in position. The Operational Firearms Commander said that the shout should first be made as soon as the chainsaw was being applied to the door and again as the breach was made. One further member of the team said that he thought best practice was to give the shout as the chainsaw was being applied, but acknowledged that he had not done so on this occasion. Several other members of the team thought that proper practice was only to make the announcement after the door had been breached.
The firearms briefing told the officers that method of entry would be conducted and “[o]nce breached, challenges will be made at the threshold and suspects will be handcuffed”. There was no further discussion or direction about when the officers should first announce their presence.
In the event, the officers at the front of the property did not shout “armed police” before breaking down the two doors at the front of the property. Before any announcement was made, Mr Fitzgerald left through the rear door of the premises and was shot by Officer K, who was providing rear containment.
In these circumstances, I am concerned that the guidance and training given to firearms officers on tactics of containing and entering properties (and specifically in relation to the containment and call out with limited entry tactic) does not ensure a clear and consistent understanding of when they should announce their presence, or what factors to consider in deciding when to make the announcement . I am also concerned that the topic was not the subject of more specific discussion or direction in the briefing.
It is important that officers conducting these kinds of highly challenging firearms operation should have proper guidance on this subject. If the approach of different officers is inconsistent, there is the clear potential for mistakes to be made and for the lives of officers and others to be put at risk. I appreciate that expert firearms training officers are best placed to produce any further guidance, and that it may not be possible to have a hard and fast rule. However, the inconsistent views of highly trained officers which were given in this inquest indicate that the subject ought to be further addressed in training and in formal guidance.
” 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 Publish the interim guidance in an NPCC national circular and circulate it to all UK police forces for immediate implementation.
Verbatim wording from the response “Following consultation with stakeholders, most notably the Independent Office of Police Conduct (IOPC), who were also in receipt of a letter of concern regarding the same matter, additional guidance has been drafted for inclusion within The College authorised professional practice on armed policing (APP-AP) and the authorised professional practice on post-incident procedures following death or serious injury. The amended APP will be published within the next 2-3 weeks and in the interim the guidance has been published in a National Police Chiefs’ Council (NPCC) national circular and circulated to all police forces in the UK for immediate implementation. The amended guidance has been included in a practical scenario that formed the basis of this year’s annual College national Post Incident Manager (PIM) training which all PIMs must receive.” Source location Response from College of Policing
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 Draft additional guidance for inclusion in authorised professional practice on armed policing and post-incident procedures.
Verbatim wording from the response “Following consultation with stakeholders, most notably the Independent Office of Police Conduct (IOPC), who were also in receipt of a letter of concern regarding the same matter, additional guidance has been drafted for inclusion within The College authorised professional practice on armed policing (APP-AP) and the authorised professional practice on post-incident procedures following death or serious injury. The amended APP will be published within the next 2-3 weeks and in the interim the guidance has been published in a National Police Chiefs’ Council (NPCC) national circular and circulated to all police forces in the UK for immediate implementation. The amended guidance has been included in a practical scenario that formed the basis of this year’s annual College national Post Incident Manager (PIM) training which all PIMs must receive.” Source location Response from College of Policing
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 Publish the amended authorised professional practice guidance within the stated two-to-three-week timeframe.
Verbatim wording from the response “Following consultation with stakeholders, most notably the Independent Office of Police Conduct (IOPC), who were also in receipt of a letter of concern regarding the same matter, additional guidance has been drafted for inclusion within The College authorised professional practice on armed policing (APP-AP) and the authorised professional practice on post-incident procedures following death or serious injury. The amended APP will be published within the next 2-3 weeks and in the interim the guidance has been published in a National Police Chiefs’ Council (NPCC) national circular and circulated to all police forces in the UK for immediate implementation. The amended guidance has been included in a practical scenario that formed the basis of this year’s annual College national Post Incident Manager (PIM) training which all PIMs must receive.” Source location Response from College of Policing
Open published response
7 Jul 2025 Elaine TARBUCK · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 5 Lack of clarity about lawful authority and responsibility for forced entry View source Sub-optimal information gathering and evaluation of emergency category View source Failure to accurately evaluate concern-for-welfare emergencies requiring forced entry View source Failure of emergency-service first-responder allocation to provide appropriate care for concern-for-welfare emergencies View source Poor training of emergency call handlers View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elaine TARBUCK · 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
Elaine TARBUCK died after an accidental fall at home, sustaining a head injury and exsanguinating before she was found unresponsive on 29 March 2025. The report identified concerns about the assessment and information gathering by emergency services, delays in arranging forced entry, and the application of the ‘Right Care, Right Person’ policy.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about lawful authority and responsibility for forced entry
Wider context from the report “4. There was lack of understanding as to whether the forced entry would be lawful, a matter for the police, or a matter for Fire and Rescue Services in circumstances that the next-of-kin, if asked, would have agreed readily to there being forced entry at the outset and well before their arrival.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Sub-optimal information gathering and evaluation of emergency category
Wider context from the report “5. There was accepted sub-optimal information gathering and evaluation of the category of this emergency with an example of poor training resulting in inappropriate language being used by a call handler.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately evaluate concern-for-welfare emergencies requiring forced entry
Wider context from the report “3. In fact, calls to the non-emergency 101 and 999 emergency lines evaluated that this was a non-critical emergency and a presumed medical event . This created a significant delay before it was appreciated that entry would need to be forced and the Fire and Rescue Service were requested to attend.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency-service first-responder allocation to provide appropriate care for concern-for-welfare emergencies
Wider context from the report “6. The emergency response had come about because of a new ‘Right Care, Right Person’ policy applied by emergency services that, in fact, delivered as a first responder, the wrong person delivering the wrong care to the deceased’s residence .
7. Prior to the implementation of ‘Right Care, Right Person’ this ‘concern for welfare’ emergency would have been dealt with by the attendance of the police on the scene as first responders who would have been likely to have achieved entry as a result of the concern for welfare.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Poor training of emergency call handlers
Wider context from the report “5. There was accepted sub-optimal information gathering and evaluation of the category of this emergency with an example of poor training resulting in inappropriate language being used by a call handler .
” 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 Support forces and partner agencies to develop and disseminate local protocols defining responsibilities for forced entry.
Verbatim wording from the response “The confusion over which agency should take responsibility for forced entry is a key learning point. The RCRP guidance encourages local partnerships to develop clear protocols that define roles and responsibilities in such scenarios. These protocols should be communicated effectively to all frontline staff to avoid hesitation or uncertainty during time-critical incidents.” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update national RCRP guidance to clarify risk assessment and address emerging learning.
Verbatim wording from the response “The College is reviewing the RCRP toolkit to ensure it provides clearer guidance on the assessment of risk in control rooms, including how to handle ambiguous or borderline cases where the threshold for police attendance may not be immediately clear.” Source location Response from College of Policing
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 Monitor the impact of RCRP and refine guidance using operational feedback and case reviews.
Verbatim wording from the response “The intent of RCRP is to ensure individuals received the most appropriate care from the most appropriate agency. However, we understand the concerns and recognise that its implementation must be sensitive to the nuances of real-world emergencies. The College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews such as this.” Source location Response from College of Policing
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 Local partnerships must determine agency responsibility for forced entry, with partner agencies potentially providing appropriate powers, training and equipment.
Verbatim wording from the response “It explicitly states that there is no general power of entry for welfare checks reaffirming the position as set out within the case of Syed v DPP [2010] EWHC 81 (Admin) in relation to the powers of entry available to the police. The toolkit states ‘There is no specific power of entry to carry out a concern for welfare check…’. It also encourages forces to work with partners—particularly the Fire and Rescue Service—who may have the appropriate powers, training and equipment to gain entry in such circumstances.
Please see an extract below and relevant link:” Source location Response from College of Policing
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 Police generally lack power to enter private dwellings for welfare checks absent a real and immediate risk, serious harm or suspected crime.
Verbatim wording from the response “The College recognises the public expectation that emergency services will respond swiftly and decisively when there is concern for someone’s welfare. However, the legal framework governing police powers of entry is clear: unless there is a real and immediate risk to life or of serious harm (as defined under Articles 2 and 3 of the ECHR), or a crime is suspected, police powers to enter a private dwelling are limited.” Source location Response from College of Policing
Open published response
25 Jun 2025 Muhammad QASIM · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Inconsistent training of standard police drivers on spontaneous pursuits View source Failure to obtain full forensic collision investigation reports in fatal incidents View source Lack of consistent APP guidance on when a spontaneous pursuit can occur View source Unclear investigative responsibilities during conduct investigations in fatal incidents 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
Muhammad QASIM · 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
Muhammad QASIM died on 2 October 2023 after a high-speed BMW collision in which the vehicle left the road and struck two trees; he suffered unsurvivable traumatic head injuries. The report raises concerns about differing interpretations and training regarding spontaneous police pursuits, and about investigative responsibilities and the absence of a full forensic collision investigation report in fatal incidents involving a conduct investigation.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Inconsistent training of standard police drivers on spontaneous pursuits
Wider context from the report “1. For the college of policing: The inquest heard evidence from 2 specialist police driving instructors in different police forces. Both had a different interpretation of when a spontaneous pursuit could occur as set out in the APP guidance. One force did not train officers who were standard drivers in relation to spontaneous pursuits as these were thought to be a type of pursuit and dependent on first satisfying the main definition of a pursuit under the APP guidance. The other force considered spontaneous pursuit to be a stand alone type of pursuit and trained standard driving officers in relation to it. The confusion around what amounts to a spontaneous pursuit and when one can occur, and the difference in training of police standard drivers , creates a risk of future deaths and action should be taken.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain full forensic collision investigation reports in fatal incidents
Wider context from the report “2. For the IOPC: The IOPC were investigating the conduct of the police driver in this case. As a result of their investigation no full forensic collision investigation report was obtained. The IOPC need to confirm where investigative responsibilities lie when a conduct investigation is being conducted in all fatal incidents to ensure lessons are learnt from the death and adequate evidence is obtained. The lack of a full forensic collision investigation report in this case creates a risk of future deaths and action should be taken.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent APP guidance on when a spontaneous pursuit can occur
Wider context from the report “1. For the college of policing: The inquest heard evidence from 2 specialist police driving instructors in different police forces. Both had a different interpretation of when a spontaneous pursuit could occur as set out in the APP guidance. One force did not train officers who were standard drivers in relation to spontaneous pursuits as these were thought to be a type of pursuit and dependent on first satisfying the main definition of a pursuit under the APP guidance. The other force considered spontaneous pursuit to be a stand alone type of pursuit and trained standard driving officers in relation to it. The confusion around what amounts to a spontaneous pursuit and when one can occur , and the difference in training of police standard drivers, creates a risk of future deaths and action should be taken.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Unclear investigative responsibilities during conduct investigations in fatal incidents
Wider context from the report “2. For the IOPC: The IOPC were investigating the conduct of the police driver in this case. As a result of their investigation no full forensic collision investigation report was obtained. The IOPC need to confirm where investigative responsibilities lie when a conduct investigation is being conducted in all fatal incidents to ensure lessons are learnt from the death and adequate evidence is obtained. The lack of a full forensic collision investigation report in this case creates a risk of future deaths and action should be taken.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review current police pursuit training requirements, including national standards and authorised training arrangements.
Verbatim wording from the response “We have reviewed the current training requirements for police pursuits:” Source location Response from the College of Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the current Police Pursuit APP guidance and identify ambiguity in the term “spontaneous pursuit”.
Verbatim wording from the response “• We have reviewed the current Police Pursuit APP guidance. While the initial definition of a police pursuit is considered clear and appropriate, we acknowledge that the term ‘spontaneous pursuit’ may be open to interpretation. This could suggest that a pursuit might occur without first meeting the established definition.” Source location Response from the College of Policing
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 Progress an amendment to replace “spontaneous pursuit” with clearer guidance aligned with the National Decision Model.
Verbatim wording from the response “• We will progress an amendment to the Police Pursuit APP to replace the reference to ‘spontaneous pursuit’ with clearer, more precise guidance aligned with the National Decision Model (NDM).” Source location Response from the College of Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring and addressing inconsistencies in police pursuit training delivery through quality-assurance frameworks and feedback mechanisms.
Verbatim wording from the response “We are committed to ensuring that the learning from this case leads to meaningful and lasting improvements in policing practice and will continue to work closely with NPCC leads and police forces to ensure that national guidance and training reflect best practice and support safe operational decision-making. We aim to publish the revised guidance by December 2025, subject to consultation and governance processes. The College will continue to monitor and address any inconsistencies in training delivery through its QA frameworks and feedback mechanisms. We will also ensure that learning from this case is disseminated nationally through our operational learning channels, including bulletins and updates to training materials.” Source location Response from the College of Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NPCC leads and police forces to align national guidance and training with best practice and safe operational decision-making.
Verbatim wording from the response “We are committed to ensuring that the learning from this case leads to meaningful and lasting improvements in policing practice and will continue to work closely with NPCC leads and police forces to ensure that national guidance and training reflect best practice and support safe operational decision-making. We aim to publish the revised guidance by December 2025, subject to consultation and governance processes. The College will continue to monitor and address any inconsistencies in training delivery through its QA frameworks and feedback mechanisms. We will also ensure that learning from this case is disseminated nationally through our operational learning channels, including bulletins and updates to training materials.” Source location Response from the College of Policing
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 Disseminate learning from the case nationally through operational learning channels, bulletins, and training-material updates.
Verbatim wording from the response “We are committed to ensuring that the learning from this case leads to meaningful and lasting improvements in policing practice and will continue to work closely with NPCC leads and police forces to ensure that national guidance and training reflect best practice and support safe operational decision-making. We aim to publish the revised guidance by December 2025, subject to consultation and governance processes. The College will continue to monitor and address any inconsistencies in training delivery through its QA frameworks and feedback mechanisms. We will also ensure that learning from this case is disseminated nationally through our operational learning channels, including bulletins and updates to training materials.” Source location Response from the College of Policing
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 Chief Officers are responsible for arranging pursuit-driver selection, training and authorisation, and determining operational deployment in accordance with national standards.
Verbatim wording from the response “• The Code of Practice on the Management of Police Pursuits (Home Office, 2011) states that Chief Officers should arrange the selection, training, and authorisation of officers involved in pursuits in accordance with national standards. These national standards are set out in the Police Driving National Policing Curriculum and cover the initial phase pursuit, tactical phase pursuit, and command and control. It is the responsibility of each Chief Officer to determine the operational deployment of officers trained and authorised in both the initial phase (response drivers) and tactical phase (advanced drivers).” Source location Response from the College of Policing
Open published response
10 Jun 2025 Amy Anne Levy · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of general guidance on when to leave voicemail messages in non-domestic-abuse cases View source Unclear applicability of voicemail guidance to police officers and control-room staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amy Anne Levy · 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
Amy Anne Levy, a 22-year-old student, took an overdose of prescription drugs on 18 June 2023 and later died in hospital on 22 June 2023. Police and ambulance services did not know her address for over two hours despite knowing that her condition was deteriorating and that the case required an immediate response. The principal concern was that police officers and call handlers did not leave voicemail messages when attempting to contact her parents, potentially delaying the discovery of her location; the inquest jury identified a catalogue of missed opportunities to obtain her correct address.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of general guidance on when to leave voicemail messages in non-domestic-abuse cases
Wider context from the report “As I have outlined above, this was an ‘immediate’ priority search to obtain the address of a young woman who whose life was believed to be at risk.
It is hard to understand the decision (made by more than one police caller) not to leave any voicemail/message.
We heard evidence from two police Inspectors (one from Avon and Somerset Constabulary and one from Surrey Police) that although there is guidance in Avon not to leave voicemails when the incident in question concerns domestic abuse, there is no general guidance about when to leave a voicemail message in other cases (ie, it is neither encouraged not discouraged by any policy or standard operating procedure) .
I was subsequently provided with an updated ‘Deployment of Resources Procedure’ from Surrey Police, which indicates that ‘call takers and dispatchers must consider whether it is appropriate to leave a voicemail, unless there is a compelling operational reason not to do so’. It is not clear from the title of the document or the wording of the guidance whether this is intended to affect police officers, or only the actions of those in Surrey’s contact centre and force control room.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Unclear applicability of voicemail guidance to police officers and control-room staff
Wider context from the report “As I have outlined above, this was an ‘immediate’ priority search to obtain the address of a young woman who whose life was believed to be at risk.
It is hard to understand the decision (made by more than one police caller) not to leave any voicemail/message.
We heard evidence from two police Inspectors (one from Avon and Somerset Constabulary and one from Surrey Police) that although there is guidance in Avon not to leave voicemails when the incident in question concerns domestic abuse, there is no general guidance about when to leave a voicemail message in other cases (ie, it is neither encouraged not discouraged by any policy or standard operating procedure).
I was subsequently provided with an updated ‘Deployment of Resources Procedure’ from Surrey Police, which indicates that ‘call takers and dispatchers must consider whether it is appropriate to leave a voicemail, unless there is a compelling operational reason not to do so’. It is not clear from the title of the document or the wording of the guidance whether this is intended to affect police officers, or only the actions of those in Surrey’s contact centre and force control room .
” 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 Update the national Contact Management Curriculum to include emergency voicemail guidance and learning from the case.
Verbatim wording from the response “○ We have liaised with Surrey Police and Avon and Somerset Police to understand the chronology of events and their subsequent actions. Surrey Police have updated their deployment procedures and developed training on voicemail protocols, scheduled for implementation from September 2025.
○ Avon and Somerset Police have revised their handling codes for incidents involving suicidal individuals and will issue guidance through their Professional Standards Department on appropriate voicemail practices.
○ The College will actively support and facilitate the sharing of these practices nationally. This will be coordinated through the relevant National Police Chiefs’ Council (NPCC) Working Groups to ensure consistent adoption across all forces.
○ We are currently updating the national Contact Management Curriculum.” Source location Response from College of Policing
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 Roll out the revised Contact Management Curriculum nationally, with forces expected to align their training programmes.
Verbatim wording from the response “revised curriculum will explicitly address the issue of voicemail guidance in emergency contexts and will incorporate the lessons learned from this case.
○ The updated curriculum is undergoing a comprehensive quality assurance process and is scheduled for national rollout by March 2026. All forces will be expected to align their training programs with this revised framework.” Source location Response from College of Policing
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 Support and facilitate national sharing of voicemail practices through relevant NPCC working groups.
Verbatim wording from the response “○ We have liaised with Surrey Police and Avon and Somerset Police to understand the chronology of events and their subsequent actions. Surrey Police have updated their deployment procedures and developed training on voicemail protocols, scheduled for implementation from September 2025.
○ Avon and Somerset Police have revised their handling codes for incidents involving suicidal individuals and will issue guidance through their Professional Standards Department on appropriate voicemail practices.
○ The College will actively support and facilitate the sharing of these practices nationally. This will be coordinated through the relevant National Police Chiefs’ Council (NPCC) Working Groups to ensure consistent adoption across all forces.
○ We are currently updating the national Contact Management Curriculum.” Source location Response from College of Policing
Open published response
Concerns raised 4 Delays caused by supervisory review of negative “Right Care, Right Person” attendance decisions View source Failure to account for mental health crisis team inability to enter locked premises when directing callers to mental health services View source Failure to make a police attendance decision after repeated serious concerns from callers View source Failure to authorise police attendance despite a reported real and immediate risk to life 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
Sophie Ann Louise Cotton · 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
Sophie Ann Louise Cotton had a long history of mental health problems and previous suicide attempts. On 6 January 2025, after she failed to attend important family contact and could not be contacted, four calls were made to the police requesting a welfare check; shortly afterwards, her family found her hanging by a ligature at home. The principal concerns were refusals or delays in police attendance under the “Right Care, Right Person” procedure, including where callers expressed a real and immediate risk to life and where mental health services could not enter locked premises.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Delays caused by supervisory review of negative “Right Care, Right Person” attendance decisions
Wider context from the report “(4) Although there is a procedure in place to have a negative “Right Care, Right Person” decision reviewed by a supervisor , this causes additional delay in circumstances when attendance could be extremely time-sensitive .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to account for mental health crisis team inability to enter locked premises when directing callers to mental health services
Wider context from the report “(2) During the 16:44 call the “Right Care, Right Person” advice to contact mental health services appears to have disregarded the fact that the mental health crisis team do not have the power to enter locked premises and so would require police attendance to facilitate entry to the premises .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to make a police attendance decision after repeated serious concerns from callers
Wider context from the report “(3) During the 16:57 call there was no decision for police to attend , even though this was the third caller (and second professional caller) that had expressed serious concerns about the Deceased .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to authorise police attendance despite a reported real and immediate risk to life
Wider context from the report “(1) During the 16:44 call, by following the “Right Care, Right Person” procedure there was a refusal to the request that the police attend , even when a family member was expressing the view that there was a real and immediate risk to life .
” 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 Monitor and work with partners on powers of entry so agencies understand legal parameters and available options.
Verbatim wording from the response “Ongoing monitoring and work is being undertaken with partners with regards to powers of entry to ensure all partners are aware of the legal parameters in which all agencies operate, including for all agencies to understand the specific legal powers available to them, and to ensure all options are being considered.” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing toolkit content and provide forces with tools, training and support to implement and deliver Right Care, Right Person.
Verbatim wording from the response “The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. The College continually reviews the content of the toolkit guidance to ensure forces are provided with the tools, training, and support to effectively implement and deliver RCRP.” Source location Response from College of Policing
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 Collate concerns raised, review them against the toolkit and guidance, and amend the toolkit where necessary.
Verbatim wording from the response “The College collates all information in respect of concerns that are raised, and reviews these against the toolkit and guidance provided to forces. The toolkit is subject to ongoing review and where necessary amendments will be made. The College continues to encourage forces to follow the guidance within their development of RCRP and provides ongoing support and advice to forces.” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational decisions and responses under Right Care, Right Person are the responsibility of individual police forces, including Durham Constabulary.
Verbatim wording from the response “In relation to the operational elements and decision-making processes, we have been in contact with Durham Constabulary and understand that a full response to these points is being provided.” Source location Response from College of Policing
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 Police cannot enter a person’s home for a welfare check where assessed risk does not reach the threshold of risk to life and limb.
Verbatim wording from the response “The College RCRP guidance reaffirms the position as set out within the case of Syed v DPP [2010] EWHC 81 (Admin) in relation to the powers of entry available to the police. The toolkit states ‘There is no specific power of entry to carry out a concern for welfare check…’” Source location Response from College of Policing
Open published response
25 Mar 2025 Oladeji Adeyemi Omishore · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 12 Failure to train call handlers and first responders to record information for dispatcher transmission View source Lack of training on where call handlers and first responders should record information View source Failure to circulate mental health information promptly during I grade calls View source Lack of dispatcher training on information to pass to responding officers View source Lack of dispatcher training on passing possible mental health concerns over the airwaves View source Lack of a NICL code for believed mental health concerns View source Failure to pass the number of units on the way over the airwaves View source Dispatcher pod failures causing mental health concerns to be missed under work pressure View source Inadequate response officer training on de-escalation and taser deployment tactics for subjects with mental ill-health View source Lack of training advice on recording mental health information concerning black men View source Inconsistent recording of mental health information by call handlers and first responders View source Insufficient NICL code capacity for recording mental health as a qualifier View source See 9 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.
×
AI-generated summary
Oladeji Adeyemi Omishore · 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
Oladeji Adeyemi Omishore died on 4 June 2022 after being tasered during an incident involving police officers on Chelsea Bridge and then entering the River Thames; his medical cause of death was complications arising from drowning. The report identified concerns about the recording and transmission of mental health information by call handlers and dispatchers, and about training for responding officers in tactical options before taser deployment.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to train call handlers and first responders to record information for dispatcher transmission
Wider context from the report “2. That the call handlers/ first responders may have a training issue in relation to the importance of recording this information in a manner which is likely to be passed on to responding officers by dispatchers , for example in the NICL codes and/ or “golden line”.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of training on where call handlers and first responders should record information
Wider context from the report “5. That call handlers/first responders may need training as to where to record such information i.e. in the “golden line” or NICL code , as long as of course it is reported to them before the “golden line” and NICL code has gone out.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to circulate mental health information promptly during I grade calls
Wider context from the report “6. That use of THRIVE usually requires time that is not available in I grade calls and does not mitigate the need to circulate promptly information as to mental health issues , in the format most likely to be digested and passed on by dispatchers that is “golden line” or NICL codes.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of dispatcher training on information to pass to responding officers
Wider context from the report “9. That dispatchers may require training in relation to what to pass out more generally given the confusion in the evidence about other units being assigned by CAD, which dispatchers themselves did not seem to appreciate and understand let alone pass such information out to responding officers .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of dispatcher training on passing possible mental health concerns over the airwaves
Wider context from the report “8. That dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a NICL code for believed mental health concerns
Wider context from the report “7. That the lack of NICL code “mental health believed” compounds this.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to pass the number of units on the way over the airwaves
Wider context from the report “10. That there are apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves , given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Dispatcher pod failures causing mental health concerns to be missed under work pressure
Wider context from the report “10. That there are apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves, given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Inadequate response officer training on de-escalation and taser deployment tactics for subjects with mental ill-health
Wider context from the report “11. That training for response officers may require review in relation to tactical options used to de-escalate prior to taser deployment , in appropriate circumstances, given the increased use of taser in black men with mental health issues; and in particular, training in relation to deploying with taser drawn and pointed with accompanying commanding language where the subject may be suffering with mental ill-health .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of training advice on recording mental health information concerning black men
Wider context from the report “3. That the above concern of potential training need is highlighted by the increased use of taser in black men and those suffering mental health issues and so the real need for this information to be recorded and passed on in the most effective form. Whilst training for first responders appears to include advice as to how to communicate with persons suffering with mental health issues, it does not appear to contain any advice in relation to the importance of such information to be recorded especially in relation to black men .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Inconsistent recording of mental health information by call handlers and first responders
Wider context from the report “1. That there is an inconsistency of approach between call handlers/first responders in the recording of information passed to them by members of the public that may represent a training issue; in this case the mental health matters reported to them .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient NICL code capacity for recording mental health as a qualifier
Wider context from the report “4. That the limitation of 3 NICL codes makes it difficult to record mental health as a qualifier in incidents such as this where the main risk factor is the weapon.
” Open source report
11 Mar 2025 Marta Elena Vento · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release View source Unavailability of National Record Locator access for South West ambulance care in Dorset View source Lack of guidance and tools for assessing violence risk in MOSOVO-managed offenders View source Lack of a process for sharing remanded prisoners’ risk information with sentencing courts View source Lack of practical national guidance for continuity of prisoners’ healthcare on release View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marta Elena Vento · 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
Marta Elena Vento was working alone as a hotel receptionist in Bournemouth when she was fatally beaten in an unprovoked attack on 9 December 2020. The report raises concerns about the sharing of remand prisoners’ risk information with sentencing courts, continuity of mental healthcare after release from prison, risk assessment of violent offenders managed by MOSOVO units, and access to patient information through the National Record Locator.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release
Wider context from the report “Evidence was given that this is not the process nationally in that some mental healthcare trusts will not accept a referral if a person is homeless . There is no national guidance about the continuity of care for prisoners upon release from prison when homeless .
I am concerned that this lack of continuity of care could lead to 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Unavailability of National Record Locator access for South West ambulance care in Dorset
Wider context from the report “Evidence was given by the Head of Clinical Development and Organisational Development at South West Ambulance Service NHS Foundation Trust (SWAST) that in the South West region all Integrated Care Boards (ICBs), apart from the ICB in Dorset, NHS Dorset, are at some stage of implementing the use of NRL so that SWAST can access this information to assist in the provision of care to those they treat.
Evidence was given that as this would limit the information SWAST had access to about a patient in Dorset , this would impact upon the care provided to those in Dorset by SWAST which could lead to a future death.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and tools for assessing violence risk in MOSOVO-managed offenders
Wider context from the report “The risk assessments detailed in the guidance are aimed at the assessment of the sexual risk of offenders and evidence was given that there is no bespoke risk assessment tool or guidance to assess the violence of such offenders to assist staff within MOSOVO units to undertake their role . There is, therefore, a lack of guidance on how to risk assess and manage offenders who are managed under MOSOVO when they present with the risk of violence, or an escalating risk of violence .
I am concerned that this will result in a failure to identify the risk of violence, or the increasing risk of violence, in those being managed by MOSOVO which may lead to a further death.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for sharing remanded prisoners’ risk information with sentencing courts
Wider context from the report “Evidence was given by the Head of the Offender Management Unit (OMU) at HMP Winchester, a Senior Probation Officer, that there is currently no formal process or guidance in place for the sharing of information by a prison with the Criminal Courts to provide an update of the person's behaviour in prison which may increase their risk of harm or risk offending .
It was explained that the person who could enquire about this at Court, if asked, would be the duty Probation Officer, and that this is especially more challenging to complete when a fast delivery report is requested.
There is currently no process from a prison perspective to share information to the sentencing Court other than that contained within the Prison Escort Record (PER), which is not provided to the sentencing Judge, the lawyers at Court or Probation staff .
I am concerned that the full extent of a remanded prisoner’s risk of harm to the public may not be appreciated by the sentencing Judge, which could impact upon the sentence imposed upon a prisoner and I am concerned that this lack of sharing of information could lead to 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of practical national guidance for continuity of prisoners’ healthcare on release
Wider context from the report “There is a lack of national guidance to assist all healthcare providers to ensure continuity of care for a prisoner with health care needs, whether physical or mental health needs, upon release from prison . There are national standards of care and NICE guidelines in place, however none of these provide practical guidance around the delivery of care to ensure continuity of care .
” 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 Liaise with Dorset Constabulary to ensure awareness of current MOSOVO guidance and available material for managing violent-offender risks.
Verbatim wording from the response “A number of actuarial tools are cited within the APP, along with more generic risk assessment factors, and the importance of professional judgement is outlined. However, it would be remiss of us not to further explore the specific application of a risk assessment tool. I have asked my Policing Standards Manager, ████████ to consult further with the NPCC Lead for MOSOVO and relevant subject matter experts to see where we can further improve our guidance and direction. Similarly, I shall also ask Sharon to liaise with Dorset Constabulary, to ensure that they are fully sighted on the current guidance and available material, to better address the risks posed by violent offenders in a MOSOVO setting.” Source location Response from College of Policing
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 Consult the NPCC MOSOVO lead and relevant subject-matter experts on improving guidance for assessing violence risk.
Verbatim wording from the response “A number of actuarial tools are cited within the APP, along with more generic risk assessment factors, and the importance of professional judgement is outlined. However, it would be remiss of us not to further explore the specific application of a risk assessment tool. I have asked my Policing Standards Manager, ████████ to consult further with the NPCC Lead for MOSOVO and relevant subject matter experts to see where we can further improve our guidance and direction. Similarly, I shall also ask Sharon to liaise with Dorset Constabulary, to ensure that they are fully sighted on the current guidance and available material, to better address the risks posed by violent offenders in a MOSOVO setting.” Source location Response from College of Policing
Open published response
4 Mar 2025 Robert John EVANS · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Lack of guidance, training and an urgent medical response pathway for non-arrested detainees suspected of swallowing drugs View source Lack of guidance for providing continued-monitoring advice on release of detainees suspected of swallowing drugs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert John EVANS · 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
Robert John EVANS was found dead at his home in Liverpool on 3 July 2022. His death resulted from drug use and underlying pneumonia, with fractures sustained during police detention contributing more than minimally to his death. The principal concerns were the lack of guidance, training, medical escalation and information-sharing when a person detained for a drug search is suspected of swallowing drugs, particularly after release from detention.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance, training and an urgent medical response pathway for non-arrested detainees suspected of swallowing drugs
Wider context from the report “The court heard that College of Policing Guidance for Custody Officers and Detention Officers provides that “...If officers know or suspect that a detainee has swallowed or packed drugs...they must treat the person as being in need of urgent medical attention and transfer them straight to hospital”. However: (a) a person detained for a search under the Misuse of Drugs Act does not come to the attention of a Custody or Detention Officer, unless arrested ; (b) there is no guidance (known to the court) to assist officers involved in such a search as to what they should do ; (c) there is seemingly no power for officers to convey to hospital somebody detained under these provisions (but not arrested), if that is against their wishes .
The upshot seems to be that, whilst the risk arising from swallowing a package containing drugs is the same in each case, there is a material difference between how different types of detainee are managed, depending upon whether an arrest has taken place .
Officers told the court that if somebody declines an offer of medical attention they simply monitor their condition, for signs of any change or deterioration. However, even if that is effective and adequate, any monitoring inevitably ends when the individual is released from detention. In this case that was little more than an hour after the suspected swallowing event.
When he was returned home, officers gave no advice to the Deceased or his family about the need for continued monitoring. There appears to be no guidance directed towards them as to what advice should be given. One officer said that nothing could be said to the family (about the need to keep him under close watch, because of the risk), because that would breach the individual’s right to privacy.
It occurs to me that a person suspected of involvement in a drugs deal (even if nothing is found on a search) might well be keen to avoid further attention from the police and/or medical services as quickly as possible, for fear of something being found that might incriminate them.
I am concerned that a person detained for the purposes of a search under the Misuse of Drugs Act, who is then suspected of having swallowed drugs, might be exposed to a risk of death (or other significant harm) if they do not receive the sort of medical attention which the guidance to Custody and Detention Officers considers an ‘urgent’ requirement , and/or if they are not given appropriate guidance on their release from detention. I am further concerned that officers are not given guidance or training in how to address this risk, by means of communication or otherwise .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for providing continued-monitoring advice on release of detainees suspected of swallowing drugs
Wider context from the report “The court heard that College of Policing Guidance for Custody Officers and Detention Officers provides that “...If officers know or suspect that a detainee has swallowed or packed drugs...they must treat the person as being in need of urgent medical attention and transfer them straight to hospital”. However: (a) a person detained for a search under the Misuse of Drugs Act does not come to the attention of a Custody or Detention Officer, unless arrested; (b) there is no guidance (known to the court) to assist officers involved in such a search as to what they should do; (c) there is seemingly no power for officers to convey to hospital somebody detained under these provisions (but not arrested), if that is against their wishes.
The upshot seems to be that, whilst the risk arising from swallowing a package containing drugs is the same in each case, there is a material difference between how different types of detainee are managed, depending upon whether an arrest has taken place.
Officers told the court that if somebody declines an offer of medical attention they simply monitor their condition, for signs of any change or deterioration. However, even if that is effective and adequate, any monitoring inevitably ends when the individual is released from detention . In this case that was little more than an hour after the suspected swallowing event.
When he was returned home, officers gave no advice to the Deceased or his family about the need for continued monitoring . There appears to be no guidance directed towards them as to what advice should be given . One officer said that nothing could be said to the family (about the need to keep him under close watch, because of the risk), because that would breach the individual’s right to privacy.
It occurs to me that a person suspected of involvement in a drugs deal (even if nothing is found on a search) might well be keen to avoid further attention from the police and/or medical services as quickly as possible, for fear of something being found that might incriminate them.
I am concerned that a person detained for the purposes of a search under the Misuse of Drugs Act, who is then suspected of having swallowed drugs, might be exposed to a risk of death (or other significant harm) if they do not receive the sort of medical attention which the guidance to Custody and Detention Officers considers an ‘urgent’ requirement, and/or if they are not given appropriate guidance on their release from detention. I am further concerned that officers are not given guidance or training in how to address this risk, by means of communication or otherwise.
” 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 Provide publicly available APP guidance requiring urgent hospital treatment, coordinated risk assessment and information sharing for suspected swallowed drugs.
Verbatim wording from the response “In relation to the specific concern that individuals suspected of having swallowed drugs may not receive urgent medical attention or appropriate guidance upon release, I can confirm that the College’s Authorised Professional Practice (APP) on Detention and Custody provides clear and robust guidance. This includes:” Source location Response from College of Policing
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 Existing Authorised Professional Practice guidance is considered sufficient to address concerns about urgent medical attention and guidance for suspected swallowed-drug cases.
Verbatim wording from the response “In relation to the specific concern that individuals suspected of having swallowed drugs may not receive urgent medical attention or appropriate guidance upon release, I can confirm that the College’s Authorised Professional Practice (APP) on Detention and Custody provides clear and robust guidance. This includes:” Source location Response from College of Policing
Open published response
14 Jan 2025 Anugrah Abraham (“Anu”) · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Unclear imminent adjustments for police officers disclosing suicidal thoughts before occupational health assessment View source Failure to investigate the quality of occupational health care after a death View source Lack of specialist Registered Mental Health nurses in the occupational health unit View source Failure to maintain accurate documented information on PCDA student officer progression View source Failure to learn from deaths and reflect on occupational health care processes View source Stress associated with the Police Constable Degree Apprenticeship route View source See 3 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
Anugrah Abraham (“Anu”) · 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
Anugrah Abraham (“Anu”), a serving West Yorkshire police officer, died by hanging on 4 March 2023 after leaving home the previous afternoon; the inquest recorded a conclusion of suicide. The report identified concerns about the management of his mental health, including delayed and inadequate Occupational Health responses, unclear action when he disclosed suicidal thoughts, poor information sharing, and aspects of the PCDA and Regulation 13 processes.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Unclear imminent adjustments for police officers disclosing suicidal thoughts before occupational health assessment
Wider context from the report “3. The court heard as to the increase in mental health issues amongst Police Officers nationally. Despite this, the question of what imminent adjustments should be made or considered once an officer discloses suicidal thoughts, was unclear . This is before an OHU appointment . In this case Anu’s mental deterioration was reportedly directly linked to his role as a police officer. It is acknowledged that this is a difficult issue and there will be issues such as confidentiality to consider.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the quality of occupational health care after a death
Wider context from the report “2. Following Anu’s death there was no investigation into the quality of care afforded to him by the OHU within WYP . Hence at the time of the inquest, there had been no reflection by practitioners as to the quality of care provided and no learning in respect of processes and procedures. It was accepted that following the inquest there were matters which would be considered. The lack of investigation meant learning from deaths in order to prevent future deaths was not 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist Registered Mental Health nurses in the occupational health unit
Wider context from the report “1. The court heard that most OHU referrals within police forces now relate to mental health issues as opposed to physical health issues. Despite this, there are no specialist Registered Mental Health nurses recruited into WYP OHU . Indeed the court heard the situation within WYP may be indicative of the national picture.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate documented information on PCDA student officer progression
Wider context from the report “5. Ensuring there is a full understanding across Police forces as to the PCDA and the sharing of accurate information with all those involved in the management of student officers so there is clear documented records and understandings as to how a student officer is progressing and whether they are likely to become an efficient constable .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from deaths and reflect on occupational health care processes
Wider context from the report “2. Following Anu’s death there was no investigation into the quality of care afforded to him by the OHU within WYP. Hence at the time of the inquest, there had been no reflection by practitioners as to the quality of care provided and no learning in respect of processes and procedures . It was accepted that following the inquest there were matters which would be considered. The lack of investigation meant learning from deaths in order to prevent future deaths was not 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Stress associated with the Police Constable Degree Apprenticeship route
Wider context from the report “4. Whilst the court heard there are now different routes into policing and there is no longer a requirement to undertake a degree. The court heard from a significant number of officers who had undertaken the PCDA. Many of the witnesses told the court of the impact this route into policing had on them at the time, including the levels of stress they incurred . The PCDA does continue to operate .
” 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 Communicate the importance of reviewing transition arrangements and guidance for student officers moving to alternative entry routes.
Verbatim wording from the response “While not directly raised as a matter of concern the College will, as part of communicating changes to PCER programme specifications, raise the importance of reviewing transition arrangements and guidance for student officers that want to or may benefit from moving to an alternative entry route, including policies and guidance for gaining credits towards an alternative qualification (where relevant).” Source location Response from College of Policing and National Police Chiefs' Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate organisational-learning concerns and outcomes to all forces and continue monitoring implementation of recommendations.
Verbatim wording from the response “The Director of the National Police Wellbeing Service provided evidence at the inquest and as the Co-Chair of the NPCC Health & Safety Wellbeing Board initiated a review into national oversight, governance, and assurance. In addition to this, the Board has communicated the areas of concern to all forces so as raise their awareness of the organisational learning outcomes and how these are best adopted and applied within forces.” Source location Response from College of Policing and National Police Chiefs' Council
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 Amend national police constable entry-route specifications to strengthen requirements for student officer mental-health and wellbeing support.
Verbatim wording from the response “Forces acquire a licence from the College to design and deliver their own local PCDA programmes, in collaboration with HEI partners. The College will be introducing a number of changes to our national programme specification for the PCDA to respond to the inquest learning. The changes will be to strengthen wording and provide extra clarity, creating impetus for collaborations to review their approaches in these areas and make any improvements as required. In all cases the College will:” Source location Response from College of Policing and National Police Chiefs' Council
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 Review national oversight, governance and assurance of organisational learning from force activity.
Verbatim wording from the response “The Director of the National Police Wellbeing Service provided evidence at the inquest and as the Co-Chair of the NPCC Health & Safety Wellbeing Board initiated a review into national oversight, governance, and assurance. In addition to this, the Board has communicated the areas of concern to all forces so as raise their awareness of the organisational learning outcomes and how these are best adopted and applied within forces.” Source location Response from College of Policing and National Police Chiefs' Council
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 Roll out the national mental-health crisis line for police officers and staff.
Verbatim wording from the response “The national suicide action plan was launched in July 2024, and this was raised during the inquest in terms of force compliance, line manager guidance and also the proposal to fund national mental health crisis line exclusively for police officers and staff.” Source location Response from College of Policing and National Police Chiefs' Council
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 Amend programme governance and staffing requirements to mandate information-sharing processes and accessible records of student officer progress and competence.
Verbatim wording from the response “Core requirement eight concerns programme staffing, including that there is clarity on responsibility and accountability for each role involved in programme development, delivery and maintenance. The College will add extra text to this core requirement, to make a more explicit requirement that there are policies/ processes/ governance in place to ensure appropriate communication and sharing of information between roles. This is particularly important for the PCDA programme, where both forces and education partners, including multiple teams within forces, are involved in delivery, assessment and providing support to student officers.” Source location Response from College of Policing and National Police Chiefs' Council
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 Support forces to adopt the national suicide action plan and conduct the scheduled September 2025 self-assessment review.
Verbatim wording from the response “The national suicide action plan was launched in July 2024, and this was raised during the inquest in terms of force compliance, line manager guidance and also the proposal to fund national mental health crisis line exclusively for police officers and staff.” Source location Response from College of Policing and National Police Chiefs' Council
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 Clarify to forces that managers should consider directing staff with serious disclosures to urgent NHS or local mental-health crisis services.
Verbatim wording from the response “The mental health crisis line will be rolled out nationally from April 2025 with an ambition for all forces to be covered by March 2026. The crisis line will provide managers with a degree of support when faced with an ‘imminent’ risk because they will be able to promote and signpost staff towards it. However, it is the view of the NPCC Health Safety and Wellbeing Board that, when faced with disclosures of such a serious nature, managers should consider supporting the member of staff to access urgent NHS services via their GP or local mental health crisis services. The NPCC Board will clarify this issue with forces by end April 2025.” Source location Response from College of Policing and National Police Chiefs' Council
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 Release an extended tutor-constable training package including student officer wellbeing content.
Verbatim wording from the response “Learner support roles, including tutor constables, are critical to the successful delivery of all PCER programmes. Throughout the optimisation programme there has been activity to promote and support their professional development. Building on this, the College will imminently be releasing a new, extended tutor constable training package which forces will be able to deliver flexibly in-house. The training is designed to align with the new tutor constable standard and curriculum, which the College released in 2024. The training will include content on student officer well-being.” Source location Response from College of Policing and National Police Chiefs' Council
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 Ensure revised information-sharing requirements specifically cover performance concerns and associated processes.
Verbatim wording from the response “The College will ensure that the response to matter of concern 5 (above), on the sharing of information, will specifically reference the sharing of information about concerns with performance and any associated processes that are commenced. However, regulation 12 and 13 of the Police Regulations 2003 are the responsibility of the Home Office and developing guidance for forces on their use is outside of the remit of the College. The Home Office is cognisant of the need to provide more comprehensive guidance on the use of regulation 13 to assistant forces with its consistent use. This was a finding of the Home Office review of the process of police officer dismissals (published in September 2023)” Source location Response from College of Policing and National Police Chiefs' Council
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 Implement the revised PCDA apprenticeship assessment model, including reduced endpoint-assessment burden and flexibility over final dissertation alternatives.
Verbatim wording from the response “In October 2024 the Secretary of State for Education approved simplified statutory assessment requirements for the PCDA, to come into effect from 1 April 2025. The PCDA will move to the regulated profession, fully-integrated degree apprenticeship model - the same as the nursing degree apprenticeship. This change frees up more opportunity to adjust assessment methods, again to make them more vocational in nature. Pressure on student officers will be reduced by a change to the ‘end-point assessment’ (EPA). The EPA will become a final approval process, with all assessment of the student officer having already been completed. It is also explicit (in College supporting guidance for the changed EPA) that forces and their education partners can consider alternatives to the final 10,000 word written dissertation.” Source location Response from College of Policing and National Police Chiefs' Council
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 Restructure national entry-route curricula and assessment requirements to improve vocational delivery and reduce workload demands on new joiners.
Verbatim wording from the response “As presented in the College evidence during the inquest, a national optimisation programme has been underway for all PCER programmes since April 2023. The programme is led by the College and designed to deliver the objectives of the ‘National Police Chiefs’ Council’ (NPCC) Optimisation Plan released in November 2022. A core objective is ‘improved student officer experience, enhancing well-being and retention’. The optimisation programme is drawing on an extensive body of knowledge and learning about how to design and deliver the police constable entry routes. The PCDA was first launched in 2018 and around 18,000 new officers have joined policing through this route since then.” Source location Response from College of Policing and National Police Chiefs' Council
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 Launch the police constable entry programme as an in-house alternative route without external accreditation.
Verbatim wording from the response “As well as promoting and supporting changes to the design and delivery of local programmes, national optimisation activity has included the launch of the new ‘police constable entry programme’ (PCEP). This route can be delivered entirely in-house by forces, without external accreditation – hence it offers a joining route for new officers that do not want to study for an academic professional policing qualification. 37 forces are due to be live with the route by the end of financial year 2024/25.” Source location Response from College of Policing and National Police Chiefs' Council
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 The Home Office is responsible for developing comprehensive guidance on Police Regulations 2003 regulations 12 and 13.
Verbatim wording from the response “The College will ensure that the response to matter of concern 5 (above), on the sharing of information, will specifically reference the sharing of information about concerns with performance and any associated processes that are commenced. However, regulation 12 and 13 of the Police Regulations 2003 are the responsibility of the Home Office and developing guidance for forces on their use is outside of the remit of the College. The Home Office is cognisant of the need to provide more comprehensive guidance on the use of regulation 13 to assistant forces with its consistent use. This was a finding of the Home Office review of the process of police officer dismissals (published in September 2023)” Source location Response from College of Policing and National Police Chiefs' Council
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 Developing guidance on Police Regulations 2003 regulations 12 and 13 is outside the College’s remit.
Verbatim wording from the response “The College will ensure that the response to matter of concern 5 (above), on the sharing of information, will specifically reference the sharing of information about concerns with performance and any associated processes that are commenced. However, regulation 12 and 13 of the Police Regulations 2003 are the responsibility of the Home Office and developing guidance for forces on their use is outside of the remit of the College. The Home Office is cognisant of the need to provide more comprehensive guidance on the use of regulation 13 to assistant forces with its consistent use. This was a finding of the Home Office review of the process of police officer dismissals (published in September 2023)” Source location Response from College of Policing and National Police Chiefs' Council
Open published response
8 Jan 2025 Matthew Brierley · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 4 Failure to provide proactive contact and support to men at elevated suicide risk View source Markedly elevated suicide risk among men in comparable circumstances View source Failure to undertake detailed individual risk assessment when applying bail conditions View source Delays in examination of devices and case decisions prolonging risk during bail View source See 1 more concern
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
Matthew Brierley · 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
Matthew Brierley died in the car park of Buttermere Court Hotel on 24 April 2024, after being arrested, bailed and placed under conditions that prevented him from living at home or having unsupervised contact with his children and stepdaughter. The inquest concluded that his death was suicide. Concerns included the potentially prolonged period before decisions were made about his devices and case, the use of standard bail conditions without an apparent specific risk assessment, and the lack of proactive follow-up support after his release on bail.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide proactive contact and support to men at elevated suicide risk
Wider context from the report “(3) Police acknowledged the increased risk and completed a standard assessment form when Matthew was released - he denied any risk and also declined referral to Liaison and Diversion service. A Family Contact Officer was also appointed but the onus remained on Matthew to seek help and there was no proactive contact which might have been helpful as men in Matthew's situation are less likely to seek help due to feelings of shame and embarrassment .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Markedly elevated suicide risk among men in comparable circumstances
Wider context from the report “(1) It is recognized that men in Matthew's circumstances are at a markedly elevated risk of suicide . Several papers refer to this - I found Kothari et al (Journal of Forensic and Legal Medicine, July 2021) particularly informative. They quote 3.2% of those arrested in operation Notarise committing suicide and explore reasons why this group is particularly vulnerable.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake detailed individual risk assessment when applying bail conditions
Wider context from the report “(2) I was told that when released on bail Matthew was informed that examination of devices and a decision in his case might take up to 18 months. Being suspended from work and unable to live at home removed normality and stability from Matthew and likely impaired his ability to cope with his situation. The length of time taken to reach a decision seems excessive, prolonging the time Matthew would be at risk. I was told devices can be "triaged" within a matter of days or more quickly, surely ceases such as this should be dealt with more expeditiously? It seems that "standard" bail conditions are applied but I am not aware of any suggestion of a specific risk to Matthew's stepdaughter , might a more detailed individual assessment of risk be helpful? I should record that Matthew's phone was examined after his death and that images found were not of a grade that would have led to a prosecution.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Delays in examination of devices and case decisions prolonging risk during bail
Wider context from the report “(2) I was told that when released on bail Matthew was informed that examination of devices and a decision in his case might take up to 18 months. Being suspended from work and unable to live at home removed normality and stability from Matthew and likely impaired his ability to cope with his situation. The length of time taken to reach a decision seems excessive, prolonging the time Matthew would be at risk . I was told devices can be "triaged" within a matter of days or more quickly , surely ceases such as this should be dealt with more expeditiously? It seems that "standard" bail conditions are applied but I am not aware of any suggestion of a specific risk to Matthew's stepdaughter, might a more detailed individual assessment of risk be helpful? I should record that Matthew's phone was examined after his death and that images found were not of a grade that would have led to a prosecution.
” 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 Produce comprehensive practitioner advice outlining measures to mitigate suicide risk among suspects of sexual offending.
Verbatim wording from the response “increased risk of suicide (such as those matching Mr Brierley’s demographics). We have produced comprehensive practitioner advice for officers and staff that outlines a series of measures to mitigate against this risk and have also added the latest guidance document from the Faculty of Forensic and Legal Medicine on how to care for suspects of sexual assault in police custody. (Please find further details here).” Source location Response from College of Policing
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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 Individual police forces and case decision-makers determine device examinations, investigation scope and bail conditions according to operational context.
Verbatim wording from the response “As operationally independent organisations, each police force will have provisions for the forensic examination of mobile phones and other digital devices. The context of each investigation will also shape the extent of both lines of enquiry and the depth or otherwise, of those examination processes, which will invariably have an impact on the time taken to complete those examinations. Similarly, the context of each case and presentation of risks would also help inform decision makers. Given the case specifics here, I would expect that officers appropriately recognise their responsibilities to safeguard children under Working Together 2023 and the Children Act 1989 and that this had a strong bearing on the bail conditions imposed.” Source location Response from College of Policing
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policing guidance, custody risk assessment and partnership arrangements are considered sufficient to address suicide and post-release support risks.
Verbatim wording from the response “increased risk of suicide (such as those matching Mr Brierley’s demographics). We have produced comprehensive practitioner advice for officers and staff that outlines a series of measures to mitigate against this risk and have also added the latest guidance document from the Faculty of Forensic and Legal Medicine on how to care for suspects of sexual assault in police custody. (Please find further details here).” Source location Response from College of Policing
Open published response
25 Oct 2024 Chad George ALLFORD · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 3 Lack of police officer awareness of the risks and safety principles of manually removing drugs from a person's mouth View source Failure to communicate the life-threatening risks of retaining concealed drugs in the mouth View source Lack of standard guidance or training for police officers responding to concealment of drugs in the mouth 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
Chad George ALLFORD · 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
Chad George Allford died at King's Mill Hospital on 27 October 2021 after placing cocaine in his mouth during a police operation to arrest him for a drug offence. The inquest evidence raised concerns that officers had not received training on this situation, did not warn him of the risks to his life, and were unaware of risks associated with placing their hands in his mouth, including choking.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer awareness of the risks and safety principles of manually removing drugs from a person's mouth
Wider context from the report “The evidence in this inquest focused, in part, on police officers’ response to concealment of drugs in the mouth. The officers were part of a team, acting on intelligence, to make a drug offence arrest. None of the officers concerned had received prior training in this regard. They employed various methods to try and control Mr Allford and although each instructed Mr Allford to spit the drugs out, none of them warned him of the risks to his life of not doing so. It was not clear that officers understood the importance of communicating the dangers.
Attempts were made by officers to open his mouth and sweep the drugs out of the mouth with their hands. A number of officers gave evidence that they were not aware of some of the risks inherent in placing their hands in someone’s mouth, including the risk of packages entering the airway and therefore choking , and they were not aware of the relevant passages in the NPCC Personal Safety Manual or importantly, the principles relating to this contained within. This was not only the position in 2021 but remained the position at the time of the inquest.
I am concerned that there is no standard provision for guidance or training for police officers in units tasked to make arrests for drug offences, to equip them to make informed decisions when faced with this situation. In the Personal Safety Manual ( Module 12 pg 42), it is described as a 'common tactic used by some subjects during arrest to conceal controlled drugs in their mouths'.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the life-threatening risks of retaining concealed drugs in the mouth
Wider context from the report “The evidence in this inquest focused, in part, on police officers’ response to concealment of drugs in the mouth. The officers were part of a team, acting on intelligence, to make a drug offence arrest. None of the officers concerned had received prior training in this regard. They employed various methods to try and control Mr Allford and although each instructed Mr Allford to spit the drugs out, none of them warned him of the risks to his life of not doing so . It was not clear that officers understood the importance of communicating the dangers.
Attempts were made by officers to open his mouth and sweep the drugs out of the mouth with their hands. A number of officers gave evidence that they were not aware of some of the risks inherent in placing their hands in someone’s mouth, including the risk of packages entering the airway and therefore choking, and they were not aware of the relevant passages in the NPCC Personal Safety Manual or importantly, the principles relating to this contained within. This was not only the position in 2021 but remained the position at the time of the inquest.
I am concerned that there is no standard provision for guidance or training for police officers in units tasked to make arrests for drug offences, to equip them to make informed decisions when faced with this situation. In the Personal Safety Manual ( Module 12 pg 42), it is described as a 'common tactic used by some subjects during arrest to conceal controlled drugs in their mouths'.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of standard guidance or training for police officers responding to concealment of drugs in the mouth
Wider context from the report “The evidence in this inquest focused, in part, on police officers’ response to concealment of drugs in the mouth. The officers were part of a team, acting on intelligence, to make a drug offence arrest. None of the officers concerned had received prior training in this regard. They employed various methods to try and control Mr Allford and although each instructed Mr Allford to spit the drugs out, none of them warned him of the risks to his life of not doing so. It was not clear that officers understood the importance of communicating the dangers.
Attempts were made by officers to open his mouth and sweep the drugs out of the mouth with their hands. A number of officers gave evidence that they were not aware of some of the risks inherent in placing their hands in someone’s mouth, including the risk of packages entering the airway and therefore choking, and they were not aware of the relevant passages in the NPCC Personal Safety Manual or importantly, the principles relating to this contained within. This was not only the position in 2021 but remained the position at the time of the inquest.
I am concerned that there is no standard provision for guidance or training for police officers in units tasked to make arrests for drug offences, to equip them to make informed decisions when faced with this situation. In the Personal Safety Manual ( Module 12 pg 42), it is described as a 'common tactic used by some subjects during arrest to conceal controlled drugs in their mouths'.
” 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 Add guidance on communicating the life-threatening risks of swallowing drugs to future Personal Safety Manual and curriculum versions.
Verbatim wording from the response “Since the time of Mr Allford's death the College of Policing has instigated a review of the current version of the Personal Safety Manual, as a result of this review it is currently being revised, which is a detailed and lengthy process. Part of this process includes an examination on the guidance for dealing with articles in the mouth. The current manual does not feature guidance on informing a subject regarding the risk to their life as a result of swallowing drugs, future versions of the manual and curriculum will do so. In the interim period while the manual is” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Personal Safety Manual, including guidance on drugs or other articles concealed in the mouth and associated risks.
Verbatim wording from the response “Since the time of Mr Allford's death the College of Policing has instigated a review of the current version of the Personal Safety Manual, as a result of this review it is currently being revised, which is a detailed and lengthy process. Part of this process includes an examination on the guidance for dealing with articles in the mouth. The current manual does not feature guidance on informing a subject regarding the risk to their life as a result of swallowing drugs, future versions of the manual and curriculum will do so. In the interim period while the manual is” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing training curricula allow relevant guidance and risk mitigation where local needs analysis identifies drug concealment as a risk.
Verbatim wording from the response “The issue of drugs being concealed in a subjects mouth may not be as widespread as the wording in the manual implies. Anecdotal evidence suggests it is ordinarily linked with a small number of subjects who practice the tactic frequently. In force areas where concealment of drugs in the mouth is an identified risk, training curriculums developed by the College of Policing allow for the provision of the relevant sections of the Personal Safety Manual to be delivered. This facility is available in both the historic Personal Safety Training and the latest Public &” Source location Response from College of Policing
Open published response
2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure carers are informed of Mental Health Act admissions within 24 hours View source Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository View source Failure to provide mental health patients with access to an independent mental health advocate View source Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks View source Failure to determine when police are the appropriate agency for mental health-related enquiries View source Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Sean Heath · 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
Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carers are informed of Mental Health Act admissions within 24 hours
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository
Wider context from the report “The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide mental health patients with access to an independent mental health advocate
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate ;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature , the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to determine when police are the appropriate agency for mental health-related enquiries
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry ;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill ;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists
Wider context from the report “That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care ; and
” 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 Publish and maintain Authorised Professional Practice guidance and an associated toolkit supporting the Right Care Right Person framework.
Verbatim wording from the response “The police response to mental health incidents is now covered by the national ‘Right Care Right Person’ (RCRP) framework, with further guidance provide by the College’s Authorised Professional Practice (APP) and an associated toolkit. The College of Policing also works closely with the National Police Chiefs’ Council which is supporting forces in the development and implementation of this policy. The toolkit and guidance were published in 2023 and the College has also created a bespoke e-learning training package, which is available to all police forces.” Source location Response from College of Policing
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 Create and provide a bespoke e-learning training package on responding to mental health incidents for all police forces.
Verbatim wording from the response “The police response to mental health incidents is now covered by the national ‘Right Care Right Person’ (RCRP) framework, with further guidance provide by the College’s Authorised Professional Practice (APP) and an associated toolkit. The College of Policing also works closely with the National Police Chiefs’ Council which is supporting forces in the development and implementation of this policy. The toolkit and guidance were published in 2023 and the College has also created a bespoke e-learning training package, which is available to all police forces.” Source location Response from College of Policing
Open published response
21 Jun 2024 Kevin Michael Cashin · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to provide training on recognising agonal breathing View source Failure to provide training on recognising cardiac arrest View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kevin Michael Cashin · 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
In the early hours of 20 July 2022, Kevin Cashin, who was experiencing an episode of Acute Behavioural Disturbance after ingesting cocaine, was restrained by police after dropping from a first-floor window. He deteriorated, stopped breathing and was later diagnosed with an unsurvivable hypoxic brain injury, dying that morning. The principal concerns were that officers did not recognise his agonal breathing and cardiac arrest promptly, with the Court also concerned that relevant recognition skills were not covered in the stated police first-aid training curricula.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide training on recognising agonal breathing
Wider context from the report “(1) The officers did not understand what agonal breathing was or how to recognise it . This included an officer who had completed the enhanced first aid training required to undertake Public Order Medic duties. Their focus had been on the fact that they could see Kevin’s chest moving and they had not appreciated that his gasping was an indicator of breathing difficulties.
(2) The Court heard that the effect of a cocaine induced Acute Behavioural Disturbance episode meant that Kevin’s agonal breathing was at a faster rate than is typical and would have looked more like regular breathing.
(3) The Court heard that there is generally a lack of knowledge on how to recognise when a person is going into a cardiac arrest. The officers had placed reliance on their observation of Kevin’s chest movements and their belief that they could feel his pulse. They had interpreted his lack of muscle tone, facial movements, poor colour and failure to respond to verbal prompts as signs of the effects of drug intoxication rather than indicators that he was in the early stages of cardiac arrest.
(4) It was the opinion of the expert that the most effective way to train responders in recognising agonal breathing and on how to identify when a person is going into a cardiac arrest is through the use of video footage rather than solely power-point presentations.
(5) The Court is concerned that the above is not currently covered in the curriculum for First Aid Learning Programme delivered to all police officers or the Enhanced First Aid Skills delivered to those officers in high risk roles and to public order medics .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide training on recognising cardiac arrest
Wider context from the report “(1) The officers did not understand what agonal breathing was or how to recognise it. This included an officer who had completed the enhanced first aid training required to undertake Public Order Medic duties. Their focus had been on the fact that they could see Kevin’s chest moving and they had not appreciated that his gasping was an indicator of breathing difficulties.
(2) The Court heard that the effect of a cocaine induced Acute Behavioural Disturbance episode meant that Kevin’s agonal breathing was at a faster rate than is typical and would have looked more like regular breathing.
(3) The Court heard that there is generally a lack of knowledge on how to recognise when a person is going into a cardiac arrest . The officers had placed reliance on their observation of Kevin’s chest movements and their belief that they could feel his pulse. They had interpreted his lack of muscle tone, facial movements, poor colour and failure to respond to verbal prompts as signs of the effects of drug intoxication rather than indicators that he was in the early stages of cardiac arrest.
(4) It was the opinion of the expert that the most effective way to train responders in recognising agonal breathing and on how to identify when a person is going into a cardiac arrest is through the use of video footage rather than solely power-point presentations.
(5) The Court is concerned that the above is not currently covered in the curriculum for First Aid Learning Programme delivered to all police officers or the Enhanced First Aid Skills delivered to those officers in high risk roles and to public order medics .
” 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 Complete the FALP review and update learning outcomes to cover agonal gasps, cardiac arrest recognition and basic life support.
Verbatim wording from the response “The College has conducted a significant review of the FALP, which was completed in August 2023. The updated version of FALP now includes specific reference to recognising agonal gasps – this is within the learning outcome relating to performing basic life support. This is taught within modules 2, 4 and 5, and as such will form part of both initial and annual refresher training for all public facing officers, and those in advanced, high-risk roles.” Source location Response from College of Policing
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 Individual forces are responsible for developing FALP learning materials, including video content, under local clinical governance procedures.
Verbatim wording from the response “The College of Policing develop the learning outcomes for FALP and individual forces develop the learning material in line with their local clinical governance procedures. The College of Policing share learning and good practice through various national platforms and will continue to work with Greater Manchester Police and other forces to do so. We encourage forces to use video footage as well as other media.” Source location Response from College of Policing
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 reviewed FALP and new PPST are considered to provide policing with the necessary skills to preserve life and keep the public safe.
Verbatim wording from the response “The main focus of the recent review of FALP was preserving life. The FALP is subject to constant update and review but we are confident that the recent review of FALP and the development of the new PPST provides those in policing with the necessary skills required to preserve life and keep the public safe.” Source location Response from College of Policing
Open published response
3 Jun 2024 Tcherno Bari · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 12 Failure to ensure police access to the written risk assessment View source Failure to provide attending police officers with the written risk rating View source Failure to maintain an accurate and up-to-date missing person policy View source Lack of police officer awareness of the required risk rating View source Failure to communicate the RCRP challenge process to BSMHFT View source Delays in communicating police disagreement with the reported risk category View source Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise View source Lack of formal notification of police disagreement about risk category View source Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients View source Failure to inform BSMHFT when missing patient investigations are closed View source Failure to invite police representatives to daily appraisal meetings View source Failure of routine monitoring to ensure completion of the risk rating View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tcherno Bari · 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
Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police access to the written risk assessment
Wider context from the report “(7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment , or require attending constables, or later the Locate team, to request a copy of the risk assessment . In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide attending police officers with the written risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy . I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’ , and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an accurate and up-to-date missing person policy
Wider context from the report “(5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP . I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer awareness of the required risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’ . Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’ .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the RCRP challenge process to BSMHFT
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT . Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it . However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process . Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Delays in communicating police disagreement with the reported risk category
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later , and WMP often close missing patient investigations without informing BSMHFT.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise
Wider context from the report “(8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. RCRP and APP appear to regard reports from mental health clinicians no differently to those from members of the public, and family and friends of the missing person . Context: police witnesses agreed that BSMHFT clinicians were the experts on mental health diagnosis, including identifying those conditions that carry an increased risk of suicide, and assessing the risk of suicide generally. However, this case demonstrates how in the heat of the moment an (inexperienced) attending constable can overlook that expertise and quickly dismiss it .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of formal notification of police disagreement about risk category
Wider context from the report “(6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category . BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients , and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case, and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to inform BSMHFT when missing patient investigations are closed
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to invite police representatives to daily appraisal meetings
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case , and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’ .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of routine monitoring to ensure completion of the risk rating
Wider context from the report “(2) A ‘monitoring tool’ in the BSMHFT Missing Patient Policy requires routine monitoring to ensure nurses are completing ‘appendix A’ and ‘appendix B’, but not ‘appendix C – risk rating’ . Context: I was told this is under review, however I was concerned this is still outstanding 9 months following the death .
” 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 Undertake a full review of the Mental Health APP and include officers’ consideration of mental health clinicians’ expertise.
Verbatim wording from the response “The College has been working with the NPCC to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. We continually keep under review any amendments required including the need to update the language used in the APP to include a stronger emphasis on consulting mental health services. The College is also currently undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process.” Source location Response from College of Policing
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 Work with the National Police Chiefs’ Council to clarify Missing Persons APP communication between police and mental health services, including stronger emphasis on consultation.
Verbatim wording from the response “• Mental health services should be consulted if a person is thought to be suicidal or suffering from a mental health crisis to find out if the person is known to them.” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing APP and toolkit guidance, together with the Mental Health APP review, are considered sufficient to address the highlighted issues.
Verbatim wording from the response “The College has been working with the NPCC to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. We continually keep under review any amendments required including the need to update the language used in the APP to include a stronger emphasis on consulting mental health services. The College is also currently undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process.” Source location Response from College of Policing
Open published response
23 Apr 2024 Ashley Crews · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of a local policy for handcuff use when executing arrest warrants 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
Ashley Crews · 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 Crews died on 20 February 2024 from injuries sustained in a fall from height after police officers attended his ninth-floor flat to execute an arrest warrant. The principal concern was that there was no local policy governing the use of handcuffs when executing an arrest warrant.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a local policy for handcuff use when executing arrest warrants
Wider context from the report “1. There is no local policy for the use of handcuffs when executing an arrest warrant.
” Open source report
19 Feb 2024 Samuel Curless (Sam) · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to provide adequate classroom-based or on-the-job training on sudden death response View source Lack of institutional learning, reflection or training following reported-death call handling incidents View source Inadequate training of attending officers to preserve the life of a hanging casualty View source Failure to provide timely First Aid refresher training on Basic Life Support for hanging casualties View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Samuel Curless (Sam) · 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
Samuel Curless died in hospital on 24 October 2022 after being found suspended from a ligature and receiving delayed life-support intervention. The concerns included failures to call an ambulance promptly, delays in checking vital signs and removing the ligature, and possible inadequacies in police training and refresher training for responding to hanging casualties.
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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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate classroom-based or on-the-job training on sudden death response
Wider context from the report “3. I heard evidence from Detective Superintendent ████████ that both attending officers were part of a cohort of at least 650 officers within GMP (and a larger cohort nationally) who received their initial police training entirely online . I am concerned that both officers’ training on Sudden Death (and the training of others) was delivered as one of over 15 online modules on a given day and that at the time of the inquest, they had not received any classroom based or on the job training . I am concerned that they are not the only officers within GMP who have received this level/method of training input and therefore there is a risk that other officers on duty have inadequate training on this issue .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of institutional learning, reflection or training following reported-death call handling incidents
Wider context from the report “1. That in respect of GMP Call Handler’s being required to call an ambulance to attend the scene, even where it is reported that someone is “dead” there has been no institutional learning following this incident . I asked ████████ if there had been any learning, reflection or training since this incident. He said that there hadn’t on this issue .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of attending officers to preserve the life of a hanging casualty
Wider context from the report “2. That the training delivered to the first two attending officers did not adequately prepare them for responding to a scene where someone is found hanging in a way which is consistent with their priority to preserve life of a hanging casualty .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely First Aid refresher training on Basic Life Support for hanging casualties
Wider context from the report “4. There was evidence given to me by Detective Superintendent ████████ that there is an unknown number of GMP officers who are not meeting the expectation of receiving First Aid refreser training within 12 months , which since May 2022 has included training on how to resuscitate a hanging casualty. I am therefore concerned that there remains a cohort of officers who have not had the post May 2022 training that includes how to provide Basic Life Support to this kind of casualty until the arrival of an ambulance .
” 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 Increase recommended annual refresher training from four to six hours and initial training from nine to twelve hours for public-facing officers.
Verbatim wording from the response “Annual refresher training is a core requirement of the FALP licence, and as a result of the above mentioned review, the recommended training time for both refresher and initial training has been increased for all public facing officers.” Source location Response from College of Policing
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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 Publish the revised First Aid Learning Programme focused on casualty care, preserving life and first-responder skills.
Verbatim wording from the response “In 2020, the College of Policing commenced a national working group to review the First Aid Learning Programme (FALP). The review engaged and consulted with police clinical subject matter experts and input from clinical governance leads in forces, in addition to recommendations made by Coroners, the Independent Office for Police Conduct and the Manchester Arena Inquiry. The FALP has now been published with a focus on casualty care, preserving life and providing police officers and staff with the first aid skills required as first responders.” Source location Response from College of Policing
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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 Complete a national review of the First Aid Learning Programme, incorporating police clinical expertise and relevant external recommendations.
Verbatim wording from the response “In 2020, the College of Policing commenced a national working group to review the First Aid Learning Programme (FALP). The review engaged and consulted with police clinical subject matter experts and input from clinical governance leads in forces, in addition to recommendations made by Coroners, the Independent Office for Police Conduct and the Manchester Arena Inquiry. The FALP has now been published with a focus on casualty care, preserving life and providing police officers and staff with the first aid skills required as first responders.” Source location Response from College of Policing
Open published response
Concerns raised 2 Failure to assess missing-person vulnerability without relying on assumptions about addiction View source Failure to give sufficient weight to family information in missing-person risk assessment View source
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AI-generated summary
Lee Bowman · 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
Lee Bowman was last seen on 31 October 2021 after being reported as having injuries consistent with an assault, and his body was found on 3 January 2022. The medical cause of death was unascertained. The principal concerns were assumptions about his whereabouts and reasons for not contacting family, insufficient weight given to information from his family, and shortcomings in the police handling and risk assessment of the missing-person reports.
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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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to assess missing-person vulnerability without relying on assumptions about addiction
Wider context from the report “1. There were significant assumptions made about the whereabouts of Lee and the reasons for his failure to contact family. The assumptions were based on the facts of Lee's addiction which on one view ought to have been identified as a vulnerability, on another view were wholly irrelevant in the context of his family confirming he was in day contact until 31 October 2021.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient weight to family information in missing-person risk assessment
Wider context from the report “2. Insufficient weight was placed on the information provided by Lee's family about his current state of mind and ordinary behaviours. Although there was a THRIVE assessment undertaken by the call handler on 2 November 2021 when the first missing person report was made, the burden of the duty fell on his PNC record and police intelligence information painting a picture which was not representative of the concerns of his family.
” 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 Update Missing Persons APP to warn against imprecise, value-laden terminology and require clear descriptions relevant to risk assessment.
Verbatim wording from the response “In reading your report, our subject matter expert was troubled by the term ‘chaotic lifestyle’ that appeared to have been used in some of the risk assessments. Terminology such as this is imprecise and invites readers of such comments to assign their own assumptions to what the term means. We will update our Missing Persons APP to alert police officers and staff to the need to avoid such value laden but imprecise terms. Instead, they should set out clearly and simply what matters and issues have been identified that have a bearing on the assessment of risk.” Source location Response from College of Policing
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 Publish Evidence Based Guidelines on vulnerability-related risk assessment, including gathering information from multiple sources to inform professional risk judgements.
Verbatim wording from the response “Your second matter of concern refers to reliance on PNC and intelligence records. Unfortunately, the report to us contains no detail of what was in these records or any commentary on why investigators gave them greater weight. It is, therefore, difficult for us to respond to these particular circumstances. However, the College has recently published Evidence Based Guidelines on Risk Assessment Vulnerability-related risks | College of Policing. This document is based on a broad range of research and sets out clear guidance on how to carry out risk assessment and is based on risk principles Risk | College of Policing. It emphasises the importance of gathering information from a range of sources to inform a decision maker’s professional judgement about the level of risk and what action should be taken to address that risk.” Source location Response from College of Policing
Open published response
25 Oct 2023 Carl FULLALOVE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 5 Failure of ABD training and recognition processes to identify nuanced signs in drug intoxication and consider prone-restraint risks View source ABD training failing to support reliable identification of underlying medical conditions and referral in dynamic settings View source First-aid training failing to include calming-intervention training View source Rigid ABD training focused on specific symptoms and failing to support recognition of other signs View source Training and research material omitting stimulant-drug effects and calming upright de-escalation before restraint View source See 2 more concerns
Responses linked to these concerns
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AI-generated summary
Carl FULLALOVE · 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
Carl Fullalove was arrested after being observed jumping on cars, behaving bizarrely and appearing to be under the influence of a substance. He was placed in prone restraint during a search in custody, became non-responsive and suffered cardiac arrest, and subsequently died in hospital. The principal concerns were that signs of acute behavioural disturbance or illness were not recognised, the risks of prone restraint and stimulant drugs were not sufficiently considered, and training did not adequately address calming intervention in an upright position.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of ABD training and recognition processes to identify nuanced signs in drug intoxication and consider prone-restraint risks
Wider context from the report “(1)Whilst the jury did not make any finding of acute behavioural disturbance (ABD) in this case, much evidence was heard about the training in identification of the signs and symptoms. National training of police officers on the identification of ABD is focused on a triad of warning flags being, hot to touch, exhibiting constant or near constant activity and extreme agitation or aggression. Some evidence identified that Carl Fullalove did not exhibit these triad symptoms but did exhibit other nuanced symptoms in the long list delivered in training. It was evident that his symptoms were not recognised as ABD due to drug intoxication, and that the consequential risks associated with prone restraint were not therefore considered. Prone restraint ultimately led to his death. There were six experts providing evidence to the inquest two of whom identified that Carl would not have died had he been recognised as unwell at the point of arrest and assessed by a health care practitioner. Such attention would have provided a calming intervention for his heart rate and breathing prior to being placed in prone restraint, which exerted additional pressure on his ability to breath freely.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation ABD training failing to support reliable identification of underlying medical conditions and referral in dynamic settings
Wider context from the report “(3)Significant training on ABD had been delivered by Cheshire Constabulary through the College of Policing Personal Safety Training package module, the key to which was to identify an underlying medical condition to refer to a health care practitioner. That may be a lot to expect of police officers in a dynamic fast paced setting. The use of the term ABD may be a distraction.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation First-aid training failing to include calming-intervention training
Wider context from the report “(5)The First Aid Learning Programme (FALP) will be in place within Forces by April 2024 and includes amongst other things positional asphyxia, unconscious and not breathing, and ABD but does not mention training in calming intervention that on balance of probabilities may have led to a different outcome in this case.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Rigid ABD training focused on specific symptoms and failing to support recognition of other signs
Wider context from the report “(2)A research paper before the inquest, namely ‘Consensus on Acute Behavioural Disturbance in the UK, September 2023 recommends that the focus remain on the triad of warning signs. ABD is clearly difficult to distinguish from drug intoxication by a non-medical practitioner. The rigidity of the training with focus on specific symptoms can cause police officers to miss other signs. The Superintendent, and head of ‘Protecting Vulnerable People’ for Cheshire accepted that with hindsight the use of prone restraint was inadvisable in this case.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Training and research material omitting stimulant-drug effects and calming upright de-escalation before restraint
Wider context from the report “(4)The effect of stimulant drugs and the need for calming de-escalation in an upright position, rather than prone restraint, had not been noted in either the training material or the research paper presented to the Court. This is on the background of recognising from College of Policing guidance that a high percentage of deaths in prone restraint are in drug related cases.
” 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 Develop and update Public and Personal Safety Training to cover ABD presentation and causes, de-escalation, restraint risks, medical assistance, monitoring, and scenario-based decision-making.
Verbatim wording from the response “The College of Policing have designed and developed a new Public and Personal Safety Training (PPST) package for all police officers with the emphasis on de-escalation. It is twelve hours, scenario-based method of delivering training and is focused on learning, decision making, understanding decisions and de-briefing decisions. Some forces have already implemented the new training package, and all forces are to go live with this training in April 2024. From the evaluation of the training pilot, early, statistically significant data shows a reduction in police use of force incidents. The updated training will include a recently updated training package for ABD.” Source location Response from College of Policing
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 Publish the revised First Aid Learning Programme outcome requiring officers to recognise signs and symptoms of acute behavioural disturbance.
Verbatim wording from the response “In 2020, the College of Policing commenced a national working group to update the First Aid Learning Programme (FALP). The review that took place considered recommendations made by Coroners and” Source location Response from College of Policing
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations