9 Jul 2019 Leroy Dacosta Junior Medford · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 7 Insufficient protected training time for police officers View source Failure of officers to know the drugs SOP requirement for an officer to be within the cell with the detained person View source Failure to safely prioritise the volume and frequency of police training updates View source Lack of easy digital access to, and efficient updating and storage of, police procedures and policies View source Failure to monitor whether police training has been taken up View source Failure to encourage officers to consult infrequently used SOPs and guidance View source Failure of the police training system to disseminate training effectively and safely View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Leroy Dacosta Junior Medford · 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
Leroy Dacosta Junior Medford, referred to as Junior, was arrested by Thames Valley Police on 1 April 2017 and detained under the drugs SOP after being suspected of concealing drugs. His condition deteriorated in his cell, and resuscitation was unsuccessful; the recorded cause of death was heroin (diamorphine) toxicity. The principal concerns were that officers of all ranks involved did not know that the SOP required observation from inside the cell, and broader concerns about how police training is delivered, monitored, prioritised and taken up.
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 Insufficient protected training time for police officers
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this . Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” 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 officers to know the drugs SOP requirement for an officer to be within the cell with the detained person
Wider context from the report “The Drugs SOP
One of the reasons that the drugs SOP was introduced by Thames Valley Police on 1st July 2016 was to prevent exactly what happened in this case. That is (one of) the reasons that the SOP requires an officer to observe from within the cell.
We heard that the SOP was circulated to all police officers in July 2016. Custody Sergeants were asked to carry out online training on this in the same month. Clearly no officer would be expected to know any SOP word for word, but these are available to be looked at on computers within the custody suite.
A key requirement of the drugs SOP is the requirement for an officer to be within the cell with the detained person.
What has concerned me in this case is that not 1 or 2 officers were unaware of this requirement. All officers – of all ranks – who were involved with Junior on the night of 1st April 2017 were unaware of this requirement.
I was however satisfied that additional training and awareness has now taken place around this particular SOP. It is a SOP that is used more frequently now.
” 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 safely prioritise the volume and frequency of police training updates
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised . There is perhaps a risk of lack of urgency if training updates are given too frequently .
” 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 easy digital access to, and efficient updating and storage of, police procedures and policies
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” 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 monitor whether police training has been taken up
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up , and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” 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 encourage officers to consult infrequently used SOPs and guidance
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly .
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” 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 the police training system to disseminate training effectively and safely
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service . I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe .
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” Open source report
12 Apr 2019 Duncan Tomlin · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 7 Insufficient training on atypical seizure and post-seizure behaviour View source Insufficient sharing and requesting of information needed to assess restraint safety View source Lack of guidance defining monitoring requirements for restrained detainees View source Reliance on breathing sounds as insufficient monitoring of prone restrained detainees View source Insufficient emphasis on heightened risks of prone restraint when multiple breathing-affecting factors are present View source Inconsistent understanding of when to commence CPR for abnormal or distressed breathing View source Failure to prioritise assessment of detainees after control is obtained over speedy removal from the scene View source See 4 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
Duncan Tomlin · 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
Duncan Tomlin died on 29 July 2014 after cardiac arrest following the use of drugs and police prone restraint, including handcuffs, leg restraints and incapacitant spray. The report identified concerns about insufficient emphasis on the heightened breathing risks of multiple factors, delayed opportunities to assess and reposition him, inadequate guidance on monitoring, the timing of CPR, and understanding atypical or post-seizure behaviour.
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 Insufficient training on atypical seizure and post-seizure behaviour
Wider context from the report “Understanding aspects of Epilepsy and Seizures
5. The training material which has been provided to me on behalf of Sussex Police covers many aspects of epilepsy and seizure that were explored during the inquest. The training material indicates that if it is available to the trainer, participants will be shown a video which informs the viewer of the way in which a person may present post seizure, namely confused, vulnerable, perceiving aggression from others and at risk of lashing out due to misunderstanding. I have also been provided with a copy of a training manual provided by Epilepsy Action which was sent to ACPO in 2011. Aspects of the evidence from the family in this inquest were entirely consistent with the less common presentations of a person in an atypical or post seizure state.
Although epilepsy was not found to be causative in the death in this Inquest, in another situation with a similar set of circumstances, the reactions of a person suffering an atypical seizure or in a post seizure state, could be misconstrued as violence and resistance were officers not to appreciate that fact that their presentation may be part of a medical condition and restraint in such circumstances could have inherent and fatal risks. It is therefore of importance that training extends beyond the two more well known types of seizure and that post seizure behaviour is also understood in general terms .
” 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 sharing and requesting of information needed to assess restraint safety
Wider context from the report “Timing of decisions and opportunity to assess
2. A further concern relates to how officers are trained to prioritise options available to them and the timing of decisions in circumstances similar to those in this inquest. It is appreciated that officers are not medically trained, they do not make clinical decisions and more detailed history will be taken formally in custody suites. However, officers do need to be in a position to have sufficient information to enable them to assess the safety of the restraint situation in which they are involved, and this includes sharing information and requesting information when participants in the restraint may not have been present from the outset . These points are particularly so when medical evidence suggests fatal consequences can arise in a matter of minutes and that by the time a detainee is unresponsive, action may be too late. In this inquest a priority of the officers, said to be in line with their training, was to remove the restrained person from the scene as soon as practicable. The officers also gave evidence on the risks involved in turning the detainee on his side and the possible acts that a violent individual can take towards officers and themselves which raise other risks of harm. However my concern is that in future similar situations officers may prioritise the need to act speedily to remove a person from the scene, rather than, when a measure of control is obtained (such as by the use of handcuffs and limb restraints), taking an opportunity to take stock in order to assess the detainee they are dealing with and why they are struggling or resisting. Are they dealing with a person who is struggling because they are violent, or because they are confused, or psychotic, or in a post seizure state, or because they are in pain, uncomfortable or struggling to breathe?
Once a measure of control is obtained, the speed of the incident is dictated by the actions the officers decide to make and balancing the risks of harm which, in the case of positional asphyxia, are fatal and therefore must be a priority.
” 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 defining monitoring requirements for restrained detainees
Wider context from the report “Monitoring
3. The training plans, manuals and policies considered in evidence in this inquest refer to monitoring in different ways, depending on the circumstance. Phrases such as close, constant, careful and regular monitoring are used. Guidance as to what constitutes monitoring does not appear to be included within the literature available to officers . A different type of monitoring may be required for, for example, a detainee who poses a suicide risk or who has a known medical condition, as compared to the type of monitoring required for a person restrained in the prone position, particularly when affected by other factors impacting on breathing. Listening to noises associated with breathing may be entirely insufficient, particularly when they can be hard to hear, mishear or misinterpreted.
” 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 breathing sounds as insufficient monitoring of prone restrained detainees
Wider context from the report “Monitoring
3. The training plans, manuals and policies considered in evidence in this inquest refer to monitoring in different ways, depending on the circumstance. Phrases such as close, constant, careful and regular monitoring are used. Guidance as to what constitutes monitoring does not appear to be included within the literature available to officers. A different type of monitoring may be required for, for example, a detainee who poses a suicide risk or who has a known medical condition, as compared to the type of monitoring required for a person restrained in the prone position, particularly when affected by other factors impacting on breathing. Listening to noises associated with breathing may be entirely insufficient , particularly when they can be hard to hear, mishear or misinterpreted .
” 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 emphasis on heightened risks of prone restraint when multiple breathing-affecting factors are present
Wider context from the report “Importance of heightened risk of prone restraint when multiple factors affecting breathing are present
1. The current and earlier training plans, manuals and policies examined as part of the evidence in this inquest make clear references to risks associated with: (a) positional asphyxia; (b) handcuffs and limb restraints; (c) incapacitant spray; (d) acute behavioural disorder or symptoms thereof; (e) lack of oxygen due to physical exertion; (f) drug/alcohol intoxication; and (g) seizures.
Although there is some cross-referencing between the various risk factors, the heightened risk to a person in prone restraint when a number of these factors are present is not emphasised or sufficiently emphasised . The multifactorial matters that can impact on a person’s ability to breathe and the heightened risks to a person in a position of prone restraint when experiencing such multiple factors are critical to the assessment of risk.
” 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 understanding of when to commence CPR for abnormal or distressed breathing
Wider context from the report “Commencing CPR
4. The evidence relating to current training and training at the time of the death concerned in this inquest indicates that CPR should commence when a person is not breathing normally (described as in 2-3 breaths in 10 seconds for an adult and 3-5 in 10 seconds for small children) or if breathing is distressed (snoring, rasping) known as agonal breathing.
The evidence in the inquest was that individual officers of some experience understood CPR should commence when breathing had stopped . Whilst that may be a misunderstanding on the part of individual officers, owing to the importance of commencing CPR at the earliest opportunity when time is critically of the essence, the timing of when CPR should start should be a central point of when training CPR and when reacting to situations akin to that seen in this inquest .
” 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 prioritise assessment of detainees after control is obtained over speedy removal from the scene
Wider context from the report “Timing of decisions and opportunity to assess
2. A further concern relates to how officers are trained to prioritise options available to them and the timing of decisions in circumstances similar to those in this inquest. It is appreciated that officers are not medically trained, they do not make clinical decisions and more detailed history will be taken formally in custody suites. However, officers do need to be in a position to have sufficient information to enable them to assess the safety of the restraint situation in which they are involved, and this includes sharing information and requesting information when participants in the restraint may not have been present from the outset. These points are particularly so when medical evidence suggests fatal consequences can arise in a matter of minutes and that by the time a detainee is unresponsive, action may be too late. In this inquest a priority of the officers, said to be in line with their training, was to remove the restrained person from the scene as soon as practicable. The officers also gave evidence on the risks involved in turning the detainee on his side and the possible acts that a violent individual can take towards officers and themselves which raise other risks of harm. However my concern is that in future similar situations officers may prioritise the need to act speedily to remove a person from the scene , rather than, when a measure of control is obtained (such as by the use of handcuffs and limb restraints), taking an opportunity to take stock in order to assess the detainee they are dealing with and why they are struggling or resisting . Are they dealing with a person who is struggling because they are violent, or because they are confused, or psychotic, or in a post seizure state, or because they are in pain, uncomfortable or struggling to breathe?
Once a measure of control is obtained, the speed of the incident is dictated by the actions the officers decide to make and balancing the risks of harm which, in the case of positional asphyxia, are fatal and therefore must be a priority.
” 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 Individual police forces choose suitable tactical options and deliver them through local Personal Safety Training programmes.
Verbatim wording from the response “The College owns and publishes the NPSM in conjunction with the NPCC SDAR and the SDAR national practitioners’ working group. The SDAR are responsible for updating, developing and maintaining the NPSM and other national training products. SDAR membership includes physicians, self-defence and restraint trainers, academics, senior managers and experts (including from the Independent Office for Police Conduct, the Home Office, the Defence science and technology laboratory and the Police Federation amongst others). The College publishes the NPSM to the police service and then individual forces choose the tactical options contained within it that best meet the needs of their officers and staff in responding to local threats and deliver this through a local Personal Safety Training programme.” Source location 2019-0135-Response-by-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 Updating the national restraint guidance and training products is the responsibility of the SDAR working group.
Verbatim wording from the response “The College owns and publishes the NPSM in conjunction with the NPCC SDAR and the SDAR national practitioners’ working group. The SDAR are responsible for updating, developing and maintaining the NPSM and other national training products. SDAR membership includes physicians, self-defence and restraint trainers, academics, senior managers and experts (including from the Independent Office for Police Conduct, the Home Office, the Defence science and technology laboratory and the Police Federation amongst others). The College publishes the NPSM to the police service and then individual forces choose the tactical options contained within it that best meet the needs of their officers and staff in responding to local threats and deliver this through a local Personal Safety Training programme.” Source location 2019-0135-Response-by-College-of-Policing
Open published response
21 Feb 2019 Terrence Arthur Albert Smith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 17 Lack of call-handling provision for identifying unrecognised ED/ABD presentations View source Inconsistency between police conveyance policy and officer training View source Conveyance policy restricting timely transport of medical emergencies View source Unavailability of national guidance for out-of-hospital rapid tranquilisation View source Lack of timely escalation of serious ED/ABD safety matters to senior management View source Insufficient coverage of ED/ABD training for front-line response staff View source Contradictory ambulance call-handling instructions View source Training that conflates ED/ABD death risk with positional asphyxia View source Conveyance policy restricting timely transport of medical emergencies View source Failure of the police Mental Health Guide to separately address ED/ABD View source Police training that mischaracterises ED/ABD as controversial View source Omission of patient containment guidance from ED/ABD training View source Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD View source Inaccurate monitoring and capture of ED/ABD incidents View source Confusing clinical-staff ED/ABD training content View source Police training that conflates ED/ABD with positional asphyxia View source Failure of call-handling guidance to capture patient restraint status View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Terrence Arthur Albert Smith · 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
Terrence Smith died in hospital on 13 November 2013 after developing amphetamine-induced Excited Delirium/Acute Behavioural Disturbance, being subjected to prolonged restraint, and stopping breathing while being transported to hospital. The principal concerns included failures to recognise the condition as a medical emergency, inadequate assessment and training, excessive restraint, delayed conveyance to hospital, and deficiencies in relevant emergency response, clinical, police and custody policies and training.
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 call-handling provision for identifying unrecognised ED/ABD presentations
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the 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 Inconsistency between police conveyance policy and officer training
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I have two concerns :
(a) I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary, and could result in a fatal delay in the provision of life-saving treatment.
(b) I am concerned that the content of this policy is inconsistent with the training I was told is given to police officers , namely that they may convey a patient to hospital by police vehicle if the use of an ambulance is not an available or practical option , and as long as the conveyance is approved by a senior officer.
” 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 Conveyance policy restricting timely transport of medical emergencies
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary , and could result in a fatal delay in the provision of life-saving treatment .
” 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 guidance for out-of-hospital rapid tranquilisation
Wider context from the report “I was told that although the London Ambulance Service has provided out of hospital rapid tranquilisation of patients (such as may well be needed by a patient suffering ED/ABD) for some years, SECAMB will not do so until a national protocol or guidance has been issued by JRCALC . In those circumstances, whilst I understand that work on the production of such guidance is being undertaken, I am nevertheless concerned that none is yet in place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of timely escalation of serious ED/ABD safety matters to senior management
Wider context from the report “I was told by the Chief Executive Officer of SECAMB that he was not aware of Terry’s death and SECAMB’s involvement in it, nor of the issues arising at the Inquest, until very shortly before being required to give oral evidence at the Regulation 28 hearing. Given the length of the Inquest and the seriousness of the issues arising in relation to SECAMB (including their failure to recognise that Terry was suffering ED/ABD and to ensure he was treated as a medical emergency and taken to an Accident and Emergency Department), I am concerned that there is no system in place to ensure that such matters are drawn to the attention of the most senior management in a timely manner so as to ensure there is strategic planning for the prevention of other 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 Insufficient coverage of ED/ABD training for front-line response staff
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be). Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created .
” 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 Contradictory ambulance call-handling instructions
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the 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 Training that conflates ED/ABD death risk with positional asphyxia
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all .
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of 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 Conveyance policy restricting timely transport of medical emergencies
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I have two concerns :
(a) I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary , and could result in a fatal delay in the provision of life-saving treatment .
(b) I am concerned that the content of this policy is inconsistent with the training I was told is given to police officers, namely that they may convey a patient to hospital by police vehicle if the use of an ambulance is not an available or practical option, and as long as the conveyance is approved by a senior officer.
” 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 the police Mental Health Guide to separately address ED/ABD
Wider context from the report “Surrey Police’s Mental Health Guide addresses ED/ABD only in bullet point form alongside reference to Positional Asphyxia . The conditions are separate and different and the absence of a separate sheet addressing ED/ABD alone could mislead those reading the Guide in to thinking that the conditions are necessarily connected .
” 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 that mischaracterises ED/ABD as controversial
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD .
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia. The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” 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 Omission of patient containment guidance from ED/ABD training
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all.
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of 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 of ambulance call-triage tools to support recognition and appropriate response to ED/ABD
Wider context from the report “The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly . I was told that it is intended that version 17 will do so but this is not yet in use. My concern is that, unless and until it is in use, there will continue to be a failure by call handlers to recognise ED/ABD and respond appropriately .
” 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 Inaccurate monitoring and capture of ED/ABD incidents
Wider context from the report “I am concerned that SECAMB is not currently monitoring accurately the incidence of cases of ED/ABD in the regions it covers. A witness told me that she believed there were very few incidents (under ten a year) and that they were all apparent from the data gathered. On the basis of the evidence heard at the Inquest it seems unlikely that there are very few incidents given that SECAMB cover three large counties with a total population of over 4 million people and given the much higher incidence in other areas. Further, there were at least two incidents of ED/ABD (from 2018 and 2019) referred to in evidence which had not been captured at all by SECAMB’s data gathering.
” 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 Confusing clinical-staff ED/ABD training content
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be) . Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created.
” 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 that conflates ED/ABD with positional asphyxia
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD.
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia . The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” 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 call-handling guidance to capture patient restraint status
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint . If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call .
” Open source report
13 Feb 2019 Matthew William Lewis · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Failure to provide clear and consistent rescue instructions in hanging episodes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew William Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew William Lewis died following a hanging on 27 February 2018; the inquest conclusion was suicide and the recorded medical cause of death was hanging. Concerns included confusion and inconsistency in call-handler instructions about whether rescuers should approach him, with the report noting that unclear instructions could cause delay in future incidents. Guidance and training for call handlers in such scenarios were identified as desirable or mandated.
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 clear and consistent rescue instructions in hanging episodes
Wider context from the report “(1) Both ████████ in their evidence expressed confusion as to the instructions that were passed to them by the call handler. In particular, whether they should approach Mr Lewis and attempt to cut him down or refrain from doing so in the interests of scene preservation
(2) The subsequent evidence of the Officer in Charge, ████████ was to the effect that his primary role as a police officer was the preservation of life. The initial instructions of the Call handler here appeared inconsistent with that expressed overriding duty.
(3) In any hanging episode, time is very much of the essence following suspension. Whilst it could be determined on the evidence the exact time that that occurred on 27.2.18, medical evidence received at the Inquest indicated that death/irreversible brain injury would likely occur, no later than 5 minutes post suspension. With such a narrow “rescue window”, the clarity of instructions to willing rescuers appears paramount . Whilst it was found on the evidence that the actions of the call handler were neither directly, nor indirectly causative of Mr Lewis’ death, there is a risk that in the future, a repeat of confusing/inconsistent call handler instructions may lead to delay & potentially contribute to the prospects of an unsuccessful rescue .
(4) Guidance/training for call handlers as to how to deal with such scenarios would seem desirable/mandated
” 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 Amend contact-management learning standards within one month to emphasize preservation of life and suitable public rescue instructions.
Verbatim wording from the response “The College of Policing produces the National Policing Curriculum which sets the learning standards for a number of key areas of policing including contact management which informs the training of police call handlers and dispatchers. In doing so we work closely with the National Police Chiefs Council lead for this area, currently Assistant Chief Constable (ACC) ████████ from the Police Service of Northern Ireland. In response to this report we will, within the next month, amend the learning standards for contact management staff to reflect that the preservation of life is paramount when considering the impact on scene preservation and that suitable instructions should be given to willing members of the public who are able to assist in preserving life and providing rescue where possible.” Source location 2019-0048-Response-by-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 Circulate a summary of the issue to heads of contact management across England and Wales to support clarification of locally delivered training.
Verbatim wording from the response “I have also asked that a summary of this issue is circulated, via ████████ to all heads of contact management across England and Wales so that they can take any necessary urgent action in respect of clarifying locally delivered training.” Source location 2019-0048-Response-by-College-of-Policing
Open published response
10 Jul 2018 Eugeniusz Niedziolko · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 8 Arrest culture excluding consideration of drunk-and-incapable arrests View source Inadequate algorithm for assessing deterioration risk in intoxicated people View source Insufficient training and knowledge for assessing alcohol intoxication View source Failure to verify receipt and understanding of critical policies and procedures View source Lack of radio read-back checks for critical information View source Absence of third-party care and deterioration provisions in the 2017 agreement View source Failure to recognise acute alcohol intoxication as a mental disorder or impairment View source Insufficient national police training on mental-disorder implications of acute alcohol intoxication View source See 5 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
Eugeniusz Niedziolko · 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
Eugeniusz Niedziolko, who was heavily intoxicated and vulnerable, was left alone in an unheated public lavatory after police and ambulance staff decided he did not require hospital care. He was found unresponsive several hours later and died from acute alcohol toxicity and hypothermia. The report identifies concerns about failures to follow protocols, assess and communicate critical information, provide appropriate training, and consider available options for keeping him safe and monitored.
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 Arrest culture excluding consideration of drunk-and-incapable arrests
Wider context from the report “f) ARREST CULTURE - I am concerned having heard evidence in particular from ████████ the former who had been told that you simply do not arrest somebody for being drunk and incapable, the latter having given evidence that there was a culture that you do not arrest for drunk and incapable . If you look at the 2017 multi-party agreement one of the fall-back positions if hospital assistance is not regarded as being necessary is the consideration of arresting that individual for being drunk and incapable. Eugeniusz had no home and was vulnerable as well; the latter confirmed by both ████████ and ████████ so the necessity requirement for arrest would have been satisfied. Eugeniusz was clearly drunk (approaching 5½ times the drink drive limit for blood alcohol) and having become incontinent of urine would also have been regarded as being incapable as I see it. In evidence, the officers regarded Eugeniusz as capable at the time they left him – that alone concerns me in terms of a blinkered view as the bladder would have needed time to refill as the body processes the alcohol and the evidence from the experts pointed to a further period of incontinence prior to death. Eugeniusz was so incapable of looking after himself he was unable to relieve himself appropriately even in a public lavatory. If such a culture exists then that is a concern as it removed here an option that was disregarded by the officers concerned and which if exercised may have resulted in Eugeniusz attending hospital or spending the night safe in custody as opposed to having been left alone in a public lavatory block. I would like you to review the guidance given to frontline officers and to consider emphasising that drunk and incapable is still an arrestable offence if the circumstances and necessity warrant such action being taken to protect life. Arresting an individual does not mean that the person will necessarily be charged.
” 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 algorithm for assessing deterioration risk in intoxicated people
Wider context from the report “g) 2017 AGREEMENT – I raised with Consultant Paramedic ████████, and he is aware of my concern, that given the evidence of ████████ Consultant in Accident & Emergency who gave evidence that even if the observations had been carried out which to the greatest sense and purpose includes the checks in algorithm on page 10 of 12 of the 2017 Agreement, I am not convinced that if another Eugeniusz was to crop up that this risk of significant deterioration and death would have been picked up and avoided using this algorithm. Sometimes you have to spell it out and there was no questioning in this case as to when the person last consumed alcohol and over what period and what quantity they had consumed relative to this decision-making process. I queried whether especially with somebody who is not being cooperative as to whether the use of a breathalyser (if they were to consent) would aid in the intelligence gathering. There is also no mention of physical presentation. In Eugeniusz’s case, he had become incontinent of urine in respect of which I asked all relevant witnesses as to how many people they knew who were deliberately incontinent of urine. The answer, not unsurprisingly, was no-one. That factor from the common-sense point of view either is suggestive of physical issue whereby Eugeniusz was incontinent or that it was related to the degree of his intoxication in that he could no longer control and had no awareness of bodily function in that respect. The algorithm needs to be reviewed and considered in the light of this case specifically so that it would pick up another “Eugeniusz”.
” 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 knowledge for assessing alcohol intoxication
Wider context from the report “b) TRAINING AND GENERAL LIFE SKILLS - It was quite clear during the evidence that both police officers had a very limited knowledge in relation to the effects alcohol has on the body . Neither officer asked, nor even attempted to ask, what I would term were obvious questions at the time, namely how much had the individual had to drink and when was the last drink was consumed and over what period the alcohol was consumed. Considering the Courts regard Police Officers as experts in relation to drunkenness (officers tend to provide evidence in relation to drink related offences) neither offered to provide any idea as regards the link between alcoholism and mental health issues; that sex, age and build being all variables can affect how the body processes alcohol; the fact that alcoholics can be quite difficult to judge having regard to tolerance levels (how much they have consumed becoming essential information so as to factor that relevant information to enable a decision to be reached, not just as to what the risk to that individual was at that stage but also in the foreseeable immediate future (in terms of the next few hours or so). The evidence from the Consultant A & E Specialist, ████████ was that there was a poor correlation between visual presentation and the amount of alcohol that might actually be in that individual’s system. I am concerned here that a blinkered approach adopted by officers attending somebody who is intoxicated can easily lead to the wrong decision being taken and one which is based on assumptions. I have been made aware of changes to training programmes but I am concerned that the training does not provide sufficient awareness and that there may be still a significant number of officers who simply do not have the life experience and general knowledge to factor that experience into professional judgement making. It would not surprise me if your officers in Swindon, more likely than not, have a better awareness of these issues and perhaps they could look to improve the training and share their experiences to officers elsewhere in the County.
” 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 verify receipt and understanding of critical policies and procedures
Wider context from the report “d) COMMUNICATION OF POLICY AND PROCEDURE
I am aware that following this incident the 2009 Agreement between the Hospitals, Ambulance Trust and Wiltshire Police as regards the assessment of people who appear to be drunk and need of medical assessment was circulated. A newer agreement was also subsequently entered into in June 2017. I am surprised and concerned that even now front-line officers, who gave evidence, were unaware of either of these 2 agreements. It would appear that important communications are being sent out but that there is no effective system in place to check that the important information is received and more importantly is understood . This also applies to e-learning which is capable of abuse if the same questions are asked at the end of modules. Interestingly, I heard from Consultant Paramedic, ████████ that in relation to their e-learning systems random questions are asked at the end of e-learning modules in an attempt to overcome the risk of abuse. I fully appreciate that front line officers are under huge amounts of pressure with increasing workloads and less resources but my fear is that there will be a repeat of this incident and other issues arising that may lead to a death occurring through the lack of effective communication of policies and procedures which, at the end of the day, are designed to guide front line personnel and ultimately protect them. With busy workloads, an expectation that these documents will be read is unrealistic and arguably idealistic.
” 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 radio read-back checks for critical information
Wider context from the report “a) RADIO PROTOCOL
When listening to the radio communications there appeared to be a non-existent radio protocol of any form . My concern relative to this particular point is the absence of a protocol which for example requires the recipient of important information such as PNC markers to reflect or even repeat the information that has been given so that it can be established both ends that the information has been correctly and effectively communicated. The situation that appears to have arisen in this case is that the controller says that all 3 markers were communicated but the transcript supports the 2 officers on the ground recollections that they only received notification of 1. I am concerned that the absence of any check could lead to critical information not being communicated which could lead in certain circumstances to errors occurring that could result in a worst case scenario to a death occurring. This issue of relaying critical information was highlighted by the jury in their Narrative Conclusion.
” 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 third-party care and deterioration provisions in the 2017 agreement
Wider context from the report “e) 2009 & 2017 MULTI PART AGREEMENT (copies enclosed) - As regards the Agreement in 2009, I noted with interest insofar as the Ambulance protocol was concerned that a risk of deterioration should be assessed and that the patient should be left in the care of a 3rd party , with advice on seeking medical assistance later if required. I am concerned and have aired as to why this is absent from the 2017 Agreement and also I am concerned as to why consideration is not given for a similar provision being incorporated into the police protocol in the 2017 Agreement . Such a measure appears to be eminently sensible as a matter of common sense.
” 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 recognise acute alcohol intoxication as a mental disorder or impairment
Wider context from the report “c) AWARENESS OF MENTAL HEALTH ISSUES
I have already highlighted a concern with the 2 officers in question who were unaware of the link between mental health and alcoholism that runs in both directions. What was more concerning was that both officers were unaware that acute alcohol intoxication amounts to a mental disorder for the purposes of the Mental Health Act 1983 and a mental impairment for the Mental Capacity Act 2005 . This point is being addressed below to the Chief Executive of the College of Policing and also the Council of Chief Police Officers Mental Health Lead as I suspect that the 2 officers involved in this case, as indeed every other Police Officer who gave evidence, was unaware of this until recently. This needs to change as a matter of urgency as in this case the use of Section 136 Mental Health Act 1983 was never considered as an option because neither officer thought that Eugeniusz was suffering from a mental disorder . ████████ a consultant psychiatrist also expressed a view to the court that he doubted that Eugeniusz actually had mental capacity when appearing to agree to being left in the lavatory block.
” 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 national police training on mental-disorder implications of acute alcohol intoxication
Wider context from the report “i) I hope in reaching this stage of the report that you will have read the points made above and you will be aware of my concern that until recently it would appear that the College of Policing and police officers within Wiltshire were unaware that acute alcohol intoxication is regarded as being a mental disorder for the purposes of the Mental Health Act 1983 and a Mental impairment for the purposes of the Mental Capacity Act 2005 (although senior Wiltshire Officers have or should have been aware of this concern since June 2017). The code of practice in relation to the Mental Health Act 1983 highlights this and as I understand ever since 1993 acute alcohol intoxication has been recognised by the World Health Organisation in ICD-10 relating to mental and behavioural disorders with acute alcohol intoxication being classified at F10 as being such a mental disorder. Front line officers need to be aware of such matters so that when dealing with situations that confront them that they have a full awareness and understanding of the range of options and powers that they may have available to them. I fully accept and understand the point that I made in Court that Section 136 of the Mental Health Act 1983 should be sparingly used but that does not mean that it should not be used because the officers concerned do not recognise that the person in front of them has a mental disorder so that they can then go on to consider whether or not the person is in need of immediate care and control and ultimately a mental health assessment. In this case they did not consider Section 136 simply because they did not think that Eugeniusz was suffering from a mental disorder at the time . I would ask you to review the training that is provided nationally to all Police Forces in this respect.
” Open source report
Concerns raised 7 Inconsistent police guidance on the appropriateness and endorsement of forced searches of detainees’ mouths View source Inconsistent police training and adoption of forced-search-of-mouth procedures View source Lack of clear police training for situations involving potentially harmful substances or items in a detainee’s mouth View source Lack of police training in control and restraint when a detainee is seen to put something in their mouth View source Lack of guidance on deploying PAVA spray when a detainee is believed to have placed something in their mouth View source Shortcomings in cascading safety information across police forces View source Unclear operational scope of FFLM recommendations on managing choking in police care and custody View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Darran Hunt · 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 8 February 2015, Darran Hunt was involved in a struggle with police after attempting to evade detention and placing a package in his mouth. He choked on the package and died despite efforts to clear his airway and provide life support. The report raises concerns about police training and guidance on using PAVA spray, forced searches of a detainee’s mouth, and control and restraint where a detainee has placed something in their mouth.
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 police guidance on the appropriateness and endorsement of forced searches of detainees’ mouths
Wider context from the report “2. Forced Search of mouth
Clarification is needed on the extent to which individual police forces are expected/mandated to adopt Module12 of the Personal Safety Manual and in particular the practical technique of undertaking a forced search of the mouth. It appears that Dyfed Powys Police have not been trained on the method of forcible search of the mouth whereas South Wales Police have. The concept of a forced search of a detainee’s mouth is in stark contrast to the guidance/direction given by Faculty of Forensic & Legal Medicine (FFLM) . Officers are, as part of their training, directed to the FFLM guidance for further reading which provides that a forced search of a detainee’s mouth “is not ever appropriate to prevent the swallowing of an object”. There is significant inconsistency in this area and consideration needs to be given to the status and endorsement that the Police give to the FFLM recommendations in its guidance entitled “Management of Choking in Police Care & Custody – Recommendations for Police Personnel”. Consideration should also be given to whether the FFLM recommendations apply in the context of just custody suites or more widely such as in the street (as 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 Inconsistent police training and adoption of forced-search-of-mouth procedures
Wider context from the report “2. Forced Search of mouth
Clarification is needed on the extent to which individual police forces are expected/mandated to adopt Module12 of the Personal Safety Manual and in particular the practical technique of undertaking a forced search of the mouth . It appears that Dyfed Powys Police have not been trained on the method of forcible search of the mouth whereas South Wales Police have . The concept of a forced search of a detainee’s mouth is in stark contrast to the guidance/direction given by Faculty of Forensic & Legal Medicine (FFLM). Officers are, as part of their training, directed to the FFLM guidance for further reading which provides that a forced search of a detainee’s mouth “is not ever appropriate to prevent the swallowing of an object”. There is significant inconsistency in this area and consideration needs to be given to the status and endorsement that the Police give to the FFLM recommendations in its guidance entitled “Management of Choking in Police Care & Custody – Recommendations for Police Personnel”. Consideration should also be given to whether the FFLM recommendations apply in the context of just custody suites or more widely such as in the street (as 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 Lack of clear police training for situations involving potentially harmful substances or items in a detainee’s mouth
Wider context from the report “There appears to be an apparent lacuna or, at least, confusion in respect of training for Police in relation to situations where a detained person puts a potentially harmful substance or item in their mouth .
” 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 in control and restraint when a detainee is seen to put something in their mouth
Wider context from the report “It is of concern that there is a 2006 case with no too dissimilar facts in the South Wales Police Force area. In that case, the lack of training in relation to the forced search of the mouth of a detainee and control and restrain where a detainee has been seen to put something in their mouth were issues highlighted by the Inquest. One of the recommendations of the Preventing Future Death’s Report in that case was that officers should be trained in the technique of forced searching of the mouth. There is an apparent shortcoming in the cascading of information across the different police forces.
” 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 on deploying PAVA spray when a detainee is believed to have placed something in their mouth
Wider context from the report “1. Use of PAVA Spray
It has been suggested by the expert during the course of the Inquest that “luck” will determine whether a person sprayed with PAVA spray will inhale or exhale at the point immediately after being sprayed. There is clearly a risk therefore that a person with an object in their mouth could choke on that item if they inhale immediately upon being sprayed. At present there does not appear to be any guidance for officers on whether they should use PAVA spray in the circumstances of this case . Consideration needs to be given to whether guidance/policy should be issued to officers about if and when PAVA spray should ever be deployed in respect of a detainee who is believed to have placed something in their mouth.
” 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 Shortcomings in cascading safety information across police forces
Wider context from the report “It is of concern that there is a 2006 case with no too dissimilar facts in the South Wales Police Force area. In that case, the lack of training in relation to the forced search of the mouth of a detainee and control and restrain where a detainee has been seen to put something in their mouth were issues highlighted by the Inquest. One of the recommendations of the Preventing Future Death’s Report in that case was that officers should be trained in the technique of forced searching of the mouth. There is an apparent shortcoming in the cascading of information across the different police forces .
” 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 operational scope of FFLM recommendations on managing choking in police care and custody
Wider context from the report “2. Forced Search of mouth
Clarification is needed on the extent to which individual police forces are expected/mandated to adopt Module12 of the Personal Safety Manual and in particular the practical technique of undertaking a forced search of the mouth. It appears that Dyfed Powys Police have not been trained on the method of forcible search of the mouth whereas South Wales Police have. The concept of a forced search of a detainee’s mouth is in stark contrast to the guidance/direction given by Faculty of Forensic & Legal Medicine (FFLM). Officers are, as part of their training, directed to the FFLM guidance for further reading which provides that a forced search of a detainee’s mouth “is not ever appropriate to prevent the swallowing of an object”. There is significant inconsistency in this area and consideration needs to be given to the status and endorsement that the Police give to the FFLM recommendations in its guidance entitled “Management of Choking in Police Care & Custody – Recommendations for Police Personnel”. Consideration should also be given to whether the FFLM recommendations apply in the context of just custody suites or more widely such as in the street (as in this case).
” Open source report
17 Mar 2016 Mr Philmore Leonard Mills · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2 Lack of training on containment as a tactical option for subjects with suspected excited delirium View source Failure to train Police Officers about the risk of death from takedown procedures 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
Mr Philmore Leonard Mills · 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
Mr Philmore Leonard Mills, a 55-year-old patient with significant comorbidities including terminal lung cancer, became confused and aggressive while in hospital and died after police attended and restrained him. The report notes concerns that police training did not identify containment as a tactical option for suspected excited delirium, and did not warn that the restraint manoeuvre could in certain circumstances be fatal.
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 training on containment as a tactical option for subjects with suspected excited delirium
Wider context from the report “(1) In the course of the evidence, the Jury heard from two independent experts on restraint techniques and Police training. They both had the opportunity to review the existing Thames Valley Police and ACPO Training in place at the time of Mr Mills’ death. This included training for Police Officers when dealing with a subject who may be suffering from excited delirium. Both Officers highlighted the fact that there is no reference to the option of containment as a tactic taught to Police Officers as part of their training in dealing with subjects with suspected excited delirium . In the evidence, containment was identified as one of the tactical options that Officers should carefully consider in any 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 Failure to train Police Officers about the risk of death from takedown procedures
Wider context from the report “(2) The Jury heard from one of the two expert witnesses, ████████ that, while Police Officers are trained as to the medical consequences of the take down procedure in restraining a subject, those consequences do not include reference to the risk of death . While they described the risk of bruising, broken bones etc, they do not suggest that such an manoeuvre could, in certain circumstances, prove fatal to the subject involved .
(3) The evidence surrounding the circumstances of the death of Philmore Mills suggests that this is a potential outcome of which Officers should be made aware .
” 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 a national training video reinforcing the medical implications of restraint and good practice, including containment.
Verbatim wording from the response “The delivery of Personal Safety Training, including the risks associated with ABD and PA, were subject of a recent national quality assurance programme, led by the College. This piece of work was commissioned by the National Policing Lead to help enhance the policing response and ensure compliance with the National Personal Safety Manual. This undertaking has led to the production of a national training video, which reinforces the medical implications of restraint and good practice elements including the tactic of ‘containment’. This video is scheduled to form part of the national Personal Safety Training Programme for 2016/17.” Source location Philmore-Mills-Response
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 Add clarity to the National Personal Safety Manual that prone restraint can carry a risk of death in certain circumstances.
Verbatim wording from the response “Whilst the medical implications contained within the National Personal Safety Manual contain the inherent risks of harm to subjects who are restrained in a prone position further clarity will be added to reinforce that, in certain circumstances, there is a risk of death. I shall ensure that these are included within the next scheduled update.” Source location Philmore-Mills-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add the national training video to the 2016/17 national Personal Safety Training Programme.
Verbatim wording from the response “The delivery of Personal Safety Training, including the risks associated with ABD and PA, were subject of a recent national quality assurance programme, led by the College. This piece of work was commissioned by the National Policing Lead to help enhance the policing response and ensure compliance with the National Personal Safety Manual. This undertaking has led to the production of a national training video, which reinforces the medical implications of restraint and good practice elements including the tactic of ‘containment’. This video is scheduled to form part of the national Personal Safety Training Programme for 2016/17.” Source location Philmore-Mills-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add an explicit reference to containment in the Acute Behavioural Disorder and Positional Asphyxia chapter of the National Personal Safety Manual.
Verbatim wording from the response “Having reviewed your observations and for completeness, a specific reference to 'containment' will be added to the ABD/PA chapter of the National Personal Safety Manual to make explicit what is currently implicit.” Source location Philmore-Mills-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a national quality assurance programme for Personal Safety Training to enhance policing responses and compliance with the National Personal Safety Manual.
Verbatim wording from the response “The delivery of Personal Safety Training, including the risks associated with ABD and PA, were subject of a recent national quality assurance programme, led by the College. This piece of work was commissioned by the National Policing Lead to help enhance the policing response and ensure compliance with the National Personal Safety Manual. This undertaking has led to the production of a national training video, which reinforces the medical implications of restraint and good practice elements including the tactic of ‘containment’. This video is scheduled to form part of the national Personal Safety Training Programme for 2016/17.” Source location Philmore-Mills-Response
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 Containment is already central to the National Personal Safety Manual, training and guidance, although it will be stated explicitly.
Verbatim wording from the response “These important wider issues, which include concepts such as containment, are central to the National Personal Safety Manual, training and guidance.” Source location Philmore-Mills-Response
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 National Personal Safety Manual already contains the inherent risks of prone restraint, although the risk of death will be clarified.
Verbatim wording from the response “The focus of the College is elsewhere where confrontation between the police and the public is a realistic proposition is the safety of all. The use of a prone restraint remains an option for police officers, and although the technique presents challenges, it still represents a necessary tactical option in this type of situation.” Source location Philmore-Mills-Response
Open published response
27 Apr 2015 Joshua Steven BROWN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Lack of compulsory practical in-car training for police driving at night-time 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
Joshua Steven BROWN · 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
Joshua Brown died after being struck by a police vehicle on the A31 Hog’s Back shortly after 03.30 on 1 December 2012, in patchy dense fog and reduced visibility. The jury found that the police officer’s speed was inappropriate in the brief period between encountering the fog and the collision, and that Joshua Brown was walking in the carriageway with his back to traffic; both elements contributed to the collision. The report raised concern about the absence of compulsory practical in-car night-time training in national police driver training requirements.
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 compulsory practical in-car training for police driving at night-time
Wider context from the report “Night-time driver training
Consideration should be given to amending the national requirement for police driver training so as to include a compulsory element of practical in-car training for driving at night-time .
” 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 police driver training, including risks associated with driving in reduced visibility and at night.
Verbatim wording from the response “The College of Policing is currently working with the National Police Chiefs Council lead for roads policing, Chief Constable ████████ on the roads policing learning project. Within this project there is a specific piece of work on police driving standards which will involve a review of police driver training. Part of this work will examine the particular risks associated with driving in reduced visibility, including night-time driving.” Source location 2015-0162-Response-by-College-of-Policing
Open published response
31 Jan 2014 Shaun Elliott · Prevention of Future Deaths report Buckinghamshire
View report summary
Concerns raised 4 Lack of clarity in the high-risk definition for missing persons View source Failure to provide effective family liaison during missing person enquiries View source Failure to apply the high-risk definition appropriately in missing person assessments View source Lack of missing person coordinator coverage at weekends View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Shaun Elliott · 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
Shaun Elliott, a vulnerable adult living in supported accommodation, went missing after an education outing and was later found in cardiac arrest. He died in hospital on 11 July 2011 after sustaining irreversible hypoxic brain damage; the recorded medical cause of death was acute bronchopneumonia due to multidrug use. Concerns included the availability of missing-person coordinators at weekends, family liaison, and the assessment of missing-person risk as high risk.
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 in the high-risk definition for missing persons
Wider context from the report “(4).Application of definition of “ High Risk” in the context of missing persons. Shaun was assessed as medium risk until 21:00 hours on 10th July. At that time a Chief Inspector had reviewed the information on the database and applied an “enlarged” interpretation of the high risk definition. The evidence revealed that up to that time officers (Sergeants and Inspectors) considered that “High” risk could not apply in the absence of evidence of “Immediate” risk. The Jury concluded that the case should have been categorised as high risk on Saturday 9th July. These definitions are used nationally and are potentially part of our review. The concerns arising are around whether the definition could ( for example) be annotated or commented on to clarify when a less literal interpretation can be applied ).
” 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 effective family liaison during missing person enquiries
Wider context from the report “(3)Family Liaison. Shaun’s family expressed a number of concerns and frustrations in this regard . However relevant to this report specific benefits could be derived from effective family liaison . Namely the family as a source of information together with the potential information sharing and cross referencing.
” 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 apply the high-risk definition appropriately in missing person assessments
Wider context from the report “(4).Application of definition of “ High Risk” in the context of missing persons. Shaun was assessed as medium risk until 21:00 hours on 10th July. At that time a Chief Inspector had reviewed the information on the database and applied an “enlarged” interpretation of the high risk definition. The evidence revealed that up to that time officers (Sergeants and Inspectors) considered that “High” risk could not apply in the absence of evidence of “Immediate” risk . The Jury concluded that the case should have been categorised as high risk on Saturday 9th July . These definitions are used nationally and are potentially part of our review. The concerns arising are around whether the definition could ( for example) be annotated or commented on to clarify when a less literal interpretation can be applied).
” 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 missing person coordinator coverage at weekends
Wider context from the report “(2) The evidence revealed that a missing person coordinator was in post but not on duty at weekends . It was apparent from the evidence that an appropriately experienced coordinator will have the time and know-how to examine cases in fine detail. The officers directly responsible for the enquiry may have many other calls on their time. The IPCC report recommended there be cover 7 days a week. A senior police officer reported that this was under review and that other police forces were being contacted to see how they were addressing the issue.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations