21 Jun 2023 Matthew David Harris · Prevention of Future Deaths report Worcestershire
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Concerns raised 1 Failure to record suicidal ideation on Person Escort Records and Suicide and Self-Harm Warning forms View source
Responses linked to these concerns
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Matthew David Harris · 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 David Harris was found suspended in his cell at HMP Long Lartin on 27 May 2022 and died from his injuries at Alexandra Hospital, Redditch, on 29 May 2022. The inquest concluded that he died by suicide. The principal concern was that recent suicidal ideation disclosed during a police interview was not recorded on the documents accompanying him between police custody, court and prison, potentially leading to the risk of suicide or self-harm being underestimated or ignored.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dyfed-Powys Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record suicidal ideation on Person Escort Records and Suicide and Self-Harm Warning forms
Wider context from the report “(1) Following his arrest, and before he was interviewed about the alleged offence of murder, Mr. Harris was assessed by a consultant forensic psychiatrist, ████████ concluded that Mr. Harris was fit to be detained and fit to be interviewed, he did not possible symptoms of Post Traumatic Stress Disorder, likely due to some trauma in Mr. Harris’ background, possible symptoms of a personality disorder, and “potentially a psychotic process, with potential underlying delusional beliefs”;
(2) During his police interview on 14.5.22, when describing his movements before the alleged murder had taken place, Mr. Harris told officers he had ████████ intending to jump off in order to take his own life, but had decided against it because “I thought no, I’ve got to reveal all this first”;
(3) Despite the fact that these comments revealed very recent suicidal ideation on Mr. Harris’ part, no mention of them appears to have been made in any of the following documents:
(a) The Person Escort Record ( PER ) and Suicide and Self-Harm ( SASH ) Warning forms which accompanied Mr. Harris from police custody at Haverfordwest Police Station to Haverfordwest Magistrates’ Court on 16.5.22;
(b) The PER and SASH Warning forms which accompanied Mr. Harris from Haverfordwest Magistrates’ Court to HMP Swansea later that same day.
(4) Although I was quite satisfied that the omission of these comments from the above documents made no difference to the sad outcome in this case, I am concerned that the failure by Dyfed-Powys Police officers to realise that such comments ought to be included on a PER and SASH Warning form , if repeated in future, may lead to a person in custody’s risk of suicide and/or self-harm, being either underestimated, or ignored completely.
” 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 Remind investigators to inform custody officers about disclosures relevant to ongoing risk management.
Verbatim wording from the response “Further, investigators have been reminded of their duty to inform the custody officer of any information disclosed to them that should be considered as part of ongoing risk management.” Source location Response from Dyfed-Powys Police
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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 Inform investigation and custody staff, anonymously, about the omission of relevant suicidal-ideation information.
Verbatim wording from the response “To confirm, on 1st August 2023 via my Head of Custody Services, all staff involved in investigations and those responsible for the care of detainees whilst in police custody have been informed, in an anonymized manner, of the nature of the omission in this case.” Source location Response from Dyfed-Powys Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Instruct custody officers to ask interviewing officers about information relevant to ongoing detainee risk assessment.
Verbatim wording from the response “Custody Officers have been instructed to specifically ask interviewing officers whether they have any information that is relevant to the ongoing duty of risk assessment; information needed to best manage the welfare of the detainee.” Source location Response from Dyfed-Powys Police
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Maxine Betty Davison and 4 others · 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 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
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 Dyfed-Powys Police; that does not assign responsibility.
PFD Monitor interpretation Failure to condition firearms licensing delegation on adequate training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training .
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training .
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dyfed-Powys Police; that does not assign responsibility.
PFD Monitor interpretation Absence of a mandatory requirement for role-specific firearms licensing training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training . I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular .
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff ;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dyfed-Powys Police; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
Concerns raised 4 Inadequate content of police training on dealing with restraint View source Inadequate content and frequency of police training on the status and responsibilities of an Appropriate Adult View source Inadequate criteria for identifying the most appropriate place of safety View source Unclear responsibilities for transporting someone detained under Section 136 MHA 1983 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.
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AI-generated summary
Meirion James · 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
Meirion James was arrested for assaulting his mother and later became agitated at Haverfordwest Police station. During restraint, he was placed prone, stopped breathing and died from positional asphyxia. The report raised concerns about police restraint training, arrangements for people detained under Section 136 of the Mental Health Act, and training concerning Appropriate Adults.
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 Dyfed-Powys Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate content of police training on dealing with restraint
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” 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 Dyfed-Powys Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate content and frequency of police training on the status and responsibilities of an Appropriate Adult
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed .
” 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 Dyfed-Powys Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate criteria for identifying the most appropriate place of safety
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” 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 Dyfed-Powys Police; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibilities for transporting someone detained under Section 136 MHA 1983
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” Open source report
Concerns raised 1 Inability to lock stationary ambulance doors to prevent egress 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
Trystan Bryant · 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
Trystan Bryant, who had a history of mental illness and had expressed suicide intent, fell from the Tamar Bridge after leaving an ambulance and crossing barriers, sustaining multiple injuries that resulted in his death on 12 May 2017. The report raised a concern that stationary ambulance doors cannot be locked to prevent egress, which may affect police containment when escorting individuals under Section 136 of the Mental Health Act.
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 Dyfed-Powys Police; that does not assign responsibility.
PFD Monitor interpretation Inability to lock stationary ambulance doors to prevent egress
Wider context from the report “Ambulance Doors
When ambulances are stationary ambulance doors cannot be locked to prevent egress from inside the vehicle.
This may affect police containment preparations when police officers are escorting individuals for the purposes of Section 136 of the Mental Health Act
” 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 Write to all Chief Constables requesting a reminder that ambulances used under section 136 are non-secure environments.
Verbatim wording from the response “Your Regulation 28 report Prevent Further Deaths (PFD) notice dated 19th October 2018 following the death of Trystan Bryant has been received and I note your concerns. Given the specifics involved, I have written to all Chief Constables asking them issue a reminder to all operational officers likely to use authorities to detain under s136 MHA that they treat all ambulances as non-secure environments and not to assume they are or can be as secure as police vehicles.” Source location 2018-0382-Response-by-NPCC
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.
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dyfed-Powys Police; 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 Dyfed-Powys Police; 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 Dyfed-Powys Police; 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 Dyfed-Powys Police; 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 Dyfed-Powys Police; 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 Dyfed-Powys Police; 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 Dyfed-Powys Police; 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 Dyfed-Powys Police; 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 1 Failure to keep the STORM report updated with actions taken and changing developments 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
Michaela Marie Haines · 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
Michaela Marie Haines died on 23 December 2016 after police were dispatched to a report of a female hanging in the stairwell of flats at Tenby Mount, Tenby. The principal concern was that the STORM report was not updated with actions taken, creating uncertainty about whether enquiries had been completed and whether evidence had been preserved.
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 Dyfed-Powys Police; that does not assign responsibility.
PFD Monitor interpretation Failure to keep the STORM report updated with actions taken and changing developments
Wider context from the report “The STORM report had not been up-dated with actions taken. This caused uncertainty as to whether outstanding enquiries had been actioned or not. This may have resulted in evidence not being preserved. It could also result in work being duplicated with enquiries being made when they have already been undertaken. If the STORM report is to be used as an effective command and control document it is essential that it is updated in the light of changing developments. Training may be required to remind those using this vital work tool of the need to keep it up to date .
” 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 Keep STORM logs open until investigations are complete or transfer enquiries to an alternative recording system.
Verbatim wording from the response “recommendations were identified which are currently subject to implementation and include:” Source location 2017-0415-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 Record all raised actions numerically.
Verbatim wording from the response “recommendations were identified which are currently subject to implementation and include:” Source location 2017-0415-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 review found no suspicious circumstances or evidence of third-party involvement despite shortcomings in recording and managing the investigation.
Verbatim wording from the response “Following the completion of the review I am firmly of the belief that there are no suspicious circumstances. The investigation concerning the events of the evening shows no evidence of third party involvement. However, it apparent that the recent separation from her boyfriend was causing Ms Haines some distress and I support your view that it was a cry for help which tragically resulted in her death.” Source location 2017-0415-Response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations