3 Aug 2021 Emma Day · Prevention of Future Deaths report Inner South London
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Concerns raised 11 Failure to identify all children when sharing risk information View source Failure to record the duration and conditions of protective orders View source Failure to require escalation of domestic-violence concerns beyond immediate risk View source Failure to include the Non-Molestation Order in the Merlin Report View source Lack of safety netting for escalation of risk View source Inadequate caseworker training on the wider domestic-violence risk context View source Lack of guidance on accepting a caller’s assessment of domestic-violence risk View source Lack of a procedure for responding to threats and passing information to other authorities View source Lack of a system for direct entry of protective orders on the Police National Computer View source Failure of case-record access and handover of key domestic-violence risk information View source Failure to hold or know protective-order conditions and arrest powers View source See 8 more concerns
Responses linked to these concerns
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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
Emma Day · 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
Emma Day died in the street on 26 May 2017 from multiple stab wounds and was found to have been unlawfully killed. The report describes a history of domestic violence, coercive and controlling behaviour, threats to her life and protective orders that had expired shortly before her murder. Principal concerns included failures to share and record risk information, inadequate domestic-violence training and guidance, and a system failure in handling reports of domestic violence within the Child Maintenance Service.
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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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to identify all children when sharing risk information
Wider context from the report “3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report, and when shared with Lambeth CSC only one of the children was mentioned .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record the duration and conditions of protective orders
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order , nor did there appear to be any safety netting if the situation escalated.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to require escalation of domestic-violence concerns beyond immediate risk
Wider context from the report “d) A caseworker who learnt from a caller of domestic violence was only required to escalate for consideration of signposting or reporting to police if there was an immediate risk of violence , not necessarily if the worker was concerned or an immediate risk was likely to eventuate in the future , in particular on reapplying for maintenance.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to include the Non-Molestation Order in the Merlin Report
Wider context from the report “3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report , and when shared with Lambeth CSC only one of the children was mentioned.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Lack of safety netting for escalation of risk
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order, nor did there appear to be any safety netting if the situation escalated .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate caseworker training on the wider domestic-violence risk context
Wider context from the report “b) Training of caseworkers at the time on domestic violence was focused on domestic violence as a criterion to grant waiver of the fee and did not provide information about the wider definition, the reluctance to self-declare or the available services to be signposted .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on accepting a caller’s assessment of domestic-violence risk
Wider context from the report “e) Nevertheless in relation to 16th May, Ms Lilley expected case workers to pick up the degree of risk from a report of past threat to kill and escalate and Mr Gilchrist thought the response of the case worker inadequate, as there was a specific request to continue the maintenance claim in the knowledge of a specific threat. But the guidance at the time was silent as to whether to accept the caller’s assessment of risk . I concluded that staff would likely be uncertain of their duties .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for responding to threats and passing information to other authorities
Wider context from the report “f) Asked about the Domestic Homicide Report’s reference to systemic issues, Mr Gilchrist’s own words were that in May 2017 is where the system fell down. There should be a threat procedure and how to initiate it and pass information to other authorities
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for direct entry of protective orders on the Police National Computer
Wider context from the report “4. The Domestic Homicide Review recommended (R24) that the Home Office work with the Ministry of Justice to implement a system whereby protective orders can be input directly to the Police National Computer . It was not clear whether all State bodies that needed to were able to make entries themselves on the Police National Computer Conflicting evidence was heard, but one police officer stated that R24 had not been adopted , and to do so would be welcomed by other agencies and that without this change there might be missed opportunities to save lives .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure of case-record access and handover of key domestic-violence risk information
Wider context from the report “The Coroner concluded that there was a system failure in Child Maintenance Service of Department of Work and Pensions in handling reports of domestic violence.
a) There was no mutual access of case records or system of handing on key risk information between CMO and CMS and so the eliciting of domestic violence risks relies upon repeated self-reporting by a victim .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to hold or know protective-order conditions and arrest powers
Wider context from the report “2. Lambeth Children’s Social Care (CSC) had no copy nor knew conditions of either Order, nor that there was a power of arrest . There seem to be steps taken by the CSC to consider action to mitigate the risk posed by the perpetrator in light of these Orders.
” Open source report
Concerns raised 3 Unavailability of mental health assessment for defendants appearing before magistrates on Saturday mornings View source Failure of the court to inform the prison about a defendant's mental illness and related problems View source Failure to provide the prison with sufficient information about a vulnerable prisoner's behaviour, mental state and custody circumstances 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
Jason Basalat · 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
Jason Basalat was arrested after grabbing the steering wheel of a bus, causing it to crash into road barriers, and was remanded to HMP Woodhill. He was found hanging in his cell the following day and later pronounced dead at hospital. Concerns included inadequate sharing of information about his behaviour and mental state with the prison, and the lack of a mental health assessment or appropriate placement consideration before his transfer.
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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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health assessment for defendants appearing before magistrates on Saturday mornings
Wider context from the report “(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state. The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture.
(2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted . The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness. Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment.
(3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure of the court to inform the prison about a defendant's mental illness and related problems
Wider context from the report “(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state. The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture.
(2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted. The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness . Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment.
(3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the prison with sufficient information about a vulnerable prisoner's behaviour, mental state and custody circumstances
Wider context from the report “(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state . The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture .
(2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted. The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness. Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment.
(3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner .
” Open source report
28 Jul 2017 SARAH LYNNE REED · Prevention of Future Deaths report London (City)
View report summary
Concerns raised 17 Insufficient information provided to prisoner visitors View source Excessive cancellation of prisoner visits View source Failure of ACCT Review team members to fully review the ACCT document View source Failure to make recorded prisoner observations accessible to all relevant team members View source Failure to complete fitness-to-plead reports and fix a hearing date in a timely manner View source Failure to assign clear responsibility for obtaining fitness-to-plead reports View source Failure to facilitate prisoner visits despite behaviour-related barriers View source Failure to record prisoner observations immediately or as soon as practicable View source Failure to notify community care coordinators of prisoner release View source Failure to conduct ACCT reviews on a multidisciplinary basis View source Inappropriate reduction of observation frequency despite deteriorating mental state View source Failure to communicate the fitness-to-plead purpose of remand to the mental health team View source Delays in holding Care Programme Approach meetings View source Failure to require Duty Governor authorisation for cancelled visits View source Inadequate multidisciplinary participation in CPA meetings View source Inadequate quality and duration of CPA meetings View source Insufficient recording of cancelled visits 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
SARAH LYNNE REED · 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
Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.
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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient information provided to prisoner visitors
Wider context from the report “(18) The Coroner also observes that the information provided to visitors including close family was often short on detail and lacked helpful information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Excessive cancellation of prisoner visits
Wider context from the report “(14) The jury concluded that the number of cancelled visits was unacceptable , particularly for a prisoner such as Sarah with Emotionally Unstable Personality Disorder where engagement is a principal means of 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure of ACCT Review team members to fully review the ACCT document
Wider context from the report “(9) The jury also found that not all members of the ACCT Review team fully reviewed the ACCT document before making a decision .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to make recorded prisoner observations accessible to all relevant team members
Wider context from the report “(10) The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be ‘detrimental’. For example, many helpful observations about Sarah’s behaviour were recorded in the prison medical notes on SystemOne by doctors and nurses, but they were not accessible to prison officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to complete fitness-to-plead reports and fix a hearing date in a timely manner
Wider context from the report “(1) The deceased had been remanded in custody for the sole purpose of the Court obtaining two reports by psychiatrists on her fitness to plead and stand trial. Yet by the time of her death, three months later, this objective had not been achieved and no date for a hearing of the issue had been fixed . It is clear from the evidence that Sarah was uncertain what was happening and when she would be going to court.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to assign clear responsibility for obtaining fitness-to-plead reports
Wider context from the report “(4) It was not clear on the evidence who took responsibility for obtaining the reports . The Court had ordered them, but the formal request for the first report, dated 27 October 2015, was (a) directed to HMP Holloway, but (b) sent by email from the Court to an administrative officer employed not by the prison but by the Central and North West London NHS Trust (CNWL) who worked from HMP Holloway. One month later, on 27 November 2015, a psychiatrist employed by CNWL in HMP Holloway wrote back to the Court, apologising for the delay and indicating that the request be directed not to CNWL but to the South London and Maudsley NHS Trust. As a result, by about six weeks after the Court’s order, no psychiatrist had yet agreed to prepare a report .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to facilitate prisoner visits despite behaviour-related barriers
Wider context from the report “(17) The Coroner also observes that with a little thought and effort arrangements could be made for a visit to Sarah even when her mental state had affected her behaviour . For example, on one occasion on 2 January 2016 (and apparently on one occasion only), Sarah’s mother was allowed to see Sarah in the adjudication room on the Segregation Unit (where Sarah was then housed). It is clear from the evidence that this visit was helpful to Sarah and that more completed visits would have assisted her . The jury so found.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record prisoner observations immediately or as soon as practicable
Wider context from the report “(11) In addition the Coroner observes that HMP Holloway maintained a practice of recording observations on prisoners which deviated from the national instruction. According to the national policy Management of prisoners at risk of harm to self, to others and from others (Safer Custody) (PSI 64/2011) observations should be recorded ‘immediately or as soon as practicable thereafter’ . According to the local policy at HMP Holloway, as implemented in this case, any observations at any time need be recorded only at four hour intervals in summary form .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to notify community care coordinators of prisoner release
Wider context from the report “(19) There was evidence from Sarah’s care coordinator in the community, a social worker with the START Team, that she was never informed by HMP Holloway of the release of any prisoner whom she had previously supported in the community , despite the care coordinator having close links with the prison, for example visiting prisoners she had supported and sometimes taking part in CPA meetings. The care coordinator said that this would be ‘incredibly helpful’.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct ACCT reviews on a multidisciplinary basis
Wider context from the report “(8) The jury also found that the above decision was not multi-disciplinary , which it should have been (as the senior Governor conceded in evidence).
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Inappropriate reduction of observation frequency despite deteriorating mental state
Wider context from the report “(7) The jury concluded that the decision to reduce the frequency of observations on Sarah Reed at ACCT Review No.4 on 5 January 2016, six days before Sarah’s death, was inappropriate given the clear evidence of the deterioration of her mental state .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the fitness-to-plead purpose of remand to the mental health team
Wider context from the report “(5) The jury found that the evidence that key members of Sarah’s mental health team in HMP Holloway were unaware that the sole purpose of her remand in custody was for the preparation of fitness to plead reports was ‘incomprehensible’.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Delays in holding Care Programme Approach meetings
Wider context from the report “(12) The jury concluded that the delay in holding a Care Programme Approach (CPA) meeting was unacceptable . The evidence showed that a CPA Meeting for assessing a prisoner’s long-term care should have been held within four weeks from reception . In this case it was held after nine weeks .
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Failure to require Duty Governor authorisation for cancelled visits
Wider context from the report “(16) The Governor conceded that the records for cancellations were insufficient and all cancellations should have been sanctioned at the level of Duty Governor (which they were not) and not by staff of lesser seniority.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate multidisciplinary participation in CPA meetings
Wider context from the report “(13) The jury also found that the quality of the meeting was not appropriate. It lasted five minutes and only the nurse care coordinator and community psychiatrist were present with the prisoner.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate quality and duration of CPA meetings
Wider context from the report “(13) The jury also found that the quality of the meeting was not appropriate . It lasted five minutes and only the nurse care coordinator and community psychiatrist were present with the prisoner.
” 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 HM Courts & Tribunals Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of cancelled visits
Wider context from the report “(16) The Governor conceded that the records for cancellations were insufficient and all cancellations should have been sanctioned at the level of Duty Governor (which they were not) and not by staff of lesser seniority.
” 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