19 May 2026 Catherine Mary MORGAN · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 10 Failure to use a viable welfare-check pathway when the resident is not known to be at the address View source Overly rigid application of deployment policy and affinity protocol View source Failure to inform the nurse in charge about leave decisions and circumstances View source Failure to include a patient photograph in the grab pack View source Inadequate monitoring and escalation of patients on leave who do not return View source Lack of a voluntary-patient checklist for measures taken to locate the patient View source Failure to conduct leave risk assessments consistently with NICE Guidelines View source Inadequate communication and recording of leave decisions View source Training that restricts professional judgement in deployment decisions View source Inconsistent approach to leave and return for detained and voluntary patients View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Incorporate learning from the case into ongoing MetCC training, briefings and governance processes.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2026. View source
Action
Incorporate updated national guidance into training, briefings and supervisory processes for consistent risk-led decision making.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2026. View source
Action
Reinforce escalation and supervisory review when agency responsibility is uncertain, disputed or associated with increasing concern.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2026. View source
Action
Review control-room escalation arrangements for timely reassessment and specialist advice when vulnerability or risk of serious harm increases.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2026. View source
Action
Review and update local policies, procedures and control-room practices to align Missing Persons policy with Right Care, Right Person.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2026. View source
Action
Support operational discretion for early deployment where risk justifies it and reinforce escalation pathways for high-risk missing persons.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2026. View source
Action
Reinforce risk-based deployment expectations through guidance, supervisory oversight, escalation and reassessment of new information.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026. View source
Action
Develop an updated Concern for Welfare policy with practical scenarios addressing deployment and Local Missing Hub referral decisions.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026. View source
Action
Review application of the Right Care, Right Person policy across Contact, Command and Control functions.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026. View source
Action
Strengthen audit and governance processes to monitor Right Care, Right Person application in vulnerable or high-risk cases.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2026. View source
Action
Review guidance, training and quality-assurance arrangements so advice to callers is practical, achievable and aligned with partner-agency responsibilities.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2026. View source
Action
Maintain governance oversight of disputed, complex or high-risk deployment decisions through the expanded Right Care, Right Person Governance Board.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2026. View source See 9 more actions
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AI-generated summary
Catherine Mary MORGAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Catherine Mary Morgan, who was receiving mental health care, left hospital on unescorted leave and was later located near Dover Castle. She jumped to her death at 20.16 on 4 September 2024. Concerns included delays in the police response to reports that she was missing, and inadequate systems for assessing, authorising, communicating and monitoring voluntary patients’ leave.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to use a viable welfare-check pathway when the resident is not known to be at the address
Wider context from the report “2. A call handler informed SLAM to call London Ambulance Service to do a welfare check at
the home address of the patient in circumstances where the ambulance service will only
attend an address if the resident is known to be there ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Overly rigid application of deployment policy and affinity protocol
Wider context from the report “1. An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted
in a delayed deployment . Even where call handlers have real concerns that someone not
returning to a mental health unit is a high risk missing person, the outcome of the toolkit not to
deploy is the same if the individual's address has not been visited, even when told that they
would not go there. The way in which the policy was applied removed any discretion by call
handlers and dispatchers to deploy whilst checks at the address were being conducted .
Evidence was given at the inquest that the call handler in the second call to MPS attempted to
convey her concerns that there should be immediate deployment to her supervisors in
despatch and was advised the police would not deploy;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the nurse in charge about leave decisions and circumstances
Wider context from the report “2. The systems in place for safeguarding voluntary patients in respect of leave and recording
the decisions was inadequate and decisions were largely communicated by word of mouth
which led to differences of understanding what had been agreed, the basis on which it had
been agreed and by whom it was agreed. Documentation in respect of leave was incomplete
and did not comply with policy. The nurse in charge was not informed of the decision for leave
or the circumstances in which leave was granted ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to include a patient photograph in the grab pack
Wider context from the report “5. A photograph of the patient was not included in the grab pack . Unlike detained patients there
was no checklist for voluntary patients as to the measures taken to locate the patient
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring and escalation of patients on leave who do not return
Wider context from the report “3. The system for monitoring leave was inadequate , reliance being placed on hourly checks.
The nurse conducting the hourly check at 12.00 when Catherine was due to return was not
aware that she was on unescorted leave and did not escalate the matter to the nurse in charge
with the result that the ward only became aware that she had not returned when her mother
arrived at 12.50. Consideration was not given to the appropriate amount of leeway to be given
to the patient before escalating the fact of them not having returned , with patients being given
30 minutes or more;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a voluntary-patient checklist for measures taken to locate the patient
Wider context from the report “5. A photograph of the patient was not included in the grab pack. Unlike detained patients there
was no checklist for voluntary patients as to the measures taken to locate the patient
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct leave risk assessments consistently with NICE Guidelines
Wider context from the report “1. Evidence was given at the inquest that although dynamic risk assessments were undertaken
in advance of leave being authorised, risk assessments were not consistent with NICE
Guidelines ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication and recording of leave decisions
Wider context from the report “2. The systems in place for safeguarding voluntary patients in respect of leave and recording
the decisions was inadequate and decisions were largely communicated by word of mouth
which led to differences of understanding what had been agreed, the basis on which it had
been agreed and by whom it was agreed . Documentation in respect of leave was incomplete
and did not comply with policy . The nurse in charge was not informed of the decision for leave
or the circumstances in which leave was granted;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Training that restricts professional judgement in deployment decisions
Wider context from the report “It was recognised by MPS at the inquest that there was an overly rigid approach to the Right
Care Right Person policy and Affinity Protocol resulting from the robust application of the
policy and protocol (see above). Some changes have been made within MPS within the
parameters allowed given national guidance and standards, but evidence was given to the
effect that training as to the application of the policy, protocol and toolkit could result in the
professional judgement of call handlers/despatchers/supervisors being restricted resulting in
delays to deployment
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent approach to leave and return for detained and voluntary patients
Wider context from the report “4. Ward staff appeared to take a different approach to leave and return depending upon the
status of the patient as a detained or voluntary patient ;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate learning from the case into ongoing MetCC training, briefings and governance processes.
Verbatim wording from the response “In response to the concern raised by the Coroner, the MPS will review guidance, training and quality assurance arrangements to reinforce that where police are not the appropriate agency to respond, advice provided to callers should be practical, achievable and consistent with the responsibilities of the agency to which they are being directed. This will include reinforcing escalation and supervisory review where there is uncertainty, disagreement or increasing concern regarding the most appropriate agency response. Learning from this case will be incorporated into ongoing training, briefing and governance processes within MetCC.” Source location Response from MPS
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 Incorporate updated national guidance into training, briefings and supervisory processes for consistent risk-led decision making.
Verbatim wording from the response “Subject to the outcome of the national consultation and the publication of updated guidance, the MPS will:” Source location Response from MPS
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 Reinforce escalation and supervisory review when agency responsibility is uncertain, disputed or associated with increasing concern.
Verbatim wording from the response “In response to the concern raised by the Coroner, the MPS will review guidance, training and quality assurance arrangements to reinforce that where police are not the appropriate agency to respond, advice provided to callers should be practical, achievable and consistent with the responsibilities of the agency to which they are being directed. This will include reinforcing escalation and supervisory review where there is uncertainty, disagreement or increasing concern regarding the most appropriate agency response. Learning from this case will be incorporated into ongoing training, briefing and governance processes within MetCC.” Source location Response from MPS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review control-room escalation arrangements for timely reassessment and specialist advice when vulnerability or risk of serious harm increases.
Verbatim wording from the response “The MPS will review escalation arrangements within our control room to ensure that incidents involving increasing vulnerability or deteriorating circumstances are subject to timely reassessment. This will include” Source location Response from MPS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update local policies, procedures and control-room practices to align Missing Persons policy with Right Care, Right Person.
Verbatim wording from the response “Subject to the outcome of the national consultation and the publication of updated guidance, the MPS will:” Source location Response from MPS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support operational discretion for early deployment where risk justifies it and reinforce escalation pathways for high-risk missing persons.
Verbatim wording from the response “Further work will include:” Source location Response from MPS
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 Reinforce risk-based deployment expectations through guidance, supervisory oversight, escalation and reassessment of new information.
Verbatim wording from the response “The MPS is reinforcing operational expectations through guidance and supervisory oversight to ensure that deployment decisions are made in line with the College of Policing Right Care, Right Person toolkit. This involves a particular focus on call handling, THRIVE+¹ assessment, deployment decision making, supervisory escalation and reassessment where new information is received. This will ensure RCRP is applied as a dynamic risk-based framework, not as a fixed non-deployment decision. Particular attention will be given to incidents involving vulnerability, suicide risk, third-party concern and potential missing person risk, where early supervisory oversight and clear recording of rationale are essential.” Source location Response from MPS
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 Develop an updated Concern for Welfare policy with practical scenarios addressing deployment and Local Missing Hub referral decisions.
Verbatim wording from the response “In addition, the MPS is developing an updated Concern for Welfare policy, supported by practical scenarios to assist decision making. This will support increased clarity around when deployment is required or when referral to LMHs is appropriate, particularly in circumstances involving vulnerability and potential missing person risk.” Source location Response from MPS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review application of the Right Care, Right Person policy across Contact, Command and Control functions.
Verbatim wording from the response “The MPS is undertaking a review of the application of RCRP within Contact, Command and Control functions. This work is focused on:” Source location Response from MPS
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 Strengthen audit and governance processes to monitor Right Care, Right Person application in vulnerable or high-risk cases.
Verbatim wording from the response “Subject to the outcome of the national consultation and the publication of updated guidance, the MPS will:” Source location Response from MPS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review guidance, training and quality-assurance arrangements so advice to callers is practical, achievable and aligned with partner-agency responsibilities.
Verbatim wording from the response “The MPS has reviewed the circumstances of this aspect of the incident. We recognise the importance of ensuring that advice provided by Met Command and Control (MetCC) staff is consistent with the responsibilities and capabilities of partner agencies and reflects the processes set out within RCRP and associated arrangements.” Source location Response from MPS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain governance oversight of disputed, complex or high-risk deployment decisions through the expanded Right Care, Right Person Governance Board.
Verbatim wording from the response “This includes oversight through the RCRP Governance Board, introduced in summer 2024, which provides operational oversight, assurance and coordination for escalation relating to RCRP deployment decisions.” Source location Response from MPS
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 Healthcare providers must undertake initial reasonable enquiries when a patient leaves a healthcare setting, using the most appropriate agency or agencies.
Verbatim wording from the response “The MPS Right Care, Right Person policy and toolkit place responsibility on healthcare providers to undertake initial reasonable enquiries when a patient leaves a healthcare setting. Those enquiries should be progressed through the most appropriate agency or agencies based on the circumstances and should not rely on referral to a single service as a default position. The MPS also recognises the importance of clear escalation routes where there are concerns that the available arrangements are insufficient to manage the presenting risk.” Source location Response from MPS
Open published response
24 Apr 2026 Edward Muwanga · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation View source Lack of awareness of the section 135 MHA 1980 process View source Fragmented healthcare record systems limiting the visibility and communication of important patient safety information View source Failure to locate and identify information about a section 135 MHA 1980 warrant View source Failure to make a detailed and measured assessment of a person’s situation View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edward Muwanga · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation
Wider context from the report “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the section 135 MHA 1980 process
Wider context from the report “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980 , and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Fragmented healthcare record systems limiting the visibility and communication of important patient safety information
Wider context from the report “(3) The sharing and visibility of important health care records between medical agencies, (held on multiple platforms by multiple health care agencies) in particular here between the treating Trust (SLAM) and NHS 111, and between the Ambulance Service (not NHS 111) and the treating Trust (SLAM). ████████ from London Ambulance Service NHS Trust writes to me in her PFD statement that “it is recognised that there remain challenges with the visibility of information from healthcare settings across London. While advances have been made, the visibility of pertinent information depends on technological developments and the coordination of a complex healthcare system.” In her written evidence to me dated 19th March 2026 ████████ Chief Medical Officer of LAS NHS Trust, writes that “..there is currently no single, comprehensive system that provides universal access to all patient records across NHS organisations. Access is influenced by information governance requirements, system interoperability, commissioning arrangements, and the extent to which partner organisations upload information to shared platforms." Whilst this fragmented situation persists with a multiplicity of systems, platforms, screens, and process in which important patient safety information is embedded the risk such information is not identified or communicated to practitioners making healthcare decisions remains and as such gives rise to a risk of death due to decisions being made on incomplete information where more complete information exists .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to locate and identify information about a section 135 MHA 1980 warrant
Wider context from the report “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant , together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to make a detailed and measured assessment of a person’s situation
Wider context from the report “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen policy and operational processes for identifying, executing, and managing requests for assistance at section 135 warrants.
Verbatim wording from the response “Separately, we acknowledge the concern regarding officers’ awareness of the existence of a section 135 warrant in this case. Recent changes to our processes ensure that section 135 warrants are recorded on police intelligence systems that are accessible to all officers. There is a clear expectation that officers will request intelligence checks when attending incidents involving vulnerable individuals, and processes have been strengthened to ensure that requests for police assistance at warrants are managed with greater clarity and consistency.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver comprehensive training on Mental Health Act sections 135 and 136, including communal-area powers, warrants, and safeguarding.
Verbatim wording from the response “The MPS acknowledges the findings of the inquest and the concerns raised in this report, and we have taken substantive steps to strengthen training, policy, and operational practice.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue operational notices clarifying the lawful use of section 136 powers in communal areas.
Verbatim wording from the response “All officers now receive structured and comprehensive training on sections 135 and 136 of the Mental Health Act. This includes specific instruction on the lawful use of section 136 powers in communal areas, with explicit clarification reinforced through operational notices issued to all frontline staff. Officers are also trained on the purpose and execution of section 135 warrants, including the respective roles of health professionals and the importance of safeguarding considerations. Training is delivered through a blended approach, combining classroom learning, scenario-based exercises, and ongoing professional development to ensure both legal understanding and effective practical application.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed enhanced supervisory oversight and escalation processes within control-room decision-making.
Verbatim wording from the response “Since the inquest, the MPS has taken further steps to strengthen these arrangements. Guidance on the application of section 136 in communal settings has been reinforced to remove any ambiguity, and updated policy and operational processes have improved consistency in identifying and executing section 135 warrants. Enhanced supervisory oversight and escalation processes are now embedded within control room decision-making. Taken together, these measures directly address the issues identified in the report and provide assurance that officers are better equipped to make lawful, informed, and proportionate decisions.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record section 135 warrants on police intelligence systems accessible to all officers.
Verbatim wording from the response “Separately, we acknowledge the concern regarding officers’ awareness of the existence of a section 135 warrant in this case. Recent changes to our processes ensure that section 135 warrants are recorded on police intelligence systems that are accessible to all officers. There is a clear expectation that officers will request intelligence checks when attending incidents involving vulnerable individuals, and processes have been strengthened to ensure that requests for police assistance at warrants are managed with greater clarity and consistency.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reinforcing Mental Health Act and Right Care, Right Person training through regular audit and quality assurance.
Verbatim wording from the response “Alongside this, the MPS will continue to reinforce training on Mental Health Act powers and the Right Care, Right Person framework, supported by regular audit and quality assurance to ensure consistent and effective decision-making.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mental health crises should be led by health services, with police involvement limited to lawful powers, crime, or immediate serious harm.
Verbatim wording from the response “The MPS operates within the nationally agreed Right Care, Right Person framework. This model is designed to ensure that individuals experiencing mental health crises receive a response from appropriately trained health professionals, with police involvement limited to circumstances where there is a legal power to exercise, a crime has occurred, or there is an immediate risk to life or serious harm requiring police capabilities. This case highlights the importance of maintaining that principle.” Source location Response from Metropolitan Police
Open published response
25 Mar 2026 Name not published · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 7 Failure to routinely seize feeding bottles and equipment pending toxicology results View source Insufficient police consideration of poisoning in unexpected child deaths View source Warning information for chlorpheniramine-containing products omitting their association with sudden unexpected death in children View source Perfunctory scene examinations in child death investigations View source Police training and guidelines requiring updating View source A person who illicitly administered chlorpheniramine to a child continuing to work as a nanny View source Absence of a national regulation system for nannies View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Name not published · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
A baby died unexpectedly at home on 15 January 2024, after being found unresponsive in a bassinet; chlorpheniramine was present in his blood and had probably been administered by the night nanny. The coroner reached an open conclusion, with expert evidence that the drug could possibly have caused or contributed to the death. Concerns included an inadequate scene examination, failure to seize feeding equipment or search relevant property, insufficient consideration of poisoning, and the lack of specific nanny regulation and guidance about chlorpheniramine.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely seize feeding bottles and equipment pending toxicology results
Wider context from the report “2. That feeding bottles and equipment are not routinely seized pending toxicology results .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient police consideration of poisoning in unexpected child deaths
Wider context from the report “3. That insufficient consideration is given the potential role of poisoning in such deaths by the police .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Warning information for chlorpheniramine-containing products omitting their association with sudden unexpected death in children
Wider context from the report “9. That the warning information on products containing chlorpheniramine, such as piriton may need to be updated to include the association between administration of the substance and sudden unexpected death in children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Perfunctory scene examinations in child death investigations
Wider context from the report “1. That child death investigation teams are too easily reassured when they attend deaths and find a well-presented home environment with no overt signs of neglect or injury to the deceased child, such that the scene examination becomes perfunctory and forensic opportunities are lost .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Police training and guidelines requiring updating
Wider context from the report “4. That police training and guidelines may need to be updated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation A person who illicitly administered chlorpheniramine to a child continuing to work as a nanny
Wider context from the report “7. That a person whom the court found administered chlorpheniramine illicitly to a child and that administration possibly contributed to that child’s death is still working as a nanny .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Absence of a national regulation system for nannies
Wider context from the report “8. That there is no national regulation system for nannies .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update MPS policy to specifically address poisoning and ingestion of harmful substances in sudden and unexpected child deaths.
Verbatim wording from the response “MPS policy was updated in May 2026 to make specific reference to poisoning and ingestion of harmful substances, reflecting national learning from cases including Daniel Pelka and Arthur Labinjo-Hughes and reinforcing awareness of toxicological considerations in sudden and unexpected child deaths. This change reflects the MPS’s consideration of the Coroner’s observations and supports the ongoing emphasis on early professional curiosity where poisoning or ingestion may be a factor.” Source location Response from MET
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 Update MPS child-death investigation policy to reflect NPCC guidance and strengthen expectations for investigative mindset, scene examination, and evidence preservation.
Verbatim wording from the response “After ████████ death, in December 2024, this approach was further reinforced through the introduction of the National Police Chiefs’ Council (NPCC) Practice Advice on Child Death Investigation, which refreshed and strengthened national guidance. The Practice Advice places continued emphasis on professional curiosity, encouraging officers to ask appropriate questions, reflect critically on information received, maintain an open mind, and avoid accepting initial accounts or assumptions at face value. It also provides clearer direction on the conduct of scene examinations, and MPS policy was updated in May 2025 to reflect the key expectations set out within this guidance.” Source location Response from MET
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 Deliver seven additional specialist training courses, training eighty-four more MPS officers over the next twelve months.
Verbatim wording from the response “Seven more courses are scheduled to take place over the next twelve months, which will mean an additional eighty-four specialist officers being trained.” Source location Response from MET
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver specialist sudden-unexpected-child-death investigation training addressing bias, false reassurance, systematic scene examination, forensic opportunities, and toxicological considerations.
Verbatim wording from the response “These expectations have been reinforced through training since May 2025, following implementation of the College of Policing Investigating Sudden Unexpected Death in Childhood programme, which specifically addresses the risk of unconscious bias and the potential for false reassurance when officers encounter a well-presented home or apparently attentive carers. The programme emphasises the importance of maintaining an open and questioning mindset, recognising that neglect, harm, or the administration of harmful substances can occur in any family context. It reinforces the need for systematic scene examination and the preservation of forensic opportunities in all cases, irrespective of initial impressions. Since May 2025, seventy-nine MPS officers have attended this training.” Source location Response from MET
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 Update MPS policy to emphasise seizing feeding bottles and equipment when enhanced toxicology analysis may be required.
Verbatim wording from the response “Following the inquest of ████████ MPS policy has since been reviewed and updated to reflect the national guidance and training, which emphasises the importance of seizing bottles and equipment should enhanced toxicology analysis be required.” Source location Response from MET
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 Updated national guidance, policy amendments and ongoing training address concerns about investigating sudden and unexpected child deaths.
Verbatim wording from the response “Since that time, national guidance and learning have developed. The introduction of the NPCC Practice Advice on Child Death Investigation (December 2024) refreshed and strengthened expectations around initial investigative mindset, scene examination, seizure of relevant items, consideration of toxicology and the risk of bias arising from early impressions of the home environment or caregivers. In response, MPS policy has been reviewed and updated to reflect this updated national guidance, including clearer reference to poisoning and ingestion of harmful substances and enhanced direction on the handling of feeding equipment and other potential evidential material.” Source location Response from MET
Open published response
5 Mar 2026 Caroline Adeyelu · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Absence of safeguarding referrals for parents at risk of adult child to parent domestic abuse View source Lack of carer support View source Failure to provide prompt direct operational liaison between mental health services and police View source Failure to appreciate risks posed by mentally unwell adult children to parents View source Absence of multi-agency risk assessment and risk management View source Insufficient safeguarding training on adult child to parent domestic abuse View source Lack of home-based risk assessment View source Lack of information gathering from wider family members View source Lack of home visits by the clinical team View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Caroline Adeyelu · 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
Caroline Adeyelu died after suffering a fatal stab wound to her chest at home on 30 October 2022, inflicted by her son, who was under the care of community mental health services. The inquest identified inadequate risk assessment and management, insufficient safeguarding and family engagement, poor care coordination and information sharing, and ineffective communication between mental health services and the police.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Absence of safeguarding referrals for parents at risk of adult child to parent domestic abuse
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of carer support
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support ; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prompt direct operational liaison between mental health services and police
Wider context from the report “2. The inquest heard concerns from multiple witnesses about the lack of effective communication systems in place between the mental health services and the Metropolitan Police Service , in circumstances where there are dual forensic and mental health concerns. Whilst there are clearly higher-level meetings that take place between the trusts and the MPS, these do not address the needs of psychiatrists and police officers working on the frontline who are having to address pressing risk issues – both in assessing and in managing risk. Such liaison needs to be prompt – in some cases immediate. Liaison may be from the MPS to the Trust (for example in risk assessing missing persons) or from the trust to the police (for both risk assessment and how to best manage risk). The inquest heard that communication both ways was challenging . The challenges have increased since the introduction of the Right Care, Right Person policy has been introduced. In some cases, communication was not attempted at all , because of the assumption that the appropriate professional was unlikely to be reached. Both trusts and the MPS are asked to consider a process for direct and immediate operational liaison between the police and NHS mental health staff for individuals presenting with a risk of violence compounded by mental ill health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate risks posed by mentally unwell adult children to parents
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son . This poor appreciation of risk was observed at all levels of clinical staff . Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Absence of multi-agency risk assessment and risk management
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management . It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient safeguarding training on adult child to parent domestic abuse
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case . In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of home-based risk assessment
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment ; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of information gathering from wider family members
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members ; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of home visits by the clinical team
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team ; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 Meet with North East London and East London NHS Foundation Trusts to discuss improved operational information flow, contact points and escalation routes.
Verbatim wording from the response “As part of strengthening partnership working, the MPS has met directly with both North East London NHS Foundation Trust (NEFLT) and East London NHS Foundation Trust (ELFT) to discuss improved operational information flow between policing and mental health services. These discussions have focused on how frontline officers and clinicians can access timely, proportionate information, how points of contact can be clarified at an operational level and how escalation routes can be strengthened when immediate clinical or police input is required.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with Mental Health Trust Leads and the Joint Mental Health and Police Group to refine operational communication and escalation arrangements.
Verbatim wording from the response “The MPS is continuing to work closely with Mental Health Trust Leads and the Joint Mental Health and Police Group (JMHPG) to refine and strengthen these arrangements. This includes agreeing escalation routes when urgent clinical input is needed, clarifying points of contact, and aligning operational processes with both clinical practice and policing risk assessment frameworks. This collaborative approach reflects our shared commitment to improving how risk is assessed and managed in real time.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a London-wide direct liaison protocol defining urgent contact arrangements, accessibility, responsibilities, escalation and lawful information sharing.
Verbatim wording from the response “To address these issues, the MPS is developing a new direct liaison protocol to support immediate frontline communication between officers and Mental Health Trust clinicians when an individual presents a combination of mental ill health and risk of violence. The protocol is being developed with local partnership governance structures and aims to clearly define who should be contacted, ensure round-the-clock accessibility to the appropriate advice, and set out the respective responsibilities of both police and clinical services under RCRP. This work also includes reinforcing existing routes available to officers, such as the use of the mental health clinical advice line, which provides timely clinical guidance where appropriate and helps support informed decision making in real time situations.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Mental Health Clinical Advice Line reminder on the Mental Health page of the Public Protection SharePoint.
Verbatim wording from the response “The protocol is being aligned with the relevant data protection and safeguarding frameworks to allow information to be shared safely and lawfully. Importantly, this work is intended to establish consistent operational expectations across all London boroughs so that frontline practitioners experience predictable and reliable routes of communication, regardless of location. It is anticipated that this work will be completed by the beginning of next year. In the interim, on 2nd April 2026, communication was issued to all Borough Commanders reminding them of the requirement to ensure that officers utilise the Mental Health Clinical Advice Line whenever they engage with or are required to make decisions concerning a person known or believed to be experiencing mental ill health. This information has also been published on the Mental Health page of the Public Protection SharePoint.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind Borough Commanders to ensure officers use the Mental Health Clinical Advice Line when responding to people experiencing mental ill health.
Verbatim wording from the response “The protocol is being aligned with the relevant data protection and safeguarding frameworks to allow information to be shared safely and lawfully. Importantly, this work is intended to establish consistent operational expectations across all London boroughs so that frontline practitioners experience predictable and reliable routes of communication, regardless of location. It is anticipated that this work will be completed by the beginning of next year. In the interim, on 2nd April 2026, communication was issued to all Borough Commanders reminding them of the requirement to ensure that officers utilise the Mental Health Clinical Advice Line whenever they engage with or are required to make decisions concerning a person known or believed to be experiencing mental ill health. This information has also been published on the Mental Health page of the Public Protection SharePoint.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review existing information-sharing pathways with Mental Health Trusts to identify inconsistencies and gaps.
Verbatim wording from the response “In response, the MPS has already undertaken a comprehensive review of existing information-sharing pathways with Mental Health Trusts. This work identified inconsistencies across London, including where current arrangements rely on informal, individual-based contact rather than clear, structured systems. The review also highlighted the absence of designated contact points that can be accessed reliably by frontline officers and clinical teams in urgent circumstances. These gaps create the potential for delays, missed opportunities for intervention, and uncertainty for those involved in managing shared risks.” Source location Response from Metropolitan Police
Open published response
20 Feb 2026 Sean Perry WILLIAMS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 12 Failure of custody nurses to recognise and describe drug withdrawal signs and symptoms View source Inadequate assessment of first aid knowledge and competence View source Failure to provide the transport vehicle location to emergency services View source Failure to assess and record the clinical picture before and after prescribing View source Delays in custody nurse assessment after detention View source Conflicting guidance on driving a casualty directly to hospital View source Delays in opening a detainee cell and administering emergency first aid View source Insufficient emphasis on urgent life-preserving first aid measures View source Failure of transport crew to maintain focus on monitoring and assisting a detainee in distress View source Failure to operate and provide clear guidance on emergency button procedures View source Failure of first aid staff to provide complete resuscitation measures View source Inadequate first aid training for seizures and other emergencies View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sean Perry WILLIAMS · 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
Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of custody nurses to recognise and describe drug withdrawal signs and symptoms
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal .
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate assessment of first aid knowledge and competence
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate ;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the transport vehicle location to emergency services
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location .
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and record the clinical picture before and after prescribing
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture . Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Delays in custody nurse assessment after detention
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours .
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Conflicting guidance on driving a casualty directly to hospital
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital ;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Delays in opening a detainee cell and administering emergency first aid
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door . They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours .
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient emphasis on urgent life-preserving first aid measures
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position ;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of transport crew to maintain focus on monitoring and assisting a detainee in distress
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to operate and provide clear guidance on emergency button procedures
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation . The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures ;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of first aid staff to provide complete resuscitation measures
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate;
- it did not include a video of a seizure;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate first aid training for seizures and other emergencies
Wider context from the report “For the MPS
The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours.
However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal.
For Serco
By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours.
The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location.
I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed.
The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt.
Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that:
- the Serco first aid training was inadequate ;
- it did not include a video of a seizure ;
- it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position;
- the Serco assessment of the first aid knowledge and competence of its staff was inadequate;
- Serco failed to provide clear guidance on the emergency button procedures;
- Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital;
- Serco gave insufficient emphasis on urgency and the paramount importance of preserving life.
” 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 Implement a daily case-finding protocol requiring healthcare practitioners and Grip Sergeants to identify detainees with unmet medical needs.
Verbatim wording from the response “A new protocol for ‘case finding’ was implemented in November 2025, where the HCP on duty runs through the custody whiteboard with the Grip Sergeant² at around 05:30hrs and checks if there are any detainees who may have unmet medical needs (i.e. they do not have a medical request on CONNECT).” Source location Response from Metropolitan Police Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver induction and annual refresher training on detainee reassessment, vital signs, and recognition of drug and alcohol withdrawal.
Verbatim wording from the response “The importance of detainee reassessment (including vital signs) each time there is a clinical review cannot be underestimated, and this is communicated to all HCPs during the induction and annual refresher programme (Immediate Life Support and Professional Development Days).” Source location Response from Metropolitan Police Service
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 Update withdrawal assessment tools and clinical guidelines to display COWS signs and symptoms and support earlier medication for detainees likely to withdraw.
Verbatim wording from the response “The template for opiate dependency / withdrawal uses the COWS score and the list of signs and symptoms are on the screen. Clinical practice guidelines have been updated to ensure that detainees who are likely to withdraw can be medicated earlier to prevent this.” Source location Response from Metropolitan Police Service
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 Audit healthcare practitioners’ clinical documentation and provide feedback, guidance, and additional training where practice or records fall below the required standard.
Verbatim wording from the response “The Clinical Practice Guidelines followed by HCP in custody highlight this approach to safe care and assessment of detainees. Compliance with guidelines and quality of care delivered is monitored through HCP audits led by the Senior HCPs in each area. Feedback and guidance are provided where the documentation falls below, standards or there are learning needs to provide the standard of care expected from all HCPs working in MPS Custody Suites.” Source location Response from Metropolitan Police Service
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 Issue operational reminders requiring custody officers to make timely medical requests for detainees needing assessment.
Verbatim wording from the response “MPS Custody Teams (Police Sergeant Custody Officer and Designated Detention Officers) complete a risk assessment and identify detainees who require medical assessment. They inform the Healthcare Practitioner (HCP) on duty (Nurse, Doctor or Paramedic). The communication takes the form of a ‘medical request’ on the MPS CONNECT¹ system, in addition, a verbal handover is sometimes included direct to the HCP.” Source location Response from Metropolitan Police Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor compliance with case-finding and withdrawal-management protocols and provide feedback to healthcare practitioners who do not follow them.
Verbatim wording from the response “The MPS are monitoring compliance with protocols regarding ‘case finding’ and withdrawal management. Individual detainee cases are reviewed monthly, and feedback provided to HCPs who are not following clinical practice guidelines and actively completing the discussion with the Grip Sergeant.” Source location Response from Metropolitan Police Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement SYSTMOne templates requiring vital-sign and other observation recording during initial assessments and clinical reviews.
Verbatim wording from the response “It is a requirement that the HCP records a full set of vital signs and other observations (e.g. COWS - Clinical Opiate Withdrawal Scale) prior to medication administration. In April 2024, the new SYSTMOne³ templates were created which mandate a set of vital signs (unless the patient refuses) to be recorded at the initial clinical assessment and when reviews take place.” Source location Response from Metropolitan Police Service
Open published response
29 Sep 2025 Jake Hickey Girton · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to inform the hospital of release from police custody View source Failure to reflect on or remediate identified performance failings View source Failure to identify shortcomings in police performance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jake Hickey Girton · 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
Jake Hickey Girton was admitted to psychiatric hospital following suicidal ideation and serious, sustained alcohol misuse, and was later arrested after an incident on the ward. He was released from police custody without the psychiatric Trust being informed and was subsequently found deceased at home on 26 January 2024; the inquest identified concerns about the failure to notify the Trust and the lack of evidence of reflection or remediation by the Metropolitan Police Service.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the hospital of release from police custody
Wider context from the report “1. Evidence heard from a Metropolitan Police Inspector at inquest indicated that the police officer who was investigating the offence for which Jake was arrested was under an obligation to inform that complainant (the hospital) of Jake’s release from custody . There is no evidence to suggest this was done . Evidence from the Psychiatric trust at inquest indicates that on the 17th January 2024, there were under the impression that Jake would remain in police custody, and had they known he was released, greater efforts may have occurred to support Jake in the community.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to reflect on or remediate identified performance failings
Wider context from the report “2. Despite a Directorate of Professional Standards review, there is no evidence that the MPS identified any shortcoming in their performance in dealing with Jake, consequently no evidence exists of any reflection or remediation of this failing .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to identify shortcomings in police performance
Wider context from the report “2. Despite a Directorate of Professional Standards review, there is no evidence that the MPS identified any shortcoming in their performance in dealing with Jake , consequently no evidence exists of any reflection or remediation of this failing.
” 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 Work with mental health partners to develop consistent London-wide arrangements, accountability lines and welfare escalation routes after release.
Verbatim wording from the response “3. The MPS is working with Mental Health Trust Leads and the Joint Mental Health and Police Group (JMHPG) to develop consistent arrangements across London. This includes establishing clear lines of accountability and escalation routes where concerns arise about a person’s welfare post release.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete mapping of existing information-sharing pathways for releases from custody.
Verbatim wording from the response “A review has already been undertaken in relation to information sharing with Mental Health Trusts which has identified a gap in current arrangements. Specifically, there is no consistent mechanism to ensure Mental Health services are notified when an individual is released from custody. This gap can result in missed opportunities for early intervention and continuity of care.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop guidance for custody and investigating officers on identifying risk, recording indicators and initiating referrals or notifications before release.
Verbatim wording from the response “4. Additional guidance is being developed for custody and investigating officers, supported by the MPS Mental Health Lead. This will reinforce the importance of identifying those at risk, recording relevant indicators and initiating the appropriate referral or notification before release.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a protocol for lawful, prompt notification of appropriate mental health services when people in crisis are released from custody.
Verbatim wording from the response “2. The MPS is developing a protocol, agreed through local partnership governance to ensure that when a person identified as being in mental health crisis or having been arrested in a mental health setting, is released from custody, relevant information can be shared promptly and lawfully with the appropriate Mental Health Trust or Community Mental Health Team, if known. This protocol is being aligned with data protection and safeguarding requirements under existing information governance frameworks.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The DPS review was appropriate and went as far as expected because it identified no conduct, performance or organisational learning.
Verbatim wording from the response “The MPS Directorate of Professional Standards (DPS) conducted a comprehensive review into this matter as per their remit and standard operating procedure. It was determined that this incident did not meet the definition of a Death or Serious Injury¹ (DSI) following police contact as defined in the Independent Office for Police Conduct (IOPC) Statutory Guidance. Upon conducting DSI reviews, the expectation is for DPS to also consider whether there is an obvious conduct matter, performance matter or opportunity for individual or organisational learning. In this instance, the review did not identify any such learning.” Source location Response from Metropolitan Police
Open published response
19 Sep 2025 Rebekah Arter · Prevention of Future Deaths report South London
View report summary
Concerns raised 2 Failure to consider domestic abuse risk at police dismissal View source Failure of investigations to identify victims of domestic abuse and coercive control View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rebekah Arter · 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
Rebekah Arter, aged 47, died in a hotel room in Barbados on 28 June 2024 in circumstances involving likely intoxication; the medical cause of death was unascertained and the inquest conclusion was open. The principal concern was that missed opportunities by the IOPC and Metropolitan Police Service may have prevented identification of Rebekah as a victim of domestic abuse and coercive control, and prevented protective action.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to consider domestic abuse risk at police dismissal
Wider context from the report “That there may have been missed opportunities for the IOPC and Metropolitan Police Service from their investigations to identify that Rebekah was a victim of domestic abuse and coercive control, which would have enabled her to be protected. This is illustrated by these facts:
• That Rebekah had met her husband initially as a victim of a crime.
• That police investigations uncovered a large number of women with whom he had inappropriate relationships and that he misused his police powers.
• That he was dismissed from the police for drug offences in May 2023, but the risk to Rebekah was not apparently considered at that time .
• A witness has alleged that a video was sent by him of Rebekah ████████ which the family allege was used to shame and enforce control over her, allegedly in 2023.
• A history of her having unexplained repeated bruises and injuries was available in 2024 to anyone who enquired about the risk of domestic abuse.
• ████████
• That in retrospect it is recognised by a Detective Chief Inspector that he was an exceptionally persistent and damaging offender against women, but no charges in relation to that had ever been brought.
The coroner did not accept submissions from the family that the inquest engaged Article 2 of the European Convention on Human Rights and ruled that details of the seven years of conduct investigations were beyond the scope of the 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to identify victims of domestic abuse and coercive control
Wider context from the report “That there may have been missed opportunities for the IOPC and Metropolitan Police Service from their investigations to identify that Rebekah was a victim of domestic abuse and coercive control , which would have enabled her to be protected. This is illustrated by these facts:
• That Rebekah had met her husband initially as a victim of a crime.
• That police investigations uncovered a large number of women with whom he had inappropriate relationships and that he misused his police powers.
• That he was dismissed from the police for drug offences in May 2023, but the risk to Rebekah was not apparently considered at that time.
• A witness has alleged that a video was sent by him of Rebekah ████████ which the family allege was used to shame and enforce control over her, allegedly in 2023.
• A history of her having unexplained repeated bruises and injuries was available in 2024 to anyone who enquired about the risk of domestic abuse .
• ████████
• That in retrospect it is recognised by a Detective Chief Inspector that he was an exceptionally persistent and damaging offender against women, but no charges in relation to that had ever been brought.
The coroner did not accept submissions from the family that the inquest engaged Article 2 of the European Convention on Human Rights and ruled that details of the seven years of conduct investigations were beyond the scope of the inquest.
” 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 Create and operate the Domestic Abuse and Sexual Offences Investigation Unit with specialist investigation teams and victim-support capacity.
Verbatim wording from the response “DASO – this was created in early 2022 in response to the cases relating to former Police Constables ████████ and ████████, a unique reactive department committed to investigating Police-Perpetrated Domestic Abuse (PPDA) and Sexual” Source location Response from Metropolitan 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 Operate the Integrity Assurance Unit to risk-assess personnel with adverse judicial findings or adverse information and impose risk-management measures where necessary.
Verbatim wording from the response “The Integrity Assurance Unit (IAU) manages officers or staff who are the subject of an Adverse Judicial Finding (AJF), evidentially tainted by virtue of a criminal or misconduct outcome or in respect of whom adverse information is held. The IAU will ensure that such officers or staff are risk assessed and handled fairly to protect both the individual, the public and the organisation. This is achieved by holistically reviewing all known information and, where applicable convening a management meeting to decide on whether Risk Management Measures need to be imposed to manage the risk presented by the taint, AJF or adverse information. The IAU oversees disclosure requirements associated with taint and maintains confidential records.” Source location Response from Metropolitan Police
Open published response
18 Jul 2025 Marie Louise Theobald · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to remand an identified suspect in custody View source Failure to subject an identified suspect to conditional bail View source Failure to impose driving disqualification on an identified suspect View source Delays in the criminal investigation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marie Louise Theobald · 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
Marie Louise Theobald, aged 48, died after being struck by a car travelling at high speed while walking her dogs near her home on 22 December 2023. The report raises concerns about delays in the criminal investigation, with no charging decision made and no conditional bail, driving disqualification or remand measures in place for the identified suspect, creating a risk of further fatal harm.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to remand an identified suspect in custody
Wider context from the report “1. Ms Theobald was killed over 18 months ago. Delays in the criminal investigation mean that an identified suspect is neither subject to conditional bail, driving disqualification nor are they remanded in custody . The absence of these measures means that a risk of further fatal harm exists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to subject an identified suspect to conditional bail
Wider context from the report “1. Ms Theobald was killed over 18 months ago. Delays in the criminal investigation mean that an identified suspect is neither subject to conditional bail , driving disqualification nor are they remanded in custody. The absence of these measures means that a risk of further fatal harm exists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to impose driving disqualification on an identified suspect
Wider context from the report “1. Ms Theobald was killed over 18 months ago. Delays in the criminal investigation mean that an identified suspect is neither subject to conditional bail, driving disqualification nor are they remanded in custody. The absence of these measures means that a risk of further fatal harm exists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Delays in the criminal investigation
Wider context from the report “1. Ms Theobald was killed over 18 months ago. Delays in the criminal investigation mean that an identified suspect is neither subject to conditional bail, driving disqualification nor are they remanded in custody. The absence of these measures means that a risk of further fatal harm exists.
” 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 Recruit additional detectives to increase Serious Collision Investigation Unit capacity.
Verbatim wording from the response “In addition to the above, delays occurred due to staffing challenges, leading to the current investigating officer inheriting a relatively large number of cases to be progressed simultaneously. The Serious Collision Investigation Unit has recently recruited a number of new detectives which will increase the capacity of the unit and ensure cases are processed expeditiously.” Source location Response from Metropolitan 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 Implement processes to improve the unit’s effective and efficient functioning.
Verbatim wording from the response “Since the start of this investigation, the leadership team overseeing the Serious Crime Collision Unit has changed and processes have been, and are being, implemented to ensure the effective and efficient functioning of the unit.” Source location Response from Metropolitan Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The suspect is currently disqualified from driving until September 2026, contrary to the concern that no disqualification measure applies.
Verbatim wording from the response “Prior to the bail period ending, the suspect had been charged by the investigation team with an offence under S172 of the Road Traffic Act, resulting in a disqualification from driving for 6 months. The driver remains disqualified from driving until September 2026, having been found guilty of an unrelated offence in July 2025.” Source location Response from Metropolitan Police
Open published response
23 May 2025 Lewis Dean JOHNSON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to disseminate relevant policies effectively View source Failure to implement relevant policies effectively View source Failure to train relevant staff on relevant policies effectively View source Lack of a consistent expectation among police officers about police controller decision-making times for pursuit authorisation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lewis Dean JOHNSON · 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
Lewis Johnson, aged 18, died following a motorcycle road traffic collision at Clapton Common A107 in London on 9 February 2016, after a police pursuit. The jury concluded that the Metropolitan Police Service failed to effectively implement, disseminate and train relevant staff on relevant policies. The report also identified inconsistent expectations among police officers about how long police control authorisation decisions generally take during pursuits.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate relevant policies effectively
Wider context from the report “1. You will see from the attached narrative that the jury concluded there was a failure by MPS to implement, disseminate and train relevant staff on relevant policies effectively .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to implement relevant policies effectively
Wider context from the report “1. You will see from the attached narrative that the jury concluded there was a failure by MPS to implement , disseminate and train relevant staff on relevant policies effectively .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to train relevant staff on relevant policies effectively
Wider context from the report “1. You will see from the attached narrative that the jury concluded there was a failure by MPS to implement, disseminate and train relevant staff on relevant policies effectively .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent expectation among police officers about police controller decision-making times for pursuit authorisation
Wider context from the report “2. Although the jury did not comment on this specifically, it seemed to me from the evidence in court that there was not a consistent expectation among police officers of how long it generally takes a police controller to make a decision on authorisation of a pursuit .
Whilst I do not suggest there should be a time limit on this, it would seem helpful if the expectation of the timing of police control decision making were to be roughly aligned between those making the decisions (in the police control room) and those waiting for the decisions (in police cars involved in the pursuits).
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate critical driving-policy updates through intranet notices, the Safer Driver Manager network, and driver acknowledgement emails.
Verbatim wording from the response “Since this incident in 2016, the RTPC PDSU has reviewed the way critical policy updates are disseminated with the aim of reducing the risk of policy updates being missed. As such, the RTPC PDSU continues to publish Operational Notices on the MPS intranet, which is then reinforced with the update being disseminated throughout the Safer Driver Manager (SDM) network. The SDM’s will then share these updates with the drivers in their command by email requesting an acknowledgement response.” Source location 2025-0241 Response from Metropolitan Police Service (MPS)
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 Disseminate internally guided policy changes and notified APP updates within 24 hours, while risk-assessing timelines for further implementation work.
Verbatim wording from the response “Whilst at times, the decision to change policy is held within the MPS, which allows for prior planning for the education of policy updates, this is not always the case. The MPS, as with other police forces, are guided by APP. At times, these updates can be dynamic due to learning within other forces and as such there can be a delay in communication to MPS officers and staff in order to determine the best manner to educate or train them. Where the MPS has guided an internal policy change, or the College of Policing has provided a timeline of APP updates, the PDSU will disseminate this information within 24 hours of being notified. Where further work is required to update officers and staff of the changes, the PDSU will assess the risk and ensure that timelines for implementation are proportionate to that risk.” Source location 2025-0241 Response from Metropolitan Police Service (MPS)
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 Scope and develop a Digital Driving Permit that can restrict vehicle booking and require acknowledgement of policy updates.
Verbatim wording from the response “In addition to the current process, as part of the Police Driver Standards Improvement Plan, the RTPC PDSU has numerous ongoing digital driving and system projects in production, specifically the MPS is scoping the introduction of a Digital Driving Permit (the initial phase due for completion by the end of July 2025, Digital Logbooks, a Chronical Systems Project,” Source location 2025-0241 Response from Metropolitan Police Service (MPS)
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 Deliver a revised three-week Pan London training course with pursuit-policy instruction, immersive practice, and written and practical competency assessments.
Verbatim wording from the response “Since MetCC have taken ownership of the Pan London training, the course has been changed from four weeks to three weeks. The first two weeks teaches staff how to work in all areas of Pan London, with the third week being dedicated to pursuit management within the control room - the Pan London Training Team (PLTT). The staff are given an electronic copy of the MPS Pursuit Policy with their joining instructions prior to the course.” Source location 2025-0241 Response from Metropolitan Police Service (MPS)
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide updated MetCC training enabling faster recognition and termination of pursuits, including direct channel control by Supervisors of Incident.
Verbatim wording from the response “The MPS has provided updated training packages to staff within the Metropolitan Police’s Command and Control Command (MetCC), whose responsibility includes the management of the Pan London MPS Pursuit radio channel. Changes to training have been made to enable faster recognition and termination of pursuits, where appropriate. Specifically, within the Supervisor of Incident (SI) role (within the control room), the direction is that the SI will take control of the channel directly to terminate pursuits if deemed necessary, whereas previously the direction to terminate was given to the channel operator with supporting rationale. The channel operator would then direct the pursuit to terminate.” Source location 2025-0241 Response from Metropolitan Police Service (MPS)
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 A fixed timeframe for obtaining pursuit information cannot be aligned because each pursuit presents different circumstances and requires case-by-case assessment.
Verbatim wording from the response “We cannot align a time limit as to how quickly this information is obtained, as each pursuit is different in what the pursuing vehicle is presented with. However, with both MetCC staff and pursuing officers knowing what questions are going to be asked and in what order, it allows the answers to be promptly given and allows the SI to make decisions in a timelier manner. Although each pursuit would need to be reviewed on its own merits, on a case-by-case basis, the aim is to authorise a pursuit as soon as practicable once relevant information has been obtained.” Source location 2025-0241 Response from Metropolitan Police Service (MPS)
Open published response
25 Mar 2025 Oladeji Adeyemi Omishore · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 12 Failure to train call handlers and first responders to record information for dispatcher transmission View source Lack of training on where call handlers and first responders should record information View source Failure to circulate mental health information promptly during I grade calls View source Lack of dispatcher training on information to pass to responding officers View source Lack of dispatcher training on passing possible mental health concerns over the airwaves View source Lack of a NICL code for believed mental health concerns View source Failure to pass the number of units on the way over the airwaves View source Dispatcher pod failures causing mental health concerns to be missed under work pressure View source Inadequate response officer training on de-escalation and taser deployment tactics for subjects with mental ill-health View source Lack of training advice on recording mental health information concerning black men View source Inconsistent recording of mental health information by call handlers and first responders View source Insufficient NICL code capacity for recording mental health as a qualifier View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oladeji Adeyemi Omishore · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Oladeji Adeyemi Omishore died on 4 June 2022 after being tasered during an incident involving police officers on Chelsea Bridge and then entering the River Thames; his medical cause of death was complications arising from drowning. The report identified concerns about the recording and transmission of mental health information by call handlers and dispatchers, and about training for responding officers in tactical options before taser deployment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to train call handlers and first responders to record information for dispatcher transmission
Wider context from the report “2. That the call handlers/ first responders may have a training issue in relation to the importance of recording this information in a manner which is likely to be passed on to responding officers by dispatchers , for example in the NICL codes and/ or “golden line”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of training on where call handlers and first responders should record information
Wider context from the report “5. That call handlers/first responders may need training as to where to record such information i.e. in the “golden line” or NICL code , as long as of course it is reported to them before the “golden line” and NICL code has gone out.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to circulate mental health information promptly during I grade calls
Wider context from the report “6. That use of THRIVE usually requires time that is not available in I grade calls and does not mitigate the need to circulate promptly information as to mental health issues , in the format most likely to be digested and passed on by dispatchers that is “golden line” or NICL codes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of dispatcher training on information to pass to responding officers
Wider context from the report “9. That dispatchers may require training in relation to what to pass out more generally given the confusion in the evidence about other units being assigned by CAD, which dispatchers themselves did not seem to appreciate and understand let alone pass such information out to responding officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of dispatcher training on passing possible mental health concerns over the airwaves
Wider context from the report “8. That dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a NICL code for believed mental health concerns
Wider context from the report “7. That the lack of NICL code “mental health believed” compounds this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to pass the number of units on the way over the airwaves
Wider context from the report “10. That there are apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves , given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Dispatcher pod failures causing mental health concerns to be missed under work pressure
Wider context from the report “10. That there are apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves, given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate response officer training on de-escalation and taser deployment tactics for subjects with mental ill-health
Wider context from the report “11. That training for response officers may require review in relation to tactical options used to de-escalate prior to taser deployment , in appropriate circumstances, given the increased use of taser in black men with mental health issues; and in particular, training in relation to deploying with taser drawn and pointed with accompanying commanding language where the subject may be suffering with mental ill-health .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of training advice on recording mental health information concerning black men
Wider context from the report “3. That the above concern of potential training need is highlighted by the increased use of taser in black men and those suffering mental health issues and so the real need for this information to be recorded and passed on in the most effective form. Whilst training for first responders appears to include advice as to how to communicate with persons suffering with mental health issues, it does not appear to contain any advice in relation to the importance of such information to be recorded especially in relation to black men .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent recording of mental health information by call handlers and first responders
Wider context from the report “1. That there is an inconsistency of approach between call handlers/first responders in the recording of information passed to them by members of the public that may represent a training issue; in this case the mental health matters reported to them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient NICL code capacity for recording mental health as a qualifier
Wider context from the report “4. That the limitation of 3 NICL codes makes it difficult to record mental health as a qualifier in incidents such as this where the main risk factor is the weapon.
” Open source report
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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 Enhance dispatcher training and lesson plans on communicating CAD-assigned units to responding officers.
Verbatim wording from the response “We recognise the need for greater clarity and understanding among dispatchers regarding what information needs to be communicated more generally. Training will be enhanced to address the confusion identified in the evidence, specifically in relation to other units being assigned via Computer Aided Despatch (CAD) and the necessity for dispatchers to fully understand and communicate this to responding officers. Lesson plans will be updated accordingly.” Source location Response from Metropolitan 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 Operate a Taser-specific Community Scrutiny Panel and feed its review of incidents into officer training.
Verbatim wording from the response “In 2024 the MPS launched a Taser specific Community Scrutiny Panel to allow Taser incidents and use to be viewed by a panel from the community and feed back into training. This has led towards the MPS being more transparency and accountable. The views of the panel are fed back to the officer. This is particularly powerful feedback as it informs the officer as to how a jury may perceive their actions and use, particularly when the justification has not been properly explained.” Source location Response from Metropolitan 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 Update dispatcher training and lesson plans to relay key information, including mental-health concerns and the number of units en route.
Verbatim wording from the response “We note the concerns regarding the potential systemic failures within the individual pods within despatch. Training will be updated to ensure despatchers are equipped to pass on key information, including mental health concerns and the number of units en route, given the importance of this information in informing officers’ application of the National Decision Model. This will also be incorporated into revised lesson plans.” Source location Response from Metropolitan 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 Review Taser activations through the dedicated Taser use review system and address use falling outside training or justification.
Verbatim wording from the response “The MPS also have a comprehensive Taser use review system where a dedicated team review every Taser activation, any Taser use on under 18’s, at height, subjects running away, in custody, and over 65years. In addition to this the team review all uses on the Basic Command Units (BCU) each month (meaning each BCU has all their Taser use reviewed once a year).” Source location Response from Metropolitan 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 Update Despatch Course lesson plans to train dispatchers to relay possible mental-health concerns over the airwaves promptly.
Verbatim wording from the response “We acknowledge the importance of dispatchers being fully aware of and training in recognising and relaying possible mental health concerns. Lesson plans for the MetCC Academy Despatch Course will be updated to explicitly emphasise the importance of passing on such information over the airwaves, particularly in light of the increased use of Taser involving black men and individuals suffering from mental ill health.” Source location Response from Metropolitan 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 Review and update First Contact training to capture mental-health indicators in remarks and NICL codes.
Verbatim wording from the response “The MetCC Academy is currently reviewing the relevant content for First Contact training and will be updating lesson plans to ensure where Mental Health is believed or indicated, the operator will ensure this information is included in the remarks at the earliest opportunity.” Source location Response from Metropolitan 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 Embed de-escalation techniques and BUGEE conflict-management skills within PPST and Taser training, including scenario-based assessment of mental distress and vulnerable persons.
Verbatim wording from the response “The foundation of all officer training begins with the Personal & Public Safety Training (PPST), which equips officers with essential skills in the use of force, their powers under the law, and de-escalation techniques. These are delivered comprehensively during an officer’s initial training and are reinforced annually through mandatory refresher sessions.” Source location Response from Metropolitan 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 Brief call operators on golden-line use, specific mental-health questioning, and capturing and passing relevant information.
Verbatim wording from the response “The MetCC Academy are in the process of reviewing their Mental Health training content, additionally operators will be briefed on their Professional Development Days around the importance of the Golden line and specific questioning when dealing with Mental Health related calls and ensuring all information is captured and passed to officers.” Source location Response from Metropolitan Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing mental-health NICL coding, CAD and remarks are considered sufficient to record and relay relevant information.
Verbatim wording from the response “The mental health NICL code is sufficient and has a definition attached it, the operator records on both the Computer Aided Despatch (CAD) and Contact Handling System (CHS) along with the ethnicity of the individual as this is a normal practice by our operators, CAD is passed to despatch and forms part of the information relayed to officers.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A separate believed-mental-health NICL code is not required because the existing mental-health qualifier covers people who appear to be suffering.
Verbatim wording from the response “The NSIR 2011 document and the new proposed NSIRA (National Standard of Incident Reporting and Assessment) document are still under review by the NPCC and describes the qualifier for Mental Health as follows:” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Frontline officers, rather than communication officers, are responsible for awareness of force against black men with mental-health issues.
Verbatim wording from the response “However, please note that it is more for officers on the frontline to be appraised and aware around use of force against black men with mental health issues than communication officers, who follow a Standard Operating Procedure when dealing with calls, irrespective of race/gender.” Source location Response from Metropolitan Police
Open published response
18 Feb 2025 Ronald Bainborough · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Delays in scheduling police execution of s135(1) warrants View source Delays in obtaining Magistrates Court hearings for s135(1) warrant applications View source Lack of an official fast-track procedure for s135(1) warrants 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
Ronald Bainborough · 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
Ronald Bainborough lived in supported living accommodation and had schizophrenia, substance misuse, malnutrition and a history of disengagement from mental health and primary care services. A warrant under section 135(1) of the Mental Health Act was sought after he refused assessment, but there were delays before it was granted and arrangements were made for execution; he was admitted to hospital with severe malnutrition before the warrant was executed and died from community acquired pneumonia and malnutrition. The concerns identified included the time taken to apply for and execute warrants, the absence of an official fast-track procedure, and the resulting risk of fatal harm to individuals awaiting assessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Delays in scheduling police execution of s135(1) warrants
Wider context from the report “(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed
(2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest.
(3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing.
(4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled.
(5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed.
(6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining Magistrates Court hearings for s135(1) warrant applications
Wider context from the report “(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed
(2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest.
(3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing.
(4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled.
(5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed.
(6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of an official fast-track procedure for s135(1) warrants
Wider context from the report “(1) During the Inquest, evidence was heard from 2 consultant psychiatrists and an Approved Mental Health Act Professional (AMHP) regarding the timescales for applying for and executing s135(1) warrants. All of them had concerns about the time taken for a warrant to be issued and executed
(2) The warrant application was submitted to the Magistrates Court on 18 August 2023, the hearing took place on 23 August and it was intended that the warrant would be executed on 7 September 2023. This was a timescale of 20 days. The jury was told that this timescale was typical of the time taken to apply for and execute a s135(1) warrant in the experience of the professionals giving evidence at the Inquest.
(3) Applications for a warrant are heard at Westminster and Uxbridge Magistrates Courts which consider applications from all 32 London Boroughs. There are a limited number of video hearing slots, so AMPH teams may have to wait several days for a hearing.
(4) Once a warrant has been issued, an appointment then needs to be arranged for police officers to execute the warrant. The evidence before the court was that it would generally take in the region of 10 days for an appointment to be scheduled.
(5) There is no official fast track procedure. Consequently, there is a risk of harm to the individual and others during the time taken for a warrant to be granted and executed.
(6) As individuals have been identified as requiring assessment under the Mental Health Act, the risk of potential harm is recognised. In the absence of treatment, there is an ongoing risk that individuals will harm themselves or others before the warrant can be executed. This includes a risk of fatal harm.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the corporate section 135 warrant process and incorporate matters raised in the report and identified learning.
Verbatim wording from the response “The MPS corporate process to s.135 warrants is currently being reviewed and the matters raised in this PFD report and learning identified will be incorporated into this.” Source location Response from MPS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review police databases, conduct warrant-execution risk assessments, and record and supervisor-ratify controls on MHAA RA3 forms.
Verbatim wording from the response “After a warrant is obtained under section 135(1) MHA 1983 information held on police databases about the person concerned is reviewed and a risk assessment is conducted. This enables officers to make an informed decision as to the police resources required to execute the warrant and ensure the safety of attending officers, healthcare professionals and the individual.” Source location Response from MPS
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 Responsibility for applying to court for a section 135(1) warrant rests with Approved Mental Health Professionals, who are the only authorised applicants.
Verbatim wording from the response “Applying for a warrant under Section 135(1) of the Mental Health Act (MHA) 1983” Source location Response from MPS
Open published response
18 Feb 2025 Zahra Sharif Mohamed · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Reliance on encouraging voluntary return before applying for a warrant View source Risk of patients harming themselves or others before s135(2) warrant execution View source Delays in obtaining and executing s135(2) warrants View source Discouragement of urgent in-person applications for s135(2) warrants View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Zahra Sharif Mohamed · 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
Zahra Sharif Mohamed, who had been detained under the Mental Health Act and sent on home leave, expressed suicidal thoughts and threatened to jump from the balcony of her fifth-floor flat. She jumped from the balcony on 12 October 2022 and died at the scene. The principal concerns were that a warrant to return her to hospital was not applied for, and that delays in obtaining and executing such warrants create a risk of patients harming themselves or others, including fatal harm.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Reliance on encouraging voluntary return before applying for a warrant
Wider context from the report “(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks.
(2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant.
(3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024.
(4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court.
(5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant .
(6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Risk of patients harming themselves or others before s135(2) warrant execution
Wider context from the report “(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks.
(2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant.
(3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024.
(4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court.
(5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant.
(6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining and executing s135(2) warrants
Wider context from the report “(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks .
(2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant.
(3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024 .
(4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court.
(5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant.
(6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Discouragement of urgent in-person applications for s135(2) warrants
Wider context from the report “(1) It was accepted that a s135(2) warrant should have been applied for on 4 October 2022. However, if an application had been submitted to the magistrates’ court that day, it is unlikely that the warrant would have been executed before Mrs Mohamed’s death. In evidence, I was informed by a number of mental health professionals that the time taken for a s135(2) warrant to be obtained from the magistrates’ court and executed by the police was in the region of 2 weeks.
(2) The process for obtaining a warrant is that an application has to be made for a video hearing at either Uxbridge or Westminster Magistrates’ Courts. It could take several days for a hearing to be arranged as the courts consider applications from all 32 London Boroughs. Once the Magistrates issued a warrant, an appointment would then be arranged for the police to execute the warrant.
(3) I was informed that a 2-week timescale for obtaining s135(2) warrants was still the case in the summer of 2024.
(4) I also heard evidence that the mental health team could attend Highbury Corner Magistrates’ Court in person to apply for a warrant in urgent cases but that they were actively discouraged from using this process by the court .
(5) The court heard that the process and timescale for issuing and executing warrants had led to the hospital team adopting a practice of asking the community team to encourage a patient to return to hospital voluntarily before making an application for a warrant.
(6) There is an ongoing risk that patients will harm themselves or others in the period before the warrant can be executed. This includes a risk of fatal harm.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review police databases, conduct a risk assessment, and record and supervisor-ratify risks and control measures before executing section 135(2) warrants.
Verbatim wording from the response “After a warrant is obtained, information held on police databases about the person concerned is reviewed and a risk assessment is conducted. This enables officers to make an informed decision as to the police resources required to execute the warrant and ensure the safety of attending officers, any healthcare professionals and the individual.” Source location Response from MPS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the corporate section 135 warrant process and incorporate learning and matters raised in the prevention of future deaths report.
Verbatim wording from the response “The MPS corporate process to s.135 warrants is currently being reviewed and the matters raised in this PFD report and learning identified will be incorporated into this.” Source location Response from MPS
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 Consider whether an immediate police response is required while a section 135(2) warrant application awaits the court’s decision.
Verbatim wording from the response “If a warrant appears to be the last option available, an application to the Magistrates’ Court will be made. If the application is made by an AMHP/duly authorised person a request for police attendance will be submitted.” Source location Response from MPS
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 Court listing timescales are outside the MPS’s remit, so it cannot comment on them.
Verbatim wording from the response “The MPS cannot comment on the length of time taken to receive a listing for an application for a s.135(2) warrant to be heard as this is a matter for the courts. However, the average time taken from application to execution is currently between 10 and 20 days.” Source location Response from MPS
Open published response
4 Feb 2025 Peter Keith JONES · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Presence of flat-topped telephone hoods enabling suicide by hanging View source Failure to provide sufficient oversight of public reception areas from station offices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Keith JONES · 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 5 November 2022, Peter Keith Jones spent approximately 18 hours in the public waiting area of Stoke Newington Police Station before jumping from the flat hood of a telephone booth onto the concrete floor. He suffered devastating injuries and died shortly afterwards. The jury identified concerns about the presence of a flat-topped telephone hood and insufficient oversight of the public reception area by police station staff.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Presence of flat-topped telephone hoods enabling suicide by hanging
Wider context from the report “The jury noted that without the presence of a flat topped telephone hood, there would have been no means for Mr Jones to take his life in this manner . However, I heard at inquest that the telephone hoods in Stoke Newington Police Station have been replaced since Mr Jones’s death, and the flat kind are nowhere else in the MPS estate.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient oversight of public reception areas from station offices
Wider context from the report “The jury also found that there was an MPS failure to have sufficient oversight of the public reception area from “the box” , the area that faces out to the public reception area.
I heard that every police station has a different geographical layout, and that some of these are old buildings. However, a senior police officer giving evidence did accept that station officers could be positioned in the box facing out towards the public area, rather than further into the office facing each other.
” 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 Alter Forest Gate Police Station’s refurbishment design to improve PAO oversight from all front-counter positions.
Verbatim wording from the response “However, we have taken the opportunity to alter the design of the ongoing refurbishment of Forest Gate Police Station to ensure that the layout of the front counter and public waiting area will provide much improved oversight for PAOs, from all counter positions. The lessons learned from this will be incorporated in a forthcoming Front Counter Design Standard that will (after staff safety) prioritise clear sight lines and PAO workplace ergonomics for all new sites or major refurbishments.” Source location Response from MPS
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 Survey active front counters to assess PAO visibility, IT access and CCTV monitoring capability.
Verbatim wording from the response “Following the receipt of this report, a survey into all active front counters across the MPS estate was commissioned (excluding permanently closed counters and those that are currently under refurbishment), and a Custody Centre which has a public waiting area but not a front counter area. The scope of the survey was to:” Source location Response from MPS
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 Refresh front-counter CCTV systems through the MPS CCTV Lifecycle Programme to enhance PAO monitoring capability.
Verbatim wording from the response “Front counter CCTV systems are due to be refreshed over the next few years as part of the MPS’s CCTV Lifecycle Programme with the Mayor’s Office for Policing and Crime (MOPAC).” Source location Response from MPS
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 Incorporate refurbishment lessons into a Front Counter Design Standard prioritising clear sight lines and PAO workplace ergonomics.
Verbatim wording from the response “However, we have taken the opportunity to alter the design of the ongoing refurbishment of Forest Gate Police Station to ensure that the layout of the front counter and public waiting area will provide much improved oversight for PAOs, from all counter positions. The lessons learned from this will be incorporated in a forthcoming Front Counter Design Standard that will (after staff safety) prioritise clear sight lines and PAO workplace ergonomics for all new sites or major refurbishments.” Source location Response from MPS
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 Provide all Public Access Officers with laptops to support work in front-counter areas and improve public-waiting-area oversight.
Verbatim wording from the response “As a result of the survey and our findings, we have taken the following action:” Source location Response from MPS
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 Remind Public Access Officers to remain visible and position laptops to improve observation of public waiting areas.
Verbatim wording from the response “As a result of the survey and our findings, we have taken the following action:” Source location Response from MPS
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 Major retrospective layout changes are constrained by substantial investment requirements and site limitations preventing action without major reconfiguration.
Verbatim wording from the response “With respect to layout and design (to produce maximum visibility/oversight), retrospectively applying major changes to existing counter areas will require very substantial investment and there are significant spatial constraints at sites which will prevent such action without major site reconfiguration.” Source location Response from MPS
Open published response
25 Oct 2024 Michael James Crane · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Lack of clear staff procedures after a resident is found by police View source Failure to report an unexpectedly absent resident missing View source Lack of MPS guidance to frontline officers on people likely to be missing but not yet reported missing View source Lack of MPS guidance to frontline officers on approaching powers under section 136 of the Mental Health Act View source Lack of clear specific policies and procedures View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael James Crane · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael James Crane lived in supported accommodation and was absent from the Home from 15 January 2024. He attended hospital and later a police station, but left without being reported missing; his body was retrieved from the River Thames on 18 January 2024. The inquest concluded that he drowned, contributed to by no missing person report being made to the police. The report raised concerns about the absence of MPS guidance for frontline officers dealing with people who may be missing but have not yet been reported as such.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clear staff procedures after a resident is found by police
Wider context from the report “1) The registered manager of Island Place Residential Home gave evidence to the inquest, and her evidence revealed the following:
• staff at the Home did not follow the Home’s own policy to report a resident missing once they have been unexpectedly absent for 24 hours;
• staff seemed vague and confused about what, if anything, they should do once they became aware that the resident had been found by the police in London ;
• staff advised the police in London that they intended to report the resident missing but then did not proceed to do so;
• details about any additional training or steps taken to reduce the risks were very vague; and
• details of specific policies and procedures in place at the time were vague.
2) There was clear evidence from MPS officers that had the resident been reported missing, they could have done more to protect and safeguard the resident.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to report an unexpectedly absent resident missing
Wider context from the report “1) The registered manager of Island Place Residential Home gave evidence to the inquest, and her evidence revealed the following:
• staff at the Home did not follow the Home’s own policy to report a resident missing once they have been unexpectedly absent for 24 hours ;
• staff seemed vague and confused about what, if anything, they should do once they became aware that the resident had been found by the police in London;
• staff advised the police in London that they intended to report the resident missing but then did not proceed to do so ;
• details about any additional training or steps taken to reduce the risks were very vague; and
• details of specific policies and procedures in place at the time were vague.
2) There was clear evidence from MPS officers that had the resident been reported missing, they could have done more to protect and safeguard the resident .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of MPS guidance to frontline officers on people likely to be missing but not yet reported missing
Wider context from the report “1) The MPS constable who gave evidence at the inquest, told me that:
• if Mr Crane had been reported missing at the time he was in Charing Cross police station then there would have been more that officers could have done to keep him safe;
• the fact that officers had heard (directly from staff) that the Home intended to report Mr Crane missing within the next 30 minutes, did not mean that there was more that the officers could have done at the time; and
• there was not, either at that time or to date, any MPS guidance to frontline officers in relation to how to approach their powers under section 136 of the Mental Health Act or in relation to people who are likely to be missing but have not yet been reported as such .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of MPS guidance to frontline officers on approaching powers under section 136 of the Mental Health Act
Wider context from the report “1) The MPS constable who gave evidence at the inquest, told me that:
• if Mr Crane had been reported missing at the time he was in Charing Cross police station then there would have been more that officers could have done to keep him safe;
• the fact that officers had heard (directly from staff) that the Home intended to report Mr Crane missing within the next 30 minutes, did not mean that there was more that the officers could have done at the time; and
• there was not, either at that time or to date, any MPS guidance to frontline officers in relation to how to approach their powers under section 136 of the Mental Health Act or in relation to people who are likely to be missing but have not yet been reported as such.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clear specific policies and procedures
Wider context from the report “1) The registered manager of Island Place Residential Home gave evidence to the inquest, and her evidence revealed the following:
• staff at the Home did not follow the Home’s own policy to report a resident missing once they have been unexpectedly absent for 24 hours;
• staff seemed vague and confused about what, if anything, they should do once they became aware that the resident had been found by the police in London;
• staff advised the police in London that they intended to report the resident missing but then did not proceed to do so;
• details about any additional training or steps taken to reduce the risks were very vague; and
• details of specific policies and procedures in place at the time were vague .
2) There was clear evidence from MPS officers that had the resident been reported missing, they could have done more to protect and safeguard the resident.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver a bespoke one-day mental-health training package based on policing guidance, legislation, service-user perspectives and scenario-based learning.
Verbatim wording from the response “In early 2019, the MPS reviewed the mental health training that was delivered to officers and developed a bespoke one-day training package. The content was based on the College of Policing Authorised Professional Practice (APP), the London Crisis Care Pathway and the MPS Mental Health Toolkit. It incorporated relevant legislation (including the Mental Health Act 1983) and the voice of the service user, lessons learnt; and tested learning through a series of animated scenarios. It encouraged officers to implement their learning as well as seeking to highlight the perspectives of service users and mental health professionals. This training was concluded in April 2020 and has been delivered to 10,300 officers.” Source location Response from Metropolitan Police Service
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 Replace the Mental Health Toolkit with an interactive Mental Health SharePoint page containing policing and mental-health guidance and legislative links.
Verbatim wording from the response “The MPS had a Mental Health Toolkit up to July 2024. This was a living document containing guidance for officers on how to deal with all aspects of people who are mentally unwell or have mental illness. This has now been superseded by the Mental Health SharePoint page which provides guidance and is also interactive. It contains sections on all topics of policing and mental health and has links to the associated legislation.” Source location Response from Metropolitan Police Service
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 Even if reported missing, officers lacked further legal powers because he was an adult and section 136 criteria were unmet.
Verbatim wording from the response “Even in the event that Mr Crane had been reported missing, the officers options were extremely limited. They had already formed the view that he did not meet the criteria for s136 MHA to be used and as Mr Crane was an adult, there were no other policing powers available to them. The care home were informed where Mr Crane was and provided no further details to the officers as to any risk Mr Crane may have posed to himself/others or any further details about his mental health that could have raised the risk to him.” Source location Response from Metropolitan Police Service
Open published response
26 Jul 2024 Zara Natasha Aleena · Prevention of Future Deaths report East London
View report summary
Concerns raised 25 Failure to provide prison risk intelligence to Integrated Offender Management meetings View source Threshold for reflective practice set too high View source Unclear understanding of when to request emergency recall View source Lack of mandatory and refreshed risk assessment training View source Lack of supervision for prison offender managers View source Failure to examine local intelligence and Computer Aided Dispatch systems in sufficient detail View source Lack of systems to support staff supervising key decisions View source Lack of alerts for handover from prison to community offender managers View source Lack of checks on sharing up-to-date and accurate risk assessments View source Failure of prison offender managers to implement sentence plans and facilitate rehabilitation View source Lack of focused risk assessment training for prison offender managers View source Lack of rigour, detail and independence in MPS investigations View source Unclear and incomplete sharing of risk information between probation and the MPS View source Failure to conduct timely risk assessments with complementary risk management plans View source Societal acceptance of unreported following behaviour View source Unclear CCTV operator training on identifying sexual predators and stalking behaviour View source Lack of assurance and refresher training for CCTV operators View source Failure to holistically assess indicators of serious harm View source Failure of alert systems to highlight restraining orders View source Lack of reporting guidance and training for business owners on sexualised or predatory behaviour View source OASYS risk assessment tool failing to support extraction and analysis of key risk areas View source Understaffing of probation delivery units View source Failure to probe information relevant to risk View source Obstacles inhibiting increases in assessed risk levels View source Failure of prison offender managers to gather and share evidence relevant to risk formulation View source See 22 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
Zara Natasha Aleena · 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
Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prison risk intelligence to Integrated Offender Management meetings
Wider context from the report “(15)The Integrated Offender Management meetings did not receive the necessary intelligence from the prison setting . There was no system in place to ensure that either the prison offender manager was invited to attend, or that the prison offender manager was asked to provide written information around risk incidents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Threshold for reflective practice set too high
Wider context from the report “(18)There were clearly learning points for the police constables, police sergeants and the local intelligence team. The MPS rejected the DPS recommendation for reflective learning, “as there was no failing in performance or conduct”. It is of concern that the threshold for reflective practice is set too high .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Unclear understanding of when to request emergency recall
Wider context from the report “(10) The evidence revealed a difference of opinion and understanding around when an emergency recall should be requested . A senior probation officer and probation services officer erroneously believed that an emergency recall could only be requested out of hours .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory and refreshed risk assessment training
Wider context from the report “(4) Risk assessment training is not part of the mandatory training framework within the probation service. Risk assessment training is not refreshed .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of supervision for prison offender managers
Wider context from the report “(12)There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender. They did not attempt to facilitate any rehabilitative interventions. There was no evidence of supervision for the prison offender manager .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to examine local intelligence and Computer Aided Dispatch systems in sufficient detail
Wider context from the report “(17)The Fast Time Review did not probe into sufficient detail into the systems of the local intelligence team and the Computer Aided Dispatch process . A more detailed, independent review should have been carried out.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of systems to support staff supervising key decisions
Wider context from the report “(2) There were no systems in place devised to assist the staff working in these stretched circumstances , such as easy reference checklists for supervising key decisions .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of alerts for handover from prison to community offender managers
Wider context from the report “(13)There was no system in place to alert the prison offender manager to handover an offender to the community offender manager when a period of sentence ended and where the offender remained in prison, on remand.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of checks on sharing up-to-date and accurate risk assessments
Wider context from the report “(5) There were no checks to ensure the provision of up to date and accurate risk assessments to partner agencies (such as the housing team).
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of prison offender managers to implement sentence plans and facilitate rehabilitation
Wider context from the report “(12)There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender . They did not attempt to facilitate any rehabilitative interventions . There was no evidence of supervision for the prison offender manager.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of focused risk assessment training for prison offender managers
Wider context from the report “(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training . Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk. There were multiple intelligence logs and records that should have been obtained by them. The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of rigour, detail and independence in MPS investigations
Wider context from the report “(16)I am concerned about the lack of rigour, detail and independence of the MPS investigation into this case. The unit involved in this case was the East Area BCU. An independent, rapid investigation (Fast Time Review) was carried out by the Directorate of Professional Standards. Despite the very limited time to complete the review, the DPS officer reached clear and valuable findings. The findings of the DPS investigator were however rejected by more senior officers within the MPS. The officers who rejected the findings were not independent and all worked within the East Area BCU. This lack of independence is of concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Unclear and incomplete sharing of risk information between probation and the MPS
Wider context from the report “(14)The system in place for sharing risk information between the probation service and the MPS was unclear . Only very limited intelligence was shared with the MPS . There was no explanation as to why that information was shared, when more concerning risk related information was not shared .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely risk assessments with complementary risk management plans
Wider context from the report “(3) The understanding around risk assessment was poor , at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times , and the assessment of risk was not accompanied by a complementary risk management plan . Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm, to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Societal acceptance of unreported following behaviour
Wider context from the report “(21) At least two other members of the public were followed by the offender before he attacked Zara Aleena. The members of the public appear to have seen the offender and appear to be aware that he was following them. This was not brought to the attention of the emergency services. I am concerned that there is a societal acceptance that such conduct does not need to be reported .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Unclear CCTV operator training on identifying sexual predators and stalking behaviour
Wider context from the report “(19)The details of training for CCTV operators includes “training on sexual harassment”, but it is not clear whether this includes identifying sexual predators and stalking type behaviour .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of assurance and refresher training for CCTV operators
Wider context from the report “(20)I am unclear from the evidence provided, whether LBR have a system for checking that training provided to CCTV operators is fully understood , or whether refresher training is provided to them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to holistically assess indicators of serious harm
Wider context from the report “(3) The understanding around risk assessment was poor, at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times, and the assessment of risk was not accompanied by a complementary risk management plan. Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm , to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of alert systems to highlight restraining orders
Wider context from the report “(8) The globe system and alert systems did not work effectively in this case. A restraining order had been put in place against the offender, but this was not highlighted , as it should have been. Key staff involved in assessing and managing the offender were unaware of the restraining order .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of reporting guidance and training for business owners on sexualised or predatory behaviour
Wider context from the report “(22)Business owners were aware of the offender’s concerning conduct on the night of Zara Aleena’s murder. For example, a public house had refused to provide more drinks to him. It is not clear whether business owners are encouraged to report such concerning behaviour to the authorities or whether they are offered any training to assist them and their staff to recognise sexualised or predatory behaviour .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation OASYS risk assessment tool failing to support extraction and analysis of key risk areas
Wider context from the report “(7) The OASYS risk assessment tool is unwieldy and difficult to navigate . It was challenging to extract the most relevant material. The content of the OASYS assessment was so dense that the probation officers seemed to get lost in the detail and failed to pull together and formulate/analyse key risk areas . One senior probation officer stated that she would not look at the OASYS when allocating cases, because OASYS assessments were “not always accurate and up to date”. It is noted that a new risk assessment tool within the probation service is a work in progress. It is hoped that the new tool will take into account the above concerns.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Understaffing of probation delivery units
Wider context from the report “(1) The probation delivery unit responsible for the offender was understaffed at the time of relevant oversight. The staffing levels were 61% in 2022 . The staffing levels at the time of the inquest in June 2024 was 58% . The inquest heard that this is a national problem and that there are other probation delivery units that have even lower levels of staffing. The low staffing level had an impact upon quality and depth of assessments; quality of supervision of junior staff (supervision was wholly reactive); excessively high workloads for probation officers and senior probation officers; lack of cover during annual leave for probation officers and poor record keeping.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to probe information relevant to risk
Wider context from the report “(6) There was a lack of professional curiosity and a lack of sufficient probing into information relevant to 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Obstacles inhibiting increases in assessed risk levels
Wider context from the report “(9) There may be obstacles to increasing risk levels . The inquest heard that senior probation staff would have to approve increases in risk. As staffing levels are so stretched, there may be reticence of junior probation officers to trouble the senior team . The risk assessment policy also includes a statement that staff “should not use risk levels to inflate risk because of anxiety or to access resources”. It is a concern that this provision may inhibit decisions to increase 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of prison offender managers to gather and share evidence relevant to risk formulation
Wider context from the report “(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training. Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk . There were multiple intelligence logs and records that should have been obtained by them . The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and use a process map guiding Police Offender Managers and supervisors to obtain, record and manage risk information before and after prison releases.
Verbatim wording from the response “Following inquest, the MPS has reflected on the sufficiency of information sharing from the HM Prison & Probation Service and the need for clarity around recalls to prison. The MPS has developed a new process map, which provides clarity and guidance for Police Offender Managers to ask HM Prison & Probation Service a broad range of questions, with the intention to increase the likelihood of all relevant information being shared with IOM partners. The new process highlights and clarifies the actions to be undertaken by Police Offender Managers and their supervisors, both before and after prison releases, including the recording of informed risk management decisions.” Source location Response from Metropolitan 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 Use CONNECT and Proactive Management Plans as the primary searchable police record for integrated offender management.
Verbatim wording from the response “Since 2022, the MPS has introduced CONNECT, a large-scale technology system for crime and intelligence reporting and record keeping. This has provided police offender managers with access to a feature called Proactive Management Plans (“PMP”). PMPs are now the primary police record for IOM offender management. PMPs allow IOM records to be searchable, linked with other police records and readily available to all MPS staff. HM Prison & Probation Service do not have direct access to these records, but PMPs create a permanent record of what has been shared between the MPS and its partners.” Source location Response from Metropolitan 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 Use the DPS Gateway Team to undertake most professional standards reviews of this nature, including conduct reviews without public complaints.
Verbatim wording from the response “The DPS fast time review following the murder of Zara Aleena was carried out in 2022. Since then the MPS has made a number of changes to our professional standards operating model and a new Gateway Team, within DPS, are now responsible for undertaking most reviews of this nature. This includes cases where DPS are asked for a conduct review (where there isn’t a public complaint). Importantly, the outcomes of such reviews are no longer considered by the Appropriate Authority (as defined in the Police Conduct Regulations) within the BCU. I discuss the role of the Appropriate Authority and independence in decision making later in this response.” Source location Response from Metropolitan 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 Transfer Appropriate Authority consideration of review outcomes from BCU senior leadership to the Directorate of Professional Standards for independent decision-making.
Verbatim wording from the response “The outcome and learning from the MPS fast time review into the circumstances surrounding the murder of Zara Aleena in 2022, were considered by the Appropriate Authority within East Area BCU. Under the Police Conduct Regulations, the Appropriate Authority is an officer, of sufficient seniority, delegated by the Commissioner to make decisions relating to matters of police conduct. Whilst the decision maker in 2022 had no direct involvement in the case, the MPS accepts that there was an opportunity for greater independence in decision making if the review outcomes had been considered by a senior leader who was not part of East Area BCU.” Source location Response from Metropolitan 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 Undertake a thematic assessment of MPS statutory and non-statutory post-death review arrangements and identify improvements to operational review independence and robustness.
Verbatim wording from the response “The SCRG have been commissioned to undertake a thematic assessment of the MPS approach to statutory and non-statutory post death reviews. This will consider:” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the revised Offender Management policy incorporating learning and improvements concerning recalls to prison processes.
Verbatim wording from the response “The findings of the Directorate of Professional Standards (“DPS”) fast time review identified learning, some of which was accepted and was covered in the witness statement of Chief Superintendent ████████ submitted to inquest. In addition to this review, the local East Area Basic Command Unit (“BCU”) also carried out a review and identified a number of additional learning points which were actioned. Importantly, learning and improvements required in relation to “recalls to prison” processes have been shared and informed a revised Offender Management policy, which is due to be implemented later in 2024.” Source location Response from Metropolitan Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MPS cannot unilaterally lower the Reflective Practice Review Process threshold because it is subject to statutory guidance.
Verbatim wording from the response “The MPS recognises the Coroner’s concern about the threshold that is applied to RPRP. Since RPRP is subject to statutory guidance, the MPS is unable to make unilateral changes. In this case, it was assessed by the Appropriate Authority that learning for officers and staff did not meet the threshold for RPRP. As discussed above, the MPS has made changes since 2022 and the Appropriate Authority for such decisions is now independent of BCUs. They are aware that if they consider the threshold for RPRP is not met, Learning Through Reflection could be used and all MPS officers and staff have responsibilities towards continual learning and professional development.” Source location Response from Metropolitan Police
Open published response
23 Jul 2024 Neil Woodley · Prevention of Future Deaths report South London
View report summary
Concerns raised 1 Failures in communication during welfare-check responses 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
Neil Woodley · 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
Neil Woodley was found ████████ at 7.25 am on 4 January 2024, and evidence from suicide notes suggested that he had killed himself overnight. A colleague called the police because he had not arrived at work, but an ambulance attended the following day after an alleged communication failure between Surrey Police and the Metropolitan Police. The concern was that failures in communication could result in avoidable fatalities in future cases, although the report states that earlier attendance would not have affected this outcome.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failures in communication during welfare-check responses
Wider context from the report “Mr Woodley’s brother and sister-in-law gave evidence at the hearing that a colleague of Mr Woodley called the police on the morning of 4 January concerned that he had not arrived at work. Their evidence was that an ambulance arrived to carry out a welfare check the following day (5 January) at around 1pm. They were told that the reason for the delay was confusion between Surrey Police and the Metropolitan Police .
On the evidence before me, including that of Mr Woodley and his wife, I am satisfied that an earlier attendance would not have affected the outcome. However, I am concerned that failures in communication could result in avoidable fatalities in future cases .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver learning to MPS staff and officers on district location sharing and compliance with relevant standard operating procedures.
Verbatim wording from the response “As an organisation, learning will be delivered to MPS staff and officers, highlighting the importance of district location sharing and compliance with standard operating procedures designed to protect front line policing and prevent correlation errors such as this incident.” Source location Response from Metropolitan Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No communication failure between Surrey Police and the Metropolitan Police occurred because no record of a relevant 4 January call exists.
Verbatim wording from the response “The MPS have no records of Mr Woodley’s work colleague or SPS contacting the MPS regarding an incident concerning Mr Woodley on 4th January 2024.” Source location Response from Metropolitan Police
Open published response
20 Jun 2024 Nicola FORSTER · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Culture of poor management and institutional defensiveness View source Failure to provide officers with a safe ability to speak out about management View source Failure of senior management to listen independently to concerns raised View source Failure of organisational review and investigation systems to act independently of senior management View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Strengthen Learning and Development leadership through revised senior leadership, supervision and wellbeing oversight arrangements.
Stated completedThe respondent said that this action was complete when they made their response on 27 June 2024. View source
Action
Operate the Raising Concerns policy with expanded reporting scope, clearer guidance, defined manager responsibilities and support for people raising concerns.
Stated completedThe respondent said that this action was complete when they made their response on 27 June 2024. View source
Action
Use inquest outcome reviews to identify case-specific learning and wider themes, then share identified improvements through organisational learning.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024. View source
Action
Implement the L&D People Strategy with coordinated wellbeing support, recognition, senior leadership engagement and oversight of professional standards and culture.
Stated completedThe respondent said that this action was complete when they made their response on 27 June 2024. View source
Action
Deliver mandatory leadership training covering trauma, wellbeing, supportive leadership and referral mechanisms, including programmes for first-line and senior leaders.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024. View source
Action
Maintain a dedicated Trust and Legitimacy leadership structure and a new directorate to drive cultural transformation and improvement.
Stated completedThe respondent said that this action was complete when they made their response on 27 June 2024. View source
Action
Deliver the Upstander programme to improve staff confidence and capability to challenge inappropriate behaviour and help leaders resolve issues.
Stated completedThe respondent said that this action was complete when they made their response on 27 June 2024. View source
Action
Provide managers with guidance following a colleague’s death and apply chief-officer oversight where workplace relationships may be a potential factor in an inquest.
Stated completedThe respondent said that this action was complete when they made their response on 27 June 2024. View source
Action
Operate the public-facing complaints and conduct reporting service with Crimestoppers.
Stated completedThe respondent said that this action was complete when they made their response on 27 June 2024. View source
Action
Provide dedicated operational and practical support and a single point of contact for officers and staff giving evidence at inquests.
Stated completedThe respondent said that this action was complete when they made their response on 27 June 2024. View source
Action
Deliver the Culture programme to build staff confidence to raise concerns and improve managers’ and leaders’ responses.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024. View source
Action
Create an L&D strategy and performance function informed by colleagues’ input and suggestions.
Stated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024. View source See 9 more actions
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AI-generated summary
Nicola FORSTER · 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
Nicola FORSTER, a Metropolitan Police Service Sergeant, was found hanging by a ligature at her home on 28 September 2022, and her death was confirmed by paramedics. The inquest concluded that she intentionally took her own life following a deterioration in her mental health exacerbated by actions of her employer. The report raised concerns about poor management, institutional defensiveness, and a fear among junior officers of speaking out about management.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Culture of poor management and institutional defensiveness
Wider context from the report “Although I was informed during the Inquest process about various changes that have been made to MPS Employment Policy and Processes since Nikki's death, including the introduction of a new 'Raising Concerns' Policy in May 2023, I believe there remains evidence of a culture of poor management and institutional defensiveness , as highlighted in the Baroness Casey Review, which these changes do not address. There is no point in encouraging concerns to be raised whilst this culture persists .
My investigation into Nikki’s death revealed clear evidence of officers, particularly the more junior ranking officers, having a fear of speaking out about their management and also an unwillingness, by the L&D Senior Management Team, to listen independently to the concerns raised. Furthermore the PSU (as well as the DPS investigation after Nikki’s death and your representation at the Inquest) appeared only to seek to support the role of senior management; even though the Inquest found that aspects of Nikki’s management had been seriously deficient and had contributed to her death. This appeared to me to confirm the criticism made by Baroness Casey that the MPS “starts from a position that nothing wrong has occurred” and their “systems support wrongdoers”.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide officers with a safe ability to speak out about management
Wider context from the report “Although I was informed during the Inquest process about various changes that have been made to MPS Employment Policy and Processes since Nikki's death, including the introduction of a new 'Raising Concerns' Policy in May 2023, I believe there remains evidence of a culture of poor management and institutional defensiveness, as highlighted in the Baroness Casey Review, which these changes do not address. There is no point in encouraging concerns to be raised whilst this culture persists.
My investigation into Nikki’s death revealed clear evidence of officers, particularly the more junior ranking officers, having a fear of speaking out about their management and also an unwillingness, by the L&D Senior Management Team, to listen independently to the concerns raised. Furthermore the PSU (as well as the DPS investigation after Nikki’s death and your representation at the Inquest) appeared only to seek to support the role of senior management; even though the Inquest found that aspects of Nikki’s management had been seriously deficient and had contributed to her death. This appeared to me to confirm the criticism made by Baroness Casey that the MPS “starts from a position that nothing wrong has occurred” and their “systems support wrongdoers”.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of senior management to listen independently to concerns raised
Wider context from the report “Although I was informed during the Inquest process about various changes that have been made to MPS Employment Policy and Processes since Nikki's death, including the introduction of a new 'Raising Concerns' Policy in May 2023, I believe there remains evidence of a culture of poor management and institutional defensiveness, as highlighted in the Baroness Casey Review, which these changes do not address. There is no point in encouraging concerns to be raised whilst this culture persists.
My investigation into Nikki’s death revealed clear evidence of officers, particularly the more junior ranking officers, having a fear of speaking out about their management and also an unwillingness, by the L&D Senior Management Team, to listen independently to the concerns raised . Furthermore the PSU (as well as the DPS investigation after Nikki’s death and your representation at the Inquest) appeared only to seek to support the role of senior management; even though the Inquest found that aspects of Nikki’s management had been seriously deficient and had contributed to her death. This appeared to me to confirm the criticism made by Baroness Casey that the MPS “starts from a position that nothing wrong has occurred” and their “systems support wrongdoers”.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of organisational review and investigation systems to act independently of senior management
Wider context from the report “Although I was informed during the Inquest process about various changes that have been made to MPS Employment Policy and Processes since Nikki's death, including the introduction of a new 'Raising Concerns' Policy in May 2023, I believe there remains evidence of a culture of poor management and institutional defensiveness, as highlighted in the Baroness Casey Review, which these changes do not address. There is no point in encouraging concerns to be raised whilst this culture persists.
My investigation into Nikki’s death revealed clear evidence of officers, particularly the more junior ranking officers, having a fear of speaking out about their management and also an unwillingness, by the L&D Senior Management Team, to listen independently to the concerns raised. Furthermore the PSU (as well as the DPS investigation after Nikki’s death and your representation at the Inquest) appeared only to seek to support the role of senior management ; even though the Inquest found that aspects of Nikki’s management had been seriously deficient and had contributed to her death. This appeared to me to confirm the criticism made by Baroness Casey that the MPS “starts from a position that nothing wrong has occurred” and their “systems support wrongdoers” .
” 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 Strengthen Learning and Development leadership through revised senior leadership, supervision and wellbeing oversight arrangements.
Verbatim wording from the response “Alongside broader cultural reforms across the MPS set out in a New Met for London, specific changes have been implemented within Learning and Development (“L&D”) over the past 12 months. These have focused on creating a positive and supportive culture for all colleagues working within L&D. Significantly, this has included a number of changes to the L&D Senior Leadership Team, bringing in experience of delivering cultural reform from elsewhere in the MPS and outside of the policing, strengthened supervision and greater levels of oversight with regards to supporting the wellbeing of colleagues across L&D.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Raising Concerns policy with expanded reporting scope, clearer guidance, defined manager responsibilities and support for people raising concerns.
Verbatim wording from the response “As set out in the letter from the MPS dated 23 May 2024, the MPS introduced a new “Raising Concerns” policy regarding the reporting of wrongdoing within the MPS. The new policy, introduced in May 2023, is directly focussed on supporting officers and staff who may have a concern about a colleague. Changes include:-” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use inquest outcome reviews to identify case-specific learning and wider themes, then share identified improvements through organisational learning.
Verbatim wording from the response “The IRSC also work closely with DLS to review inquest outcomes for both case specific learning and to identify themes that arise through analysis of different inquest proceeding. The MPS has introduced guidance for managers following the death of a colleague and a chief officer provides additional oversight of all inquest proceedings, where it is considered that workplace relationships may be a potential factor. This is improving how the MPS seeks to learn and ensure that any identified improvements are shared through wider organisational learning, for example changes to leadership training and wellbeing support.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the L&D People Strategy with coordinated wellbeing support, recognition, senior leadership engagement and oversight of professional standards and culture.
Verbatim wording from the response “Investment in a new L&D People Strategy in 2023 was in direct response to staff feedback from the 2022 staff survey and aims to makes a positive difference for those working in L&D, as well as fostering a culture of trust. Significant improvements include a more structured, co-ordinated and comprehensive programme of wellbeing and welfare support for L&D staff; recognition for those staff who go ‘above and beyond’ in embodying the MPS’s guiding principles and values; visible Senior Leadership Team engagement across all teams and locations; and an increased focus in identifying common themes with regards to professional standards and culture which are overseen by the Director L&D.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory leadership training covering trauma, wellbeing, supportive leadership and referral mechanisms, including programmes for first-line and senior leaders.
Verbatim wording from the response “In April 2023, the MPS introduced new leadership training for all first line leaders. This is mandatory and equates to between 3 and 8 days of training depending on the role being performed. A dedicated module focused upon trauma and wellbeing is included within this new leadership programme. Between April 2023 and April 2024, 6260 leaders across the MPS have completed this training. Based on a 98% course feedback response rate, 93% said they found the course valuable and would recommend to colleagues. Informal weekly feedback from course facilitators consistently highlighted trauma and wellbeing as a priority theme that delegates found valuable.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a dedicated Trust and Legitimacy leadership structure and a new directorate to drive cultural transformation and improvement.
Verbatim wording from the response “The MPS recognises that changes to policy and practice alone, will not change culture within the MPS. The MPS has a dedicated Assistant Commissioner and Deputy Assistant Commissioner for Trust and Legitimacy, and established a Culture programme as part of the New Met for London commitments, focused on driving the culture changes we recognise are needed across the organisation. The Culture programme seeks to build staff confidence to speak up and raise concerns, and for managers and leaders to listen and respond. Activity includes:” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Upstander programme to improve staff confidence and capability to challenge inappropriate behaviour and help leaders resolve issues.
Verbatim wording from the response “• The launch of the Upstander programme: designed to improve the confidence and capability of staff to challenge behaviours that are inappropriate and not aligned with our values. The Upstander programme is also designed to increase the understanding and capabilities of leaders to support staff and resolve issues.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide managers with guidance following a colleague’s death and apply chief-officer oversight where workplace relationships may be a potential factor in an inquest.
Verbatim wording from the response “The IRSC also work closely with DLS to review inquest outcomes for both case specific learning and to identify themes that arise through analysis of different inquest proceeding. The MPS has introduced guidance for managers following the death of a colleague and a chief officer provides additional oversight of all inquest proceedings, where it is considered that workplace relationships may be a potential factor. This is improving how the MPS seeks to learn and ensure that any identified improvements are shared through wider organisational learning, for example changes to leadership training and wellbeing support.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the public-facing complaints and conduct reporting service with Crimestoppers.
Verbatim wording from the response “Whilst staff are encouraged and supported to report concerns openly in person, there are a number of ways a report can be made, including via anonymised telephone and online reporting. To ensure individuals have the flexibility to choose the most appropriate method of reporting for them. In November 2022, the MPS was the” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide dedicated operational and practical support and a single point of contact for officers and staff giving evidence at inquests.
Verbatim wording from the response “At all times, it is made clear to officers and staff that they are the Coroner’s witness, not the Commissioner’s witness, and their evidence is their own. The MPS also has a dedicated team within its Inquiry & Review Support Command (IRSC), who provide operational and practical support to police officers and staff who give evidence at inquests, where the Commissioner is an interested party. This inquest team provide a single point of contact for witnesses, both prior to and during inquest proceedings.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Culture programme to build staff confidence to raise concerns and improve managers’ and leaders’ responses.
Verbatim wording from the response “The MPS recognises that changes to policy and practice alone, will not change culture within the MPS. The MPS has a dedicated Assistant Commissioner and Deputy Assistant Commissioner for Trust and Legitimacy, and established a Culture programme as part of the New Met for London commitments, focused on driving the culture changes we recognise are needed across the organisation. The Culture programme seeks to build staff confidence to speak up and raise concerns, and for managers and leaders to listen and respond. Activity includes:” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create an L&D strategy and performance function informed by colleagues’ input and suggestions.
Verbatim wording from the response “Looking ahead, L&D are in the process of creating a new strategy and performance function. To inform this work senior leaders are actively seeking colleagues’ inputs and suggestions on what more leaders can do to better support colleagues.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The DPS investigation was independent of Learning and Development and did not seek to support its leaders; an independent authority found no misconduct case.
Verbatim wording from the response “The investigation was independent of L&D, and did not seek to support the leaders within L&D. In accordance with the statutory regulations, once the investigation was completed, it was considered by an independent Appropriate Authority, who reviewed the evidence and concluded that the line manager had no case to answer for misconduct, as defined in the Police (Conduct) Regulations.” Source location Response from Metropolitan Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inquest witnesses received support while giving their own evidence, including when that evidence was frank or critical of the MPS.
Verbatim wording from the response “At inquest the Commissioner was represented by the Directorate of Legal Services (“DLS”). Nicola Forster’s line manager was separately legally represented as she was given Interested Person status at inquest. All police witnesses, except one individual, who gave evidence at inquest were supported by the MPS. You will be aware that some witnesses gave frank and often critical evidence about the MPS, this did not change the support they were provided.” Source location Response from Metropolitan Police
Open published response
15 Mar 2024 Sydney Alex Piper · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Lack of policing of homeless encampments in wooded areas View source Lack of monitoring of homeless encampments in wooded areas View source Failure to adequately supervise vulnerable persons View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sydney Alex Piper · 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
Sydney Alex Piper, a 69-year-old man living in supported accommodation, left a mental health clinic while inadequately supervised on 23 February 2023 and was discovered deceased in a tent in Epping Forest on 24 March 2023. His death was caused by morphine toxicity, although it was not possible to determine how he was administered morphine or came to be at the site. The concerns were inadequate supervision of a vulnerable person and insufficient monitoring and policing of encampments, which increased the risk of fatal harm.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of policing of homeless encampments in wooded areas
Wider context from the report “2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas along the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring of homeless encampments in wooded areas
Wider context from the report “2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas along the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately supervise vulnerable persons
Wider context from the report “1. The support worker who accompanied Mr Piper on the day of his disappearance claimed that she did not constantly supervise Mr Piper as alternatively; she did not wish to crowd him, she was allergic to cigarette smoke, and finally that she needed to rest her legs. The witness accepted that she had neither read Mr Piper’s support plan, nor the relevant policies and procedures relevant to her duties that day.
I am concerned that there is no clear evidence before me that the risk of a similar incident of inadequate supervision of a vulnerable person has been effectively mitigated.
” 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 Continue joint police-partnership work with local authorities to focus on rough sleeping and support the local authority strategy.
Verbatim wording from the response “I can confirm that ongoing work is being undertaken with the respective local authorities and there is strategic police/partnership joint working to focus on rough sleeping. The police neighbourhood teams are supporting the local authority strategy for rough sleeping, which includes community safety, housing and enforcement.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with local authorities and Epping Forest Park Rangers to ensure early identification of rough sleeping is addressed through partnership working.
Verbatim wording from the response “We have increased engagement with local residents who use the forest and surrounding environs to encourage reporting of rough sleeping they become aware of directly to the Local Authority. The MPS is working closely with the Local Authorities and the Epping Forest Park Rangers to ensure any early identification of rough sleeping is addressed as a partnership.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase engagement with forest and surrounding-area residents to encourage direct reporting of rough sleeping to local authorities.
Verbatim wording from the response “We have increased engagement with local residents who use the forest and surrounding environs to encourage reporting of rough sleeping they become aware of directly to the Local Authority. The MPS is working closely with the Local Authorities and the Epping Forest Park Rangers to ensure any early identification of rough sleeping is addressed as a partnership.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No other deaths identified in the area suggest a specific or ongoing public safety risk or significant criminal activity.
Verbatim wording from the response “The MPS have liaised with the Coroner and have been unable to identify any other deaths in this area which would suggest any specific or ongoing risk to public safety, or significant criminal activity.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Unauthorised encampments posing safety risks are addressed through a multi-agency approach led by the local authority, while police investigate reported crimes.
Verbatim wording from the response “In accordance with statutory guidance, any unauthorised encampment which poses a risk of safety to occupants and others will be addressed as a public safety/public health issue through a multi-agency approach led by the local authority. Further, where individual crimes are reported there will be a duty for police to investigate.” Source location Response from Metropolitan Police
Open published response
16 Feb 2024 Mr Roberto Bottello · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 7 Continued shortages in psychiatric care provision View source Failure to provide evidence in accordance with the duty of candour View source Insufficient training of SPA call handlers in patient identification and information seeking View source Failure of psychiatric liaison clinicians to consider diagnoses made by other doctors View source Insufficient use of protective film over glass in areas where patients are at increased risk of smashing windows View source Insufficient psychiatric service response capacity out of hours for section 136 usage View source Failure to identify CNWL staff operating outside policy View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Roberto Bottello · 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
Roberto Bottello, who had been experiencing depression, anxiety, panic attacks and later an acute psychotic episode, was detained under section 136 of the Mental Health Act after police found him acutely disturbed. While in a hospital cubicle, he broke the window and fell 25 feet, suffering multiple injuries including a divided axillary vein and artery; his death was announced at 07:27 on 16 September 2020. Substantive concerns included the unsuitability and inadequate safety of the cubicle, communication and information-management failures, insufficient mental-health nursing provision, confusion over his identity, limited access to section 136 suites, and wider concerns about training and psychiatric-care resources.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Continued shortages in psychiatric care provision
Wider context from the report “10. That there are continued shortages in psychiatric care provision .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide evidence in accordance with the duty of candour
Wider context from the report “1. That CNWL failed in its duty of candour in relation to provision of evidence 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of SPA call handlers in patient identification and information seeking
Wider context from the report “3. That SPA call handlers were not sufficiently trained in how to identify patients by using computer searches and by not seeking information appropriately for example by using the international phonetic alphabet and using the word for the month in a person’s date of birth .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of psychiatric liaison clinicians to consider diagnoses made by other doctors
Wider context from the report “6. That the psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors for example those who see such patients repeatedly in A&E 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient use of protective film over glass in areas where patients are at increased risk of smashing windows
Wider context from the report “9. That the use of film over glass in areas where patients are at increased risk of smashing windows should be more widespread in the NHSE estate .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient psychiatric service response capacity out of hours for section 136 usage
Wider context from the report “7. That most section 136 usage is out of hours when there is less resource to respond from psychiatric services .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to identify CNWL staff operating outside policy
Wider context from the report “5. That CNWL were and may still be unaware that CNWL staff operate outside policy .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide recruit officers with phonetic-alphabet training through handouts, simulated radio transmissions and Street Duties role-play practice.
Verbatim wording from the response “All MPS officers complete a mandatory training package developed by the College of Policing (the professional body setting training standards for forces across England and Wales) called “Airwaves Radios”. This is hosted on College Learn (the national online training platform for police officers and staff). Within the first three weeks of initial learning, recruit police officers are provided with a handout” Source location Response from Metropolitan Police Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the airwave-etiquette handout to emphasise using the phonetic alphabet for name checks.
Verbatim wording from the response “¹ This document is being amended to emphasise the requirement to use the phonetic alphabet to conduct a name check (Example 3). This was presented as a minor change for immediate action, and implementation will be confirmed at the next Curriculum Design Authority Group next month.” Source location Response from Metropolitan Police Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing MPS provision is considered sufficient to meet the phonetic-alphabet learning need for new recruits.
Verbatim wording from the response “MPS Learning and Development undertake a learning needs analysis following any recommendations (for example, from external reports and inquiries) to understand if there is an organisational learning need and who the learner audience is. Where the learner audience is exclusively new recruits, the Centre for Initial Recruit Learning will address the learning need through an established Curriculum Design Authority. This will include an assessment of whether the learning need is being met through our current provision, or whether new or updated content is required. This will be assessed in the context of the National Police Curriculum set by the College of Policing.” Source location Response from Metropolitan Police Service
Open published response
7 Sep 2023 Lamont Ashley Roper · Prevention of Future Deaths report North London
View report summary
Concerns raised 7 Failure to ensure officers know that the MPS dive team can attend submerged-person incidents when not on call or at night View source Failure to ensure safe cycling patrols and pursuits near bodies of water View source Failure to manage the safety of cycle patrols near bodies of water View source Unavailability of suitable water rescue equipment for officers patrolling near bodies of water View source Failure to provide throw lines on all marked emergency vehicles View source Failure to factor water rescue equipment availability into dynamic patrol risk assessments View source Insufficient number of qualified divers available to police View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 11
Action
Provide throw-line access for officers conducting pre-planned operations near bodies of water.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Refresh cycle training, maintain deployment records, and prohibit operational cycling without current training.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Brief current and new pan-London control-room supervisors on Dive Team capacity and call-out procedures.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Route every body-of-water incident to the Marine Unit Duty Officer for assessment of possible out-of-hours Dive Team call-out.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Publish and disseminate the Open Water Rescue and Recovery Guide explaining Dive Team call-out procedures and contact arrangements.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Continue reviewing and assessing police dive-team size against threat, harm, risk, and demand.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Incorporate Dive Team capacity and call-out training into the MPS Leader’s Programme.
Stated plannedThe respondent said that this action was planned when they made their response on 30 October 2023. View source
Action
Deliver local cycle training covering pursuits, pursuit procedures, and risks of cycling near bodies of water.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Require Basic Command Units to establish management arrangements for deploying, using, and maintaining throw lines.
Stated plannedThe respondent said that this action was planned when they made their response on 30 October 2023. View source
Action
Maintain the updated MPS Water Intervention Risk Assessment addressing risks from water and water entry.
Stated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Continue working with water-rescue stakeholders to consider viable future technologies for police officers.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source See 8 more actions
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AI-generated summary
Lamont Ashley Roper · 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
Lamont Ashley Roper was found dead at the bottom of Lock 17 after entering the canal following a cycling pursuit, a stop-and-search request, and a struggle with a police officer near the canal railings. The concerns included the availability of water-rescue equipment and resources, access to specialised divers, and the risks and training associated with police cycle patrols and pursuits near bodies of water.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure officers know that the MPS dive team can attend submerged-person incidents when not on call or at night
Wider context from the report “4. The Coroner makes a recommendation to the MPS to ensure that its officers are made aware the MPS dive team can attend a critical incident involving someone submerged in water even when the team are not on call and / or at night , and that this possibility should therefore be explored at an early stage . This may be achieved by special training and the publication of an operational notice.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe cycling patrols and pursuits near bodies of water
Wider context from the report “7. The Coroner recommends to the MPS that they provide specific training about cycling, whether during a pursuit or otherwise, near to the bodies of water in particular as there is a serious risk of future deaths occurring as a result of MPS cycle patrols and pursuits at up to 15mph [on electric bicycles] near bodies of water . The Coroner recommends that specific policies and training are put in place to ensure that such pursuits are undertaken safely and in a manner such as to mitigate risks of accidents or injury .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to manage the safety of cycle patrols near bodies of water
Wider context from the report “2. If this not possible to source alternative water rescue equipment that can be carried by officers on cycle patrol, then the family considers that the risks of cycle patrols near to bodies of water outweighs the benefits. The Coroner recommends in the alternative that the MPS amends their policies and training to reflect the fact that cycle patrols alongside bodies of water are potentially very dangerous more so in the absence of water rescue equipment and that in these circumstances careful consideration to continuing the patrol will need to be undertaken at a senior level .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of suitable water rescue equipment for officers patrolling near bodies of water
Wider context from the report “1. The Coroner recommends to the MPS that they consider whether there is any alternative and less cumbersome water rescue equipment [to throw lines] that could be issued to officers on patrol near bodies of water , for example some sort of device which could be inflated quickly and thrown to the person in the water to assist them in floating until a throw line is available .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide throw lines on all marked emergency vehicles
Wider context from the report “5. The Coroner recommends that [throw lines] must be available and issued to all MPS marked emergency vehicles .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to factor water rescue equipment availability into dynamic patrol risk assessments
Wider context from the report “3. The coroner recommends to the MPS to implement a requirement for officers conducting pre-planned operations along stretches of a canal or other bodies of water to make themselves aware of the availability (or non-availability) of water rescue equipment in order for this to be factored into their ongoing dynamic risk assessment whilst on patrol ”
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient number of qualified divers available to police
Wider context from the report “6. The Coroner makes a recommendation that steps should be taken to increase the number of qualified divers available to the police to assist with the respond to an incident.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide throw-line access for officers conducting pre-planned operations near bodies of water.
Verbatim wording from the response “Officers either specifically tasked with patrols by bodies of water, or part of planned operations, are required to have a throw line available to them. This may extend to access from a nearby vehicle.” Source location Response from Metropolitan Police Service
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 Refresh cycle training, maintain deployment records, and prohibit operational cycling without current training.
Verbatim wording from the response “Following this incident, at the beginning of 2022 the MPS reviewed and refreshed its cycle training and now maintains training and resourcing records, for the deployment of officers and staff who have received this training. From April 2023, officers and staff are not permitted to cycle operationally without this current training.” Source location Response from Metropolitan Police Service
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 Brief current and new pan-London control-room supervisors on Dive Team capacity and call-out procedures.
Verbatim wording from the response “• All current and new Met Grip Chief Inspectors (pan London Control Room supervisors) are briefed by the Dive Team on their capacity and call out procedure. The last course took place at the beginning of September 2023.” Source location Response from Metropolitan Police Service
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 Route every body-of-water incident to the Marine Unit Duty Officer for assessment of possible out-of-hours Dive Team call-out.
Verbatim wording from the response “• All incidents involving people in a body of water is now brought to the attention of the 24/7 Marine Unit Duty Officer by the Incident Room. The Marine Unit Duty Officer will review the incident and assess if there is a possibility of a Dive Team call out during out of hours. Discussions will be had with the incident commander around the tactical options and implement any call out if required.” Source location Response from Metropolitan Police Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and disseminate the Open Water Rescue and Recovery Guide explaining Dive Team call-out procedures and contact arrangements.
Verbatim wording from the response “In June 2022, an e-mail was sent to all MPU officers confirming the Dive Team’s capability and availability.” Source location Response from Metropolitan Police Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing and assessing police dive-team size against threat, harm, risk, and demand.
Verbatim wording from the response “The MPS Taskforce Command constantly review and assess team sizes based on the threat, harm and risk balanced with the demand. At this time, the assessment is that there is sufficient police dive team capacity to meet its demand.” Source location Response from Metropolitan Police Service
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 Incorporate Dive Team capacity and call-out training into the MPS Leader’s Programme.
Verbatim wording from the response “• Until recently, all police inspectors’ promotion training courses had a Dive Team input to upskill new and current inspectors around capacity and call out procedure. From 2024, this input will be incorporated into the new MPS Leader’s Programme.” Source location Response from Metropolitan Police Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver local cycle training covering pursuits, pursuit procedures, and risks of cycling near bodies of water.
Verbatim wording from the response “Training is delivered locally by trainers who have attended a Central Trainer’s Course on each Basic Command Unit/Operational Command Unit who in turn will train their officers and staff. The training includes a specific input about pursuits and an understanding of the MPS Pursuits Standard Operating Procedures is covered as part of the cycle training. Advice to officers and staff using cycles near to bodies of water is covered in the MPS patrolling risk assessments.” Source location Response from Metropolitan Police Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require Basic Command Units to establish management arrangements for deploying, using, and maintaining throw lines.
Verbatim wording from the response “• Basic Command Units are to establish system management for the deployment, use and maintenance of throw lines.” Source location Response from Metropolitan Police Service
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 Maintain the updated MPS Water Intervention Risk Assessment addressing risks from water and water entry.
Verbatim wording from the response “The MPS Water Intervention Risk Assessment was reviewed and updated at the end of 2021 to outline the risk water and water entry pose. Additional measures include:” Source location Response from Metropolitan Police Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with water-rescue stakeholders to consider viable future technologies for police officers.
Verbatim wording from the response “In addition, the MPS Public and Personal Safety Unit (“PPSU”) has scoped the current marketplace to ascertain if there are any viable alternatives that would offer carriage of water rescue equipment on the person. No product has currently been identified which would overcome the issues previously outlined, i.e. the cumbersome product design and weight that would have to be additionally factored in. The PPSU will continue to work with stakeholders with key responsibilities in water rescue, to consider the viability in the use of future technologies for use by police officers in such circumstances.” Source location Response from Metropolitan Police Service
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 Throw lines in marked emergency vehicles are considered to mitigate cycle patrol officers’ lack of immediate access to rescue equipment.
Verbatim wording from the response “The circumstances of cycle patrol are the same as those of general patrol duties, in that they are not planned taskings or operations. Throw lines are now available in all marked emergency vehicles which mitigates the risk of officers on foot or cycle patrols having ready access to this provision.” Source location Response from Metropolitan Police Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing police dive team is assessed as having sufficient capacity to meet demand.
Verbatim wording from the response “The MPS Taskforce Command constantly review and assess team sizes based on the threat, harm and risk balanced with the demand. At this time, the assessment is that there is sufficient police dive team capacity to meet its demand.” Source location Response from Metropolitan Police Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The RNLI, London Fire Brigade and UK Coastguard have the relevant expertise and responsibilities for water rescue.
Verbatim wording from the response “Other agencies, such as the RNLI, LFB and the UK Coastguard have the relevant expertise and responsibilities in water rescue.” Source location Response from Metropolitan Police Service
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 Officers on pre-planned operations near water are already required to have access to throw lines under the Water Intervention Risk Assessment.
Verbatim wording from the response “As above, officers conducting pre-planned operations along bodies of water, are now required to have access to throw lines which is covered in the MPS Water Intervention Risk Assessment.” Source location Response from Metropolitan Police Service
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 No viable wearable water-rescue equipment alternative has been identified because product weight and cumbersome design remain barriers.
Verbatim wording from the response “In addition, the MPS Public and Personal Safety Unit (“PPSU”) has scoped the current marketplace to ascertain if there are any viable alternatives that would offer carriage of water rescue equipment on the person. No product has currently been identified which would overcome the issues previously outlined, i.e. the cumbersome product design and weight that would have to be additionally factored in. The PPSU will continue to work with stakeholders with key responsibilities in water rescue, to consider the viability in the use of future technologies for use by police officers in such circumstances.” Source location Response from Metropolitan Police Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Marine Policing Unit is not responsible for rescuing people in difficulty in water.
Verbatim wording from the response “In response to the Coroner’s matter of concern, whilst it is not the responsibility of the MPS Marine Policing Unit to rescue persons who are in difficulty in water, officers will seek to identify water rescue equipment which is easily accessible when such spontaneous incidents arise or when patrolling near bodies of water. This includes throw lines, which are retained in every MPS marked emergency vehicle.” Source location Response from Metropolitan Police Service
Open published response
5 Jul 2023 Name not published · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to provide active secondary safety-officer support during resuscitation View source Failure to recognise deterioration and commence CPR promptly View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Name not published · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 18 March 2021, the deceased took cocaine, developed features of acute behavioural disturbance, arrested before an ambulance arrived, and died in hospital the following day after resuscitation. The substantive concerns were the delay in moving him to the floor and commencing CPR, and insufficient proactive support from officers not directly monitoring his vital signs during the resuscitation.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide active secondary safety-officer support during resuscitation
Wider context from the report “2. Whilst the officers worked well as a team in many respects, it seemed to me that there could have been more focus on pro-active support from those not directly monitoring ████████ vital signs.
For example, the experienced officer who initially held down ████████ legs and then later stood close by, would have assisted further if he had been asked. However, because he was confident in his colleagues’ abilities he did not act as what would have been a very useful pair of eyes. He did not provide that focused consideration of a situation that can be so useful when other members of the team are very busy with immediate tasks.
I heard at inquest about the MPS training to speak up, speak out in such a situation. I know that the MPS trains on the value of a helicopter view from a secondary safety officer. However, it seemed to me that this was not completely embedded within the frame of reference of the officers attending. It is not about criticism of one’s colleagues, it is about remaining active in the resuscitation.
I am wary of recommending a counsel of perfection but, as this is an issue I have observed on previous occasions, I feel I would be failing in my duty if I did not raise it with you.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deterioration and commence CPR promptly
Wider context from the report “1. What was particularly challenging for the officers was knowing when to move ████████ to the floor and when to commence CPR.
████████ was in peri arrest/arrest for probably around three and a half minutes before CPR was commenced. Although earlier CPR would not have changed the outcome for him, it might for another casualty.
The intensive care consultant giving evidence at inquest articulated his view of the point at which ████████ was in peri arrest.
He recognised that this was a difficult call to make, but told me that if in doubt about such an arrest situation, first aiders should move straight to CPR.
I am aware of the work the MPS has undertaken to improve the first aid training of its front line officers. The recognition of the deteriorating patient is notoriously difficult, sometimes even in a hospital setting. However, given that it is a difficulty I have seen recur for the MPS , it seems to me that it would benefit from further consideration.
” 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 Deliver expanded Emergency Life Support Module 2 and refresher training, including additional practical scenario-based drills and techniques.
Verbatim wording from the response “In May 2023, the National Police Chief Council endorsed recommendations from its First Aid Forum’s review following the Manchester Arena public inquiry. This increased ELS Module 2 training from 9-12 hours (and increased refresher training by 2 hours). This training will introduce techniques such as the ‘jaw thrust’ and also provide more practical scenario-based drills with the aim of improving officers’ confidence in dealing with casualty situations. The MPS will start to deliver this additional training from April 2024.” Source location Response from Metropolitan Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require all officers to complete digital training on recognising agonal breathing to support earlier CPR.
Verbatim wording from the response “Since this incident in March 2021, the MPS has introduced the following changes to the MPS Emergency Life Support (ELS) training, which will assist in reducing any delays in administering CPR.” Source location Response from Metropolitan 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 Introduce a first aid safety officer role during annual training to oversee casualty-care checks, monitoring and team-wide first-aid delivery.
Verbatim wording from the response “In April 2024, the MPS will be introducing the “first aid safety officer” as part of the annual first aid training cycle, which all officers are required to attend. This role is for when there are a number of officers dealing with a casualty, one officer steps back and takes an overview of the first aid delivery and requirement and ensures that all checks and monitoring are completed.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardise jaw-thrust airway management, retain casualties on their backs, limit recovery-position use to clearing fluids, and commence CPR when noisy breathing persists.
Verbatim wording from the response “Since this incident in March 2021, the MPS has introduced the following changes to the MPS Emergency Life Support (ELS) training, which will assist in reducing any delays in administering CPR.” Source location Response from Metropolitan Police
Open published response
19 Jun 2023 Nicholas LEGER · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to proactively seek information about the mental health of people being charged by PCR View source Lack of a formal mental health and suicide or self-harm risk assessment at PCR delivery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicholas LEGER · 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
Nicholas Leger took his own life sometime between 7:30pm and 10:30pm on 20 February 2023, after learning via his solicitor that he had been charged. He had previously attempted to take his own life and had disclosed concerns about his mental health, but there had been no formal police assessment of his mental health or risk of suicide or self-harm for more than three months. The report identified a risk that people charged by Postal Charge Requisition could take their own lives where there was no formal mechanism to assess their mental health and risk at the time of charge.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively seek information about the mental health of people being charged by PCR
Wider context from the report “• That whether an individual is, exceptionally, considered to be in a high-risk category (such as to cause a PCR to be delivered in person) is reliant on information about their mental health coming to the attention of the OIC . There is no formal requirement for the OIC proactively to seek this information.
• That there is no formal process for assessing an individual’s mental health and/or risk of suicide or self-harm at the time of delivery of a PCR.
It is important to note the following:
• At the point of charge, nothing has been proven against the individual concerned. They face an allegation, and are innocent if and until proven guilty to the criminal standard.
• Many people are RUI’d. As such, PCR is now routinely used to bring most criminal charges.
• Individuals who have been RUI’d can remain with this status for long periods of time (months or years) before a decision is made whether or not to charge them.
• Whilst there are formal procedures to assess an individual’s mental health and risk of self-harm or suicide when they attend a police station for interview, once they have left the police station there are no such formal procedures (as above), notwithstanding the potential for a substantial period to elapse between the time they last attended a police station and the time that they are charged.
• Being charged with any criminal offence, especially one which carries the potential for a custodial sentence, can, self-evidently, have a significant deleterious effect on an individual’s mental health.
It appears to me that, in the absence of a formal mechanism to assess, at the time of being charged, an individual’s mental health and risk of suicide or self-harm, there is an obvious risk of individuals in the future taking their own lives as a result of being charged by way of a PCR (potentially following a lengthy period of having been RUI’d and potentially months or years since there was last any consideration by the police of their mental health and risk of suicide or self-harm).
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal mental health and suicide or self-harm risk assessment at PCR delivery
Wider context from the report “• That whether an individual is, exceptionally, considered to be in a high-risk category (such as to cause a PCR to be delivered in person) is reliant on information about their mental health coming to the attention of the OIC. There is no formal requirement for the OIC proactively to seek this information.
• That there is no formal process for assessing an individual’s mental health and/or risk of suicide or self-harm at the time of delivery of a PCR.
It is important to note the following:
• At the point of charge, nothing has been proven against the individual concerned. They face an allegation, and are innocent if and until proven guilty to the criminal standard.
• Many people are RUI’d. As such, PCR is now routinely used to bring most criminal charges.
• Individuals who have been RUI’d can remain with this status for long periods of time (months or years) before a decision is made whether or not to charge them.
• Whilst there are formal procedures to assess an individual’s mental health and risk of self-harm or suicide when they attend a police station for interview, once they have left the police station there are no such formal procedures (as above) , notwithstanding the potential for a substantial period to elapse between the time they last attended a police station and the time that they are charged.
• Being charged with any criminal offence, especially one which carries the potential for a custodial sentence, can, self-evidently, have a significant deleterious effect on an individual’s mental health.
It appears to me that, in the absence of a formal mechanism to assess, at the time of being charged, an individual’s mental health and risk of suicide or self-harm , there is an obvious risk of individuals in the future taking their own lives as a result of being charged by way of a PCR (potentially following a lengthy period of having been RUI’d and potentially months or years since there was last any consideration by the police of their mental health and risk of suicide or self-harm).
” 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 Develop a policy requiring supervised, documented risk assessments before issuing PCRs to recordable-offence suspects, including risk management and decisions on personal service.
Verbatim wording from the response “Following this Prevention of Future Deaths report, a proposal will be made for the implementation of a new policy requiring a risk assessment to be completed by the OIC, no earlier than fourteen days prior to issuing the PCR. This would build on the intelligence already gathered through the relationship between the OIC and the suspect, including any risk assessments completed at the time of their arrest/detention/voluntary interview under caution and by the Custody Sergeant upon release from custody. This would then form the basis of a decision as to whether to post or serve the PCR in person.” Source location Response from Metropolitan Police
Open published response
12 Jun 2023 Heather FINDLAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 15 Omissions from serious incident investigations View source Failure to communicate the appropriate level of suicide risk to police View source Lack of ward assistance and contingency planning for retrieval of an absconded patient View source Lack of instructions for staff following an absconded patient View source Failure to prepare clinical staff to maintain line of sight when a patient absconds View source Failure to recognise imminent suicide risk after a patient absconds View source Failure to volunteer the trust's risk grading when reporting a patient to police View source Confusion about police contact when a patient is missing View source Lack of training for doctors and nurses in street restraint and patient transport View source Unavailability of police assistance for clinicians responding to an absconded patient View source Failure of police and health-trust partnership working to allocate responsibility for patient retrieval View source Lack of learning culture at ELFT View source Inconsistent terminology and definitions between police and mental-health services View source Failure of police reporting information to align with local policies View source Failure to routinely record all useful risk information in police reports View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Heather FINDLAY · 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
Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Omissions from serious incident investigations
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation .
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the appropriate level of suicide risk to police
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide . Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection .
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of ward assistance and contingency planning for retrieval of an absconded patient
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task . I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward.
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of instructions for staff following an absconded patient
Wider context from the report “2. By the time the HCA rang the duty senior nurse for advice Ms Findlay was out of sight, and so the HCA was instructed to return to the ward.
I heard evidence that an email is to be sent out shortly to explain that a new ELFT absent without leave policy will be in place by the end of June 2023. The new policy will confirm that, if it is safe to do so an escort may follow a patient who has absconded, keeping them in line of sight whilst ringing the duty senior nurse for instructions.
However, there is no ELFT policy for what those instructions should be or even what they could include . No member of ELFT gave evidence of any organisational thought having gone into how then to progress such a situation, other than the ward calling the police to report a missing person. No member of ELFT giving evidence was able to set out what the staff member following should do .
This appears to be a significant omission.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare clinical staff to maintain line of sight when a patient absconds
Wider context from the report “1. When Ms Findlay ran off, the HCA escorting her was so panicked that she did not even think of following. Ms Findlay had run across a road and so chasing her at speed did present safety considerations. However, the ELFT policy, training, culture and expectation was such, that there the HCA did not at any point consider attempting to walk after her to keep her in sight . Clinical staff must be adequately prepared for such an eventuality .
That means more than simply a change in policy wording.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise imminent suicide risk after a patient absconds
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff .
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to volunteer the trust's risk grading when reporting a patient to police
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it .
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Confusion about police contact when a patient is missing
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves ; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing .
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of training for doctors and nurses in street restraint and patient transport
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task. I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward .
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of police assistance for clinicians responding to an absconded patient
Wider context from the report “3. Moreover, one of the MPS policy leads in this area gave evidence that in such a situation the police would not necessarily attend , even if called direct by a hospital staff member in the street following a patient about whom they are worried.
I spent some time examining the police regarding this point, and I was left with the impression that a clinician calling the police in what the clinician perceived to be an emergency situation might not be assisted by the police .
That concerned me.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of police and health-trust partnership working to allocate responsibility for patient retrieval
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task. I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward.
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility , whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of learning culture at ELFT
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT .
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inconsistent terminology and definitions between police and mental-health services
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions .
It seems that this would benefit from consideration.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of police reporting information to align with local policies
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies , whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely record all useful risk information in police reports
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine , and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” 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 Implement the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.
Verbatim wording from the response “The Commissioner of the Metropolitan Police, ████████, wrote to Health and Social Care Partners on 24th May 2023, to set out the Met Police’s intention to implement the national Right Care, Right Person approach. Under Assistant Commissioner ████████ a team is now working to put this in place, and an initial senior board has taken place with senior health and social care providers to work towards RCRP implementation. This is also in parallel with the work being done by health care providers on the London mental health concordat. A key aspect of this is working with all of the” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an external partner delivery group with health and social care partners to clarify responsibilities and support Right Care, Right Person implementation.
Verbatim wording from the response “The preparatory work being done on implementing Right Care, Right Person provides the Mental Health Trusts with the opportunity to refresh their policies and training to allow them to meet their legal obligations under s18 Mental Health Act and Article 2 and 3 ECHR, in respect of someone who has absconded. In many cases this will be about asking trusts to implement in practise policies that currently exist. The MPS will be meeting with Health and Social Care partners from July to establish a RCRP External Partner Delivery Group to allow all parties to be clear on roles and responsibilities and for health and social care partners to develop their contingency plans to respond to patients who are Absent Without Leave from Mental Health facilities and the other pillars of Right Care, Right Person.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Retrieving sectioned patients who leave medical settings is generally a healthcare responsibility unless locating or detaining them engages core policing duties.
Verbatim wording from the response “The core responsibilities of the police are to prevent and detect crime, protect life and property and maintain the Kings Peace. The retrieval of persons sectioned under the Mental Health Act, who have left the medical setting in which they reside, is a health care responsibility unless the need to locate them and/or take them into police custody, falls into one of the core policing duties. Involving the police in mental health issues where there is no crime or threat to life risks criminalisation of patients, and in London in particular, where there is a higher percentage of mental illness within some minority communities, has a disproportionate criminalising effect on them.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Health partners generally remain responsible for transporting located patients back to hospital, rather than police providing transport.
Verbatim wording from the response “In instances where police do respond, unless the patient is subject to criminal proceedings (e.g. Part III MHA 1983), or S18 MHA applies, then police will generally not provide transport for the purpose of returning patients from the location they are found. This is clearly set out in the National Missing Adult Framework and is therefore a position which makes clear with which partner the responsibility sits. The National Missing Adult Framework also highlights that for many patients, being transported in a police vehicle is a traumatic experience and the most appropriate professional should return the patient.” Source location Response from Metropolitan Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Affinity Protocols, Joint Responsibility Agreements and national frameworks sufficiently define police and health partners’ roles for absconded patients.
Verbatim wording from the response “The MPS and medical agency partners already work to an existing framework which sets out roles and responsibilities. They are:” Source location Response from Metropolitan Police
Open published response
23 May 2023 Daniel LYLE · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Insufficient focus in police officer training on symptoms and presentation of mental health conditions View source Insufficient focus in police officer training on practical strategies for decision making in mental health situations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Daniel LYLE · 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
Daniel LYLE, who suffered from paranoid psychosis, experienced a psychotic episode on 20 March 2020 and climbed approximately 30 feet into a tree while displaying paranoid and delusional beliefs. He fell from the tree, sustained fatal head and chest injuries, and died despite resuscitation efforts. The principal concern was that police training was not sufficiently focused on understanding mental health symptoms and presentation, or on practical strategies to support decision-making during mental health crises.
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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient focus in police officer training on symptoms and presentation of mental health conditions
Wider context from the report “(1) Whilst recognising that police officers cannot be doctors or nurses nor should they be, it is a concern that training for officers whether initial or refresher is not sufficiently focused on:
(a) an understanding of the symptoms and presentation of mental health conditions ;
(b) possible practical strategies informed by mental health professionals and those suffering such conditions as will enable officers to optimise their decision making under the national decision making model.
” 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 Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient focus in police officer training on practical strategies for decision making in mental health situations
Wider context from the report “(1) Whilst recognising that police officers cannot be doctors or nurses nor should they be, it is a concern that training for officers whether initial or refresher is not sufficiently focused on:
(a) an understanding of the symptoms and presentation of mental health conditions;
(b) possible practical strategies informed by mental health professionals and those suffering such conditions as will enable officers to optimise their decision making under the national decision making model.
” Open source report
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.
×
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 Metropolitan Police Service; 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 Metropolitan Police Service; 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 Metropolitan Police Service; 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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require firearms licensing decision-makers to complete current training and accreditation, with supervisory accreditation and governance oversight before independent decision-making.
Verbatim wording from the response “MPS arrangements for “Delegated Authority” under the Firearms Act 1968 state that all members of the Firearms Enquiry Team (FET – MPS Designation for FELU) of Sergeant rank or above possess full decision making powers. This is then supplemented by a separate Decision Making Governance, which ensures that appropriate oversight is given. All decision makers have received the current agreed training package and undertaken accreditation which is overseen by the FET Inspector. Each new Supervisory officer joining the team receives an accreditation meeting with the FET Inspector and the MO19 senior leader responsible for FET, before being authorised to undertake independent decision making.” Source location Response from Metropolitan 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 Deliver and update local firearms licensing training for all officers, supervisors and management in line with current statutory, non-statutory and College of Policing guidance.
Verbatim wording from the response “The MPS assessment is that adequate local training has been implemented to all staff operating within their Firearms FET. This includes both the original statutory and non-statutory guidance to police and subsequent iterations of these. This training has been delivered to all Firearms Enquiry Officers (FEO), supervisors and the MPS FET management team has an ongoing continuous development programme, overseen by a newly implemented monthly board.” Source location Response from Metropolitan 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 Maintain continuous professional development through mentoring, supervised competence assessment, quarterly training and enhanced decision-making and risk-management instruction.
Verbatim wording from the response “FEOs are mentored by an experienced member of staff and their practical application of knowledge is assessed by supervisors against 23 key areas of competence, which reflect the FEO Learning Standards and most recent statutory and non-statutory guidance. Ongoing training to all FET staff and new joiners is a key performance indicator. Continuous professional development is embedded within the FET with staff trained quarterly. Training content follows trends identified in the national Firearms and Explosives Licensing Working Group (FELWG) as well as any local or national learning opportunities identified by the FET management team. Supervisors and decision makers have been provided with an enhanced level of training in relation to decision making, risk management and professional curiosity. This is delivered in partnership with colleagues from the MPS Directorate of Legal Services.” Source location Response from Metropolitan Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing local training, accreditation, oversight and continuous development are considered adequate despite no nationally accredited training package.
Verbatim wording from the response “MPS arrangements for “Delegated Authority” under the Firearms Act 1968 state that all members of the Firearms Enquiry Team (FET – MPS Designation for FELU) of Sergeant rank or above possess full decision making powers. This is then supplemented by a separate Decision Making Governance, which ensures that appropriate oversight is given. All decision makers have received the current agreed training package and undertaken accreditation which is overseen by the FET Inspector. Each new Supervisory officer joining the team receives an accreditation meeting with the FET Inspector and the MO19 senior leader responsible for FET, before being authorised to undertake independent decision making.” Source location Response from Metropolitan Police
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations