Concerns raised 2 Lack of formal guidance, training, and protocols for correlating COMPACT risk assessments with ACT stop priority instructions View source Mismatch between COMPACT risk assessments and ACT stop priority instructions 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
HANNAH WARREN · 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
Hannah Warren was reported missing on 3 February 2016 after leaving London by car while expressing delusional thoughts, and her body was found in Port Talbot harbour the following morning. The inquest concluded that she died from drowning and a head injury. Concerns included shortcomings in the missing-person investigation, including delayed or insufficient use of the ANPR Bureau, communication failures, failure to contact family, and the use of a low-priority vehicle stop despite a medium risk assessment; the report also identified a lack of formal guidance, training, or protocols linking these systems.
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 formal guidance, training, and protocols for correlating COMPACT risk assessments with ACT stop priority instructions
Wider context from the report “(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling;
(2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle.
(3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems ; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all.
(4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT.
(5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.
(6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically.
” Open source report × Source evidence
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 Mismatch between COMPACT risk assessments and ACT stop priority instructions
Wider context from the report “(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling;
(2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle.
(3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all.
(4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT.
(5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.
(6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically.
” 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 Adapt national ACT and ReACT guidance into an MPS digital training package for frontline officers, covering risk alignment, priority grading, information and response requirements.
Verbatim wording from the response “In November 2022, the College of Policing published the Information and Communications Technology (ICT) learning document “ACT and ReACT reports on PNC”. The document is a Home Office approved training tool aimed at frontline officers and supervisors, it details all aspects of the ACT process and responds to the failures and knowledge gaps identified during the inquest into Hannah’s death.” 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 an SLA requiring inspector authorisation for low- and medium-priority ACT reports, 24-hour nominated contacts, and ownership of review and removal of obsolete entries.
Verbatim wording from the response “To improve the accuracy of ACT report submissions, risk assessments and to ensure the ongoing management of the information held on the system, the MPS will shortly be introducing a new Service Level Agreement (SLA). This requires all low and medium priority ACT reports to have been authorised by an officer of at least the rank of inspector prior to submission (currently only high priority reports require a superintendent’s authority). In addition, all ACT reports must have nominated contact who is available 24hrs per day and suitably informed to provide updates and direction in the event of an activation. It will be the responsibility of the owning officer to review and remove entries from the system, if they are no longer required. The SLA is awaiting final approval, for publication in May 2023.” Source location Response from Metropolitan Police
Open published response
13 Feb 2023 Michael ROBERTS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure of DBS certificates to accurately record relevant convictions 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
Michael ROBERTS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Roberts died by suicide on the evening of 20 August 2022 after shooting himself with a gun taken from his workplace, where he had access to firearms. A DBS certificate recorded no convictions despite his past conviction for a violent offence, which had led to his dismissal as a police officer; the report states that he would not have been employed at Proof House if the conviction had been correctly recorded. It was unclear whether the inaccurate DBS certificate resulted from an error by the DBS or the MPS.
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 DBS certificates to accurately record relevant convictions
Wider context from the report “Before he was employed as a proof assistant testing new guns, Mr Roberts’ prospective employer asked for a DBS (Disclosure and Barring Service) certificate. This was provided and recorded no convictions, cautions, reprimands or warnings.
However, Mr Roberts had in the past been convicted of a violent offence for which he had received a custodial sentence. This was the reason for his dismissal from his former occupation as a police officer in the MPS (Metropolitan Police Service).
If Mr Roberts’ DBS certificate had correctly recorded his conviction, he would not have been employed at Proof House where he had access to firearms.
It is unclear to me whether the inaccuracy of the DBS certificate was caused by an error made by the DBS or by the MPS.
” Open source report
14 Dec 2022 Fatima Abukar · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Reduced legal enforcement of unlawful e-scooter use View source Failure to provide prominent written warnings about the illegal use of e-scooters View source Failure to require head protection for riders of legally authorised scooters View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Fatima Abukar · 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
Fatima Abukar, a 14-year-old girl, died from catastrophic head injuries after the privately owned e-scooter she was riding entered the carriageway and struck a mini-bus. The concerns included e-scooter fatalities and enforcement, the absence of a requirement for riders of legally authorised scooters to wear head protection, and inconsistent or insufficiently prominent warnings about illegal e-scooter use.
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 Reduced legal enforcement of unlawful e-scooter use
Wider context from the report “1. Evidence in this inquest confirmed that since 2019 here have been 8 recorded fatalities involving e-scooters in London and 31 in the country at large. At the time of her death Ms Abukar was riding a privately owned e-scooter on a public highway. Despite the ubiquity of such devices on London’s streets, riding them on public roads is unlawful.
Whereas approximately 4000 unlawfully used scooters were seized by the Metropolitan Police Service in 2021, only 1100 were confiscated in 2022 . The reduction is attributable to a change in policy introduced in November 2021.
An inverse correlation exists between the rate of legal enforcement and the rate of deaths caused by e-scooters. The number of deaths in Q1 & 2 of 2022 is more than double that of Q1 & 2 of 2021.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prominent written warnings about the illegal use of e-scooters
Wider context from the report “3. Some manufacturers and retailers of e-scooters in England and Wales provide consumers with written warnings about the illegal use of e-scooters, others do not. Where such warnings are present, often they are not prominent.
” Open source report × Source evidence
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 require head protection for riders of legally authorised scooters
Wider context from the report “2. Ms Abukar died due to traumatic head injuries. Riders of legally authorised scooters (those hired from licenced operators) are not required to wear head protection.
” 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 Send annual joint letters to e-scooter retailers requesting prominent point-of-sale warnings about e-scooter legality.
Verbatim wording from the response “Some manufacturers and retailers of e-scooters in England and Wales provide consumers with written warnings about the illegal use of e-scooters, others do not. Where such warnings are present, often they are not prominent.” 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 full statutory release conditions, including valid insurance and driving licence, before releasing seized e-scooters and other covered vehicles.
Verbatim wording from the response “6.9 Prior to July 2022 the Met exercised its discretion and waived some of the release conditions for production of a valid certificate of insurance and/or a valid driving licence when reclaiming non-standard mechanically propelled vehicle that had been seized under Sec 165A RTA 1988 at the Met car pounds. This was to afford the owner or registered keeper the ability to reclaim the vehicle. However, as of July 2022 the Met” 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 and reinforce policing policy requiring a graduated, proportionate response to illegal e-scooter use, including guidance on lawful locations and responsible riding.
Verbatim wording from the response “The MPS updated their policy titled “Seizure of vehicles for No Licence and Insurance Standard Operating Procedure” which covers the seizure and enforcement of offences connected with the use of illegal e-scooters, in September 2021. There was no specific update to the policy concerning the seizure of E-scooters at this time. An element of discretion has applied in relation to the seizure of e-scooters and other non-standard mechanically propelled vehicles for a number of years prior to this by way of the following paragraph:” 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 Advocate to the Department for Transport and Transport for London for protective headwear use by authorised e-scooter riders.
Verbatim wording from the response “Ms Abukar died due to traumatic head injuries. Riders of legally authorised scooters (those hired from licenced operators) are not required to wear head protection.” 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 does not accept a correlation between e-scooter enforcement levels and deaths, and says no supporting evidence was presented at the inquest.
Verbatim wording from the response “An inverse correlation exists between the rate of legal enforcement and the rate of deaths caused by e-scooters. The number of deaths in Q1 & 2 of 2022 is more than double that of Q1 & 2 of 2021.” 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 DfT and TfL made the policy decisions on licensed e-scooter trial parameters and head protection, so they are best placed to explain the rationale.
Verbatim wording from the response “Ms Abukar died due to traumatic head injuries. Riders of legally authorised scooters (those hired from licenced operators) are not required to wear head protection.” Source location Response from Metropolitan Police
Open published response
21 Nov 2022 Andrew MacIntyre Brown · Prevention of Future Deaths report West London
View report summary
Concerns raised 3 Unclear scope or threshold of the silent approach exception View source Unclear application of the Blue Lights exception to response drivers View source Insufficient consideration of other road users and pedestrians’ safety in the driver and vehicle SOP View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew MacIntyre Brown · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew MacIntyre Brown, aged 23, died after being struck by a police vehicle at a pedestrian crossing on 5 November 2019. The vehicle was travelling at an unsuitable speed at night and was not using lights and sirens. The report identifies concerns that police driving policies insufficiently addressed the safety of pedestrians and other road users and were unclear about the circumstances in which a silent approach could be used.
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 Unclear scope or threshold of the silent approach exception
Wider context from the report “1. There is insufficient reference to other road users and pedestrians and their safety in the Metropolitan Police Service Police Driver & Vehicle Policy - Vehicle and Equipment Standard Operating Procedure (SOP).
2. The Metropolitan Police Service Police Driver & Vehicle Policy - Vehicle and Equipment Standard Operating Procedure (SOP) is too open to interpretation in the section on “silent approach” in section 1.55 Warning equipment – (sirens, blue lights and headlamp flasher) and the first three paragraphs of section 1.57 Blue Lights. The scope or threshold of the exception in the two sections is not clear and it is also not clear where the exception in the latter section applied to response drivers.
” Open source report × Source evidence
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 application of the Blue Lights exception to response drivers
Wider context from the report “1. There is insufficient reference to other road users and pedestrians and their safety in the Metropolitan Police Service Police Driver & Vehicle Policy - Vehicle and Equipment Standard Operating Procedure (SOP).
2. The Metropolitan Police Service Police Driver & Vehicle Policy - Vehicle and Equipment Standard Operating Procedure (SOP) is too open to interpretation in the section on “silent approach” in section 1.55 Warning equipment – (sirens, blue lights and headlamp flasher) and the first three paragraphs of section 1.57 Blue Lights. The scope or threshold of the exception in the two sections is not clear and it is also not clear where the exception in the latter section applied to response drivers .
” Open source report × Source evidence
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 consideration of other road users and pedestrians’ safety in the driver and vehicle SOP
Wider context from the report “1. There is insufficient reference to other road users and pedestrians and their safety in the Metropolitan Police Service Police Driver & Vehicle Policy - Vehicle and Equipment Standard Operating Procedure (SOP).
2. The Metropolitan Police Service Police Driver & Vehicle Policy - Vehicle and Equipment Standard Operating Procedure (SOP) is too open to interpretation in the section on “silent approach” in section 1.55 Warning equipment – (sirens, blue lights and headlamp flasher) and the first three paragraphs of section 1.57 Blue Lights. The scope or threshold of the exception in the two sections is not clear and it is also not clear where the exception in the latter section applied to response drivers.
” Open source report
×
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 policy will not be amended because further detail would be too prescriptive and potentially unworkable alongside the Highway Code and Road Craft.
Verbatim wording from the response “I can confirm that the MPS have carefully considered the Coroner’s concerns and whether there are any helpful amendments which would make to the policy. However, on this occasion it was agreed that any amendment would make the policy too prescriptive. As outlined in the evidence to the Court during the inquest, police driving is based on the Highway Code and Road Craft, both of which are focussed on the safety of road users and pedestrians. A delicate balance must therefore be struck on the level of detail within the MPS policy to ensure that it is not unworkable.” 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 A prescriptive silent-approach threshold or list is not feasible because incidents vary and it would restrict drivers’ professional judgment in dynamic situations.
Verbatim wording from the response “Police drivers deal with a wide range of incidents on a daily basis, each with their own set of unique circumstances resulting in drivers facing numerous decisions regarding their driving response choices and the different methods that can be used, whether that be the use of full warning equipment, part warning equipment or a silent approach. The use of this equipment cannot be prescriptive as the decision whether to make use of any exemptions or use warning equipment will always rest with the driver who is responsible for ensuring the vehicle is driven in a safe manner in line with their training and skill level.” Source location Response from Metropolitan Police
Open published response
15 Sep 2022 Harper DENTON · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Lack of an offender register or equivalent protection for children from people convicted of cruelty against a child View source Failure to require Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children View source Failure to adopt MOSOVO guidance for managing sexual and violent offenders, particularly PDPs View source Lack of proactive police information sharing to protect children from people convicted of violence or cruelty against a child 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
Harper DENTON · 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
Harper DENTON, aged one month, was unlawfully killed by her father, who had previously been convicted of violent offences against a two-year-old child. The inquest found that failures by state agencies to manage the continuing risk he posed contributed to her death. Concerns included police information-sharing and risk-management practices, the absence of an offender register for people convicted of cruelty offences against children, and the non-mandatory nature of full safeguarding assessments by health visitors.
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 an offender register or equivalent protection for children from people convicted of cruelty against a child
Wider context from the report “3. There is nothing today, such as form of Offender Register, to protect children from an individual who has already been convicted of a cruelty offence against a child and served their sentence.
” Open source report × Source evidence
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 require Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children
Wider context from the report “4.The need for a Health Visitor to carry out a full safeguarding assessment of a father’s/co-parent's potential risks to a child is currently only ‘best practice’ and not mandatory .
” Open source report × Source evidence
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 adopt MOSOVO guidance for managing sexual and violent offenders, particularly PDPs
Wider context from the report “1.The MPS does not appear to have adopted ACPO Guidance on Protecting the Public: Managing Sexual Offenders and Violent Offenders 2010 and subsequent APP College of Policing MOSOVO Guidance , particularly with respect to PDPs .
” Open source report × Source evidence
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 proactive police information sharing to protect children from people convicted of violence or cruelty against a child
Wider context from the report “2. There appears to be a lacuna in pro-active information sharing practices by Police (similar to those found under Clare’s Law and Sarah’s Law) in order to protect children from those who may present a threat to them as a result of having previous convictions for violence/cruelty offences against a child - this concern is directed to the CEO College of Policing and the Chair of the NPCC.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review existing MAPPA processes, including the feasibility of introducing a Potentially Dangerous Person process.
Verbatim wording from the response “The MPS is currently reviewing its existing MAPPA processes. This review will include consideration of a new scoping exercise to assess the feasibility of introducing a PDP process as outlined by the College of Policing’s APP Guidance. It is currently anticipated that the outcome of this review will be completed within six months and will determine whether the MPS adopts the CoP APP guidance with regard to PDP’s.” 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 volume of potential PDPs in London makes implementing a PDP process unworkable, even after applying strict filtering parameters.
Verbatim wording from the response “On a number of previous occasions, the MPS has scoped the feasibility of introducing a PDP process as outlined in the guidance provided by the NPCC Policing Practice 2017 and College of Policing Authorised Professional Practice (APP), which superseded the ACPO Guidance on ‘Protecting the Public: Managing Sexual Offences and Violent Offenders 2010’.” 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 absence of a legislative framework makes implementing a PDP process problematic, particularly for partnership working.
Verbatim wording from the response “On a number of previous occasions, the MPS has scoped the feasibility of introducing a PDP process as outlined in the guidance provided by the NPCC Policing Practice 2017 and College of Policing Authorised Professional Practice (APP), which superseded the ACPO Guidance on ‘Protecting the Public: Managing Sexual Offences and Violent Offenders 2010’.” Source location Response from Metropolitan Police
Open published response
29 Jun 2022 Louise Theresa Bailey · Prevention of Future Deaths report South London
View report summary
Concerns raised 2 Failure to provide drivers with information about whether other units are closer for emergency-call risk assessment View source Lack of training on when officers should assign themselves over the radio View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Louise Theresa Bailey · 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
Louise Theresa Bailey died after being struck by a police car responding to an incident while she was running across the road to catch a bus. The concern was that the police system and training did not ensure responding drivers had information about whether other units were closer, preventing them from completing a full risk 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 Failure to provide drivers with information about whether other units are closer for emergency-call risk assessment
Wider context from the report “Chapter 13 of Roadcraft, the Police Driver’s Handbook, provides that before officers begin their response to an emergency call, they should go through a process of risk assessment. That includes consideration of whether other units are closer. However, in this case the driver and operator did not know the answer to that question. In part that was due to the fact that officers are encouraged to avoid assigning themselves over the radio during an ongoing incident to prevent clogging up of airwaves. However, I heard evidence that several units did in fact assign themselves over the radio, though not all with their location, and that no training is provided as to when to assign over the radio and when not to. Moreover, there is an emergency button which allows the originating officer to override other broadcasts if needed mitigating any risk of clogging up airwaves. My concern is that the current system and training does not facilitate drivers being provided with the information they need to answer the question “are other units closer?” which means they are unable to complete a full risk assessment .
” Open source report × Source evidence
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 when officers should assign themselves over the radio
Wider context from the report “Chapter 13 of Roadcraft, the Police Driver’s Handbook, provides that before officers begin their response to an emergency call, they should go through a process of risk assessment. That includes consideration of whether other units are closer. However, in this case the driver and operator did not know the answer to that question. In part that was due to the fact that officers are encouraged to avoid assigning themselves over the radio during an ongoing incident to prevent clogging up of airwaves. However, I heard evidence that several units did in fact assign themselves over the radio, though not all with their location, and that no training is provided as to when to assign over the radio and when not to . Moreover, there is an emergency button which allows the originating officer to override other broadcasts if needed mitigating any risk of clogging up airwaves. My concern is that the current system and training does not facilitate drivers being provided with the information they need to answer the question “are other units closer?” which means they are unable to complete a full risk assessment.
” 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 Procure and replace the CAD command-and-control system with OnCall, enabling deployment decisions based on vehicle distance and officer skill set.
Verbatim wording from the response “The MPS is currently in the process of procuring a replacement Command and Control system to replace the current CAD system. The proposed replacement, “OnCall” is a map based despatch programme which is designed to drive efficiency in deployment of officers to incidents. The function of the OnCall system means that more control and responsibility will be given to MetCC Despatch Operators.” 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 manual to instruct officers not to use the radio to self-assign to emergency incidents.
Verbatim wording from the response “The CAD mapping system is accessed and monitored in the MetCC control rooms. Its use is encouraged when dispatching incidents and is widely used by MetCC operators to ensure efficiency and to limit travel time. It is acknowledged that there is a lack of formal instruction around self-assignment with regards to what is deemed an urgent assistance CAD. To resolve this issue and ensure a consistent approach across the organisation, the MPS is in the process of amending the “Standards of Radio Procedure” section of the Airwave manual to state that the radio should not be used as a tool for officers to assign themselves to emergency incidents. This will ensure a consistent and corporate approach across all 12 BCU’s and reduce unnecessary radio traffic in the event of an emergency assistance” 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 Vehicle mapping cannot reliably support fast-time driver decisions because legal restrictions limit in-car display use to speeds below five miles per hour.
Verbatim wording from the response “There is a facility within the IVMA in-car system which allows supervisors to view where local resources are, however, the accuracy of this depends on the signal strength received by the vehicle and its consistency is location dependent. However, Regulation 109 of the Road Vehicles (Construction and Use) Regulations 1986 makes it unlawful for display screens within vehicles, which show text, to be deployed in a position where the equipment can be seen by and potentially distract the driver. This means the IVMA in vehicles can only be viewed below a speed of 5 mph limiting the ability of the IVMA in fast time or spontaneous incidents.” 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 It is not practical or appropriate to control urgent incidents using mapping data or select attending vehicles based on location.
Verbatim wording from the response “As detailed above, there is a requirement for all officers to assign themselves to calls until informed otherwise and to keep all radio transmissions to an absolute minimum. It is not practical to control the incident based on mapping data, nor is it appropriate to select or deselect vehicles or officers to attend based on location.” 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 Urgent assistance requires all available vehicles to respond until cancellation because delay could increase risks to officers, suspects and the public.
Verbatim wording from the response “The OnCall system will have the ability to calculate the travelling times of units and show information surrounding the policing skills of the officers in each vehicle, which in turn will enable a more intelligence based approach to deployments. It is the MPS’ view that the OnCall system will address the concerns raised by HM Assistant Coroner in his report, by ensuring appropriate assignment of vehicles based on distance and skill set. The system will not, however, change the expected response of officers to incidents of urgent assistance, for the reasons outlined. Due to the individual nature of those incidents, this will still require an initial multi-unit response in accordance with current practice.” Source location Response from Metropolitan Police Service
Open published response
22 Jun 2022 Luke Anthony Flynn · Prevention of Future Deaths report North London
View report summary
Concerns raised 1 Lack of a MET Police policy governing the use of handcuffs when medical staff request their use for hospital patients being treated for a medical condition View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke Anthony Flynn · 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
Luke Anthony Flynn died in hospital on 17 July 2019 after being restrained by members of the public, detained in hospital, and handcuffed to his bed at clinicians’ request. The concern was that there was no Metropolitan Police policy covering the use of handcuffs when medical staff requested them for a hospital patient being treated for a medical condition rather than a mental health condition.
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 a MET Police policy governing the use of handcuffs when medical staff request their use for hospital patients being treated for a medical condition
Wider context from the report “1. That there is no MET Police policy covering the use handcuffs when medical staff request their use with a patient in hospital for treatment with a medical condition rather than a mental health condition .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and implement a handcuff policy requiring officers to assess proportionality, necessity, legality and ethics and justify decisions in writing after the event.
Verbatim wording from the response “The officers’ decision to handcuff Mr Flynn remained with them to justify (this is supported by the literature previously provided to you in our solicitor’s e-mail dated 16th December 2021). This point is set out in the new Metropolitan Police Handcuff policy (published in November 2021). Officers are expected to make their own assessment of the circumstances in which they find themselves, and on that basis take action (or inaction) based on proportionality, necessity, legality and ethics, whilst fully justifying their decisions in writing post event. Although the policy does not specifically address the use of handcuffs in a healthcare setting for medical treatment, upon reviewing both the policy and the legal powers afforded to officers, both are sufficiently robust to allow officers to make an informed decision as to the use of handcuffs in any given setting.” 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 handcuff policy and legal powers sufficiently guide healthcare-setting decisions, so no policy change addressing that specific scenario is considered appropriate.
Verbatim wording from the response “The officers’ decision to handcuff Mr Flynn remained with them to justify (this is supported by the literature previously provided to you in our solicitor’s e-mail dated 16th December 2021). This point is set out in the new Metropolitan Police Handcuff policy (published in November 2021). Officers are expected to make their own assessment of the circumstances in which they find themselves, and on that basis take action (or inaction) based on proportionality, necessity, legality and ethics, whilst fully justifying their decisions in writing post event. Although the policy does not specifically address the use of handcuffs in a healthcare setting for medical treatment, upon reviewing both the policy and the legal powers afforded to officers, both are sufficiently robust to allow officers to make an informed decision as to the use of handcuffs in any given setting.” Source location Response from Metropolitan Police
Open published response
8 Jun 2022 Mr Ian McDonald Taylor · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to provide access to prescribed emergency inhaler medication during public-place police detention View source Failure to identify and address officer training or attitudinal deficits through supervision View source Failure to conduct and record an adequate ongoing risk assessment View source Failure to communicate detainee medical distress with appropriate urgency View source Unavailability of timely paramedic response during exceptional ambulance-service demand 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
Mr Ian McDonald Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Ian McDonald Taylor suffered a cardiac arrest after a physical altercation while in police detention and died in hospital. Concerns included the police officer’s assessment and communication of Mr Taylor’s breathing difficulties, access to his inhaler while awaiting an ambulance, and the exceptionally delayed ambulance response.
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 access to prescribed emergency inhaler medication during public-place police detention
Wider context from the report “Mr Taylor was in police detention in a public place and was known to be a sufferer of both COPD and asthma, required to take a regular combination of inhalers and had a history of emergency admission to hospital with life threatening asthma. He repeatedly asked urgently for his inhaler, which he said was in his pocket, and that he needed it and that he felt he was going to die. Police did not find it (although a broken inhaler found later at the scene might have been his). If he had been in a custody suite he would have had access to a custody nurse or medical practitioner who could have prescribed it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and address officer training or attitudinal deficits through supervision
Wider context from the report “In court he was asked if he had learnt any lessons from the incident and he did not acknowledge he had. He was asked if he would do anything different in future, he made excuses for his comments and he said that he would be more sensitive in future. He was not able to answer a question about what considerations should be made to form the view somebody did not need hospital. He did not accept that he had made an inadequate risk assessment. He did not accept that such comments could have or might in future contribute to death by indicating a lack of urgency to a sergeant not at the scene. He was given an opportunity to make any other comment and could not bring himself to apologize to the family.
There was no evidence heard in court of the content or effect of supervision of the officer after the incident or whether training or attitudinal deficits had been identified and addressed. The family are concerned as to whether the officer should be suspended pending further investigations, and I disclose that merely as a measure of their level of concern about public safety, as it is inappropriate for me to make any such recommendation.
” Open source report × Source evidence
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 and record an adequate ongoing risk assessment
Wider context from the report “Whilst PC ████████ was away from Mr ████████ he accepts that he is heard shortly after 18.14 stating to his sergeant on the radio “He’s currently on the floor playing the whole poor me poor me; he’s going to have to go to hospital though as a matter of course.” And at 18.24: “He’s saying he has chest pains he cant breathe blah blah; it’s a load of nonsense but there we go”
He said in court that he formed these views as Mr Taylor seemed iller than he would expect from the nature of the previous altercation. He denied he thought Mr Taylor was faking. He claims to have made a continual risk assessment, but there is no record or evidence of that. He said that his views were influenced by a previous incident in which a man sprang to violence from previous calmness. They were not his final conclusion. There was no evidence as to his forming a different conclusion in the following 8 minutes before the cardiac arrest.
” Open source report × Source evidence
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 detainee medical distress with appropriate urgency
Wider context from the report “Whilst PC ████████ was away from Mr ████████ he accepts that he is heard shortly after 18.14 stating to his sergeant on the radio “He’s currently on the floor playing the whole poor me poor me; he’s going to have to go to hospital though as a matter of course.” And at 18.24: “He’s saying he has chest pains he cant breathe blah blah; it’s a load of nonsense but there we go”
He said in court that he formed these views as Mr Taylor seemed iller than he would expect from the nature of the previous altercation. He denied he thought Mr Taylor was faking. He claims to have made a continual risk assessment, but there is no record or evidence of that. He said that his views were influenced by a previous incident in which a man sprang to violence from previous calmness. They were not his final conclusion. There was no evidence as to his forming a different conclusion in the following 8 minutes before the cardiac arrest.
” Open source report × Source evidence
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 timely paramedic response during exceptional ambulance-service demand
Wider context from the report “Because of wholly exceptional demands on the ambulance service, a paramedic was not available until after he had suffered a cardio-respiratory arrest , from which he did not survive. A consultant paramedic and London Ambulance Service Director was asked about the feasibility of an inhaler device being available to police to offer to known asthmatics in exceptional circumstances when medical help was not available, such as is now in place in schools. He said that there were many difficulties: The difficulties included the adequacy of assessment of need by non medically trained persons on the scene, the difficulties of remote assessment, the threshold for confirmation of the person in distress being an established asthmatic, avoiding giving it to those with non asthmatic causes of breathlessness, and police training. Nevertheless he said that lives might be saved and it should be looked at. Advice was given to the court that such a proposal would need legislative change.
” 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 Implement the Reflective Practice Review Process for the officer, including reflection on the missed apology and identification of any additional training needs.
Verbatim wording from the response “The AA has determined that the conduct does not meet the threshold for justifying disciplinary proceedings. The AA has identified practice requiring improvement and determined that the officer will be referred the reflective practice review process, as set out in Part 6 of the Police (Conduct) Regulations 2020. In particular the AA has determined that the reflective practice review process will include an opportunity for the officer to reflect on the missed opportunity to offer an apology to Mr Taylor’s family.” 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 officer’s comments had no bearing on the circumstances of the incident.
Verbatim wording from the response “It is the position of the AA that whilst the officer’s comments had no bearing on the circumstances of the incident, the flippant nature of the words demonstrate a lack of professionalism and are in breach of the standards of professional behaviour outlined in the code of ethics issued by the college of policing.” 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 conduct did not meet the threshold for disciplinary proceedings, so no disciplinary action was pursued.
Verbatim wording from the response “The AA has determined that the conduct does not meet the threshold for justifying disciplinary proceedings. The AA has identified practice requiring improvement and determined that the officer will be referred the reflective practice review process, as set out in Part 6 of the Police (Conduct) Regulations 2020. In particular the AA has determined that the reflective practice review process will include an opportunity for the officer to reflect on the missed opportunity to offer an apology to Mr Taylor’s family.” Source location Response from Metropolitan Police
Open published response
21 Jan 2022 Anthony Walgate and 3 others · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Lack of clarity about specialist and forensic support available when BCU retains primacy View source Use of “unexplained” death categorisation distracting officers from treating sudden deaths as suspicious until investigation establishes otherwise View source Failure to carry out handwriting verification appropriately and sensitively View source Lack of ownership and responsibility among officers leading unexplained-death investigations View source Closure of CRIS investigations without completion review and critical assessment of non-suspicious classification View source Lack of identity verification for users engaging escorts through the Sleepyboy website View source Lack of clarity in the policy framework guiding primacy decisions View source Inaccessibility or poor understanding of the SCRG as a complex-investigation review resource View source Failure to record investigation lines, actions and outcomes View source See 6 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
Introduce tighter governance for unexpected deaths under investigation, including action tracking, local progress oversight and dip sampling.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source
Action
Add death-investigation leadership responsibilities to the DS and DI course curriculum.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source
Action
Present SCRG information to the senior leadership teams of all 12 BCUs.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source
Action
Develop an open MPS SharePoint channel for updating and sharing SCRG information.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source
Action
Amend and publish the Death Investigation Policy to require recording post-mortem recommendations, rationale for non-compliance, structured death-investigation definitions, supervisor actions and ADR use.
Stated in progressThe respondent said that this action was in progress when they made their response on 25 January 2022. View source
Action
Issue CONNECT policy guidance reinforcing supervisors’ responsibilities for reviewing and recording investigative actions as completed.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source
Action
Design a formal lesson plan on specialist homicide, forensic and crime-scene support and include it in DC, DS, DI and SIO training.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source
Action
Share the SCRG newsletter with all PIP3 SIOs.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source
Action
Add a DS and DI curriculum lesson on reviewing and signing investigative actions as complete.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source
Action
Obtain approval, incorporate into policy, and embed clarified investigative responses and primacy arrangements across the MPS.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source
Action
Present SCRG information annually to Public Protection and Investigation Superintendents at their monthly meetings.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source
Action
Obtain approval for four death classifications, amend policy, and embed the classifications across the MPS.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2022. View source See 9 more actions
×
AI-generated summary
Anthony Walgate and 3 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
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor were four young men who were drugged with GHB and murdered. The report raises concerns about serious investigative failings, including how sudden deaths were categorised, the allocation and support of homicide investigations, leadership, recording and review of investigative actions, handwriting verification, death notifications and the response to coroners’ concerns. It also identifies concern that users of the Sleepyboy website could engage escorts without verifying their identities.
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 clarity about specialist and forensic support available when BCU retains primacy
Wider context from the report “It remains a matter of concern that there is a lack of clarity surrounding the levels of support that can be expected from the specialist homicide investigators and crime scene managers or other forensic practitioners in the investigation of deaths where primacy remains with the BCU (MC2B).
” Open source report × Source evidence
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 Use of “unexplained” death categorisation distracting officers from treating sudden deaths as suspicious until investigation establishes otherwise
Wider context from the report “It is a matter of concern that although the current MPS policy, the Death Investigation Policy, dated 24 May 2021, similarly stipulates that officers attending the scene of a sudden death should treat the scene and incident as suspicious until satisfied that it is not, the term “unexplained” as used in the current policy may once again distract officers from the correct and necessary approach , which is for the death to be treated as suspicious unless and until the police investigation has established that it is not (MC1).
” Open source report × Source evidence
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 carry out handwriting verification appropriately and sensitively
Wider context from the report “Therefore, although it may only very rarely be the case that the verification of a person’s handwriting might have a critical impact on future deaths, it is a matter of concern to me that this task be carried out appropriately and sensitively to afford the police the best opportunity of any identification being accurate (MC5).
” Open source report × Source evidence
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 ownership and responsibility among officers leading unexplained-death investigations
Wider context from the report “It is a matter of concern that despite the regularly refreshed training that is now in place for detective sergeants and detective inspectors, and the additional leadership training in which the MPS has invested, a lack of ownership and responsibility for the investigations of unexplained deaths may persist in officers who are supposed to be leading investigations into unexplained deaths (MC3A).
” Open source report × Source evidence
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 Closure of CRIS investigations without completion review and critical assessment of non-suspicious classification
Wider context from the report “A further, related, matter of concern is that the CRIS was closed by supervising officers without any review of whether the actions had been completed or any critical assessment at detective sergeant level or detective inspector level of whether the investigation had established that the death was non-suspicious (MC4B).
” Open source report × Source evidence
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 identity verification for users engaging escorts through the Sleepyboy website
Wider context from the report “It is a matter of concern that users of the Sleepyboy website can engage escorts without having to verify their identity (MC6).
” Open source report × Source evidence
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 clarity in the policy framework guiding primacy decisions
Wider context from the report “It is a matter of concern that the current policy framework guiding decisions on primacy still lacks clarity (MC2A).
” Open source report × Source evidence
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 Inaccessibility or poor understanding of the SCRG as a complex-investigation review resource
Wider context from the report “It nevertheless remains a matter of concern that the SCRG, which DAC ████████ commended as an asset to assist in the process of review of complex investigations is not, in practice, accessible and/or properly understood as a resource (MC3B).
” Open source report × Source evidence
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 record investigation lines, actions and outcomes
Wider context from the report “It remains a matter of concern that whatever the system, CRIS or CONNECT, officers may not record lines of investigation, actions and outcomes (MC4A).
” 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 Introduce tighter governance for unexpected deaths under investigation, including action tracking, local progress oversight and dip sampling.
Verbatim wording from the response “The existing MPS Crime Report Information System (CRIS) has functionality that allows supervisors to issue key actions and track progress against an investigation. Already used extensively within criminal investigations, it will need to extend to Crime Related Incidents (CRI), also recorded on CRIS, used as a means of recording unexpected death investigations, and will allow key enquiries and forensic submissions to be tracked and progress reviewed.” Source location 2022-0017-Response-from-MPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add death-investigation leadership responsibilities to the DS and DI course curriculum.
Verbatim wording from the response “The MIT/BCU working group has agreed and set out clear guidelines detailing the responsibilities that officers of different ranks have in each death investigations. This should leave them in no doubt as to their responsibilities and those of their colleagues. They are as follows:” Source location 2022-0017-Response-from-MPS_Published
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 Present SCRG information to the senior leadership teams of all 12 BCUs.
Verbatim wording from the response “Moving forward, in order to continue raising awareness of the SCRG and what they can do to support BCU officers, they will also:” Source location 2022-0017-Response-from-MPS_Published
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 open MPS SharePoint channel for updating and sharing SCRG information.
Verbatim wording from the response “Moving forward, in order to continue raising awareness of the SCRG and what they can do to support BCU officers, they will also:” Source location 2022-0017-Response-from-MPS_Published
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 Amend and publish the Death Investigation Policy to require recording post-mortem recommendations, rationale for non-compliance, structured death-investigation definitions, supervisor actions and ADR use.
Verbatim wording from the response “Review of Death Investigation Policy and associated guidance on police attendance at Coronial Inquest, role and responsibilities of officer in attendance and expectations on the capture of any comments/findings by the Coroner and police response and subsequent action.” Source location 2022-0017-Response-from-MPS_Published
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 CONNECT policy guidance reinforcing supervisors’ responsibilities for reviewing and recording investigative actions as completed.
Verbatim wording from the response “b. The CONNECT Investigation platform is replacing CRIS. When it goes live, all new investigations will be recorded and investigated on CONNECT. Outstanding actions on a CONNECT investigation are clearly visible, so when an investigation is going through the two-stage closure process (OIC’s Supervisor & Crime Management Services) it will be clear to the user that an action has or has not been completed. Where an action is marked as complete, it needs a supervisor to review, agree and show the action as complete. The CONNECT Action Plan functionality therefore assists in mitigating the risk of closing an investigation when actions are still outstanding. As with CRIS, it does not – and cannot – prevent a supervisor marking an action as complete when this is inaccurate.” Source location 2022-0017-Response-from-MPS_Published
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 Design a formal lesson plan on specialist homicide, forensic and crime-scene support and include it in DC, DS, DI and SIO training.
Verbatim wording from the response “Presently there is no formal lesson plan or training provided to staff in relation to the levels of support that they can expect to receive from specialist homicide investigators, crime scene managers or other forensic practitioners in the investigation of deaths, which remain on BCU for progression.” Source location 2022-0017-Response-from-MPS_Published
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 Share the SCRG newsletter with all PIP3 SIOs.
Verbatim wording from the response “Moving forward, in order to continue raising awareness of the SCRG and what they can do to support BCU officers, they will also:” Source location 2022-0017-Response-from-MPS_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a DS and DI curriculum lesson on reviewing and signing investigative actions as complete.
Verbatim wording from the response “As part of a forthcoming revision of the existing MPS Death Investigation Policy, stricter guidance will be introduced which will mandate tighter governance around those investigations classed as ‘unexpected death – under investigation’. The Head of Profession for Investigation will ensure that this includes the following:” Source location 2022-0017-Response-from-MPS_Published
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 Obtain approval, incorporate into policy, and embed clarified investigative responses and primacy arrangements across the MPS.
Verbatim wording from the response “The working group referred to above has clarified that the following shall be the investigative response for death investigations:” Source location 2022-0017-Response-from-MPS_Published
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 Present SCRG information annually to Public Protection and Investigation Superintendents at their monthly meetings.
Verbatim wording from the response “Moving forward, in order to continue raising awareness of the SCRG and what they can do to support BCU officers, they will also:” Source location 2022-0017-Response-from-MPS_Published
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 Obtain approval for four death classifications, amend policy, and embed the classifications across the MPS.
Verbatim wording from the response “This working group has agreed four new classifications so as to provide absolute clarity to officers responding to and investigating deaths. They are:” Source location 2022-0017-Response-from-MPS_Published
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 Introducing an “N” CRIS classification is subject to a national paper submitted to the NPCC Homicide Lead.
Verbatim wording from the response “It is proposed a new “N” code will be introduced to classify death investigations on the CRIS system which are not classified as murder but require further investigation to clarify the circumstances. This will allow for analysis of cases under investigation and support the investigation and supervision protocol described above. Introduction of the “N” code CRIS classification will be subject to a national paper submitted to the NPCC Homicide Lead.” Source location 2022-0017-Response-from-MPS_Published
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 SCRG information and awareness arrangements mean the group is widely known and accessible to relevant MPS officers.
Verbatim wording from the response ““We found then that the SCRG had worked hard over the previous 12 months to promote its services, taking part in relevant senior detective meetings, and giving inputs on courses….. senior detectives were well aware of the SCRG. It was also pleasing to find a good level of awareness at BCU sergeant and inspector levels.”” Source location 2022-0017-Response-from-MPS_Published
Open published response
5 Nov 2021 Katrina Makunova · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Failure to consistently record knife possession View source Failure to recognise knife possession in risk assessments View source Failure to investigate and identify gang affiliation as a risk factor View source Insufficient Child Safety Unit workforce capacity to fulfil safeguarding responsibilities safely 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
Katrina Makunova · 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
Katrina Makunova had experienced abuse, coercive and controlling behaviour, and threats before she was fatally pushed by her ex-boyfriend on 12 July 2018. The report identified concerns about knives and gang affiliation not being consistently recognised or recorded as risk factors, and about workload pressures affecting the capacity of police Child Safety Units to carry out safeguarding effectively and safely.
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 consistently record knife possession
Wider context from the report “Concern 1:
Whilst significant steps have been taken to recognize contextual abuse by all the organizations since the death, there remains a concern. Police officers knew of the perpetrator’s wearing of a knife. Possession of a knife was not recognized in risk assessments and not always recorded by police, nor social services . It was also unclear from police evidence when gang affiliation should be explored and when it would be recognized as a risk. Those around Katrina, knew of her past and present association with gang members; yet this too never seems to have been investigated and identified by police as a risk factor. Evidence was heard from her brother and another witness that her fear of what harm the might do led her not to make a full disclosure of his controlling behaviour to 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 Failure to recognise knife possession in risk assessments
Wider context from the report “Concern 1:
Whilst significant steps have been taken to recognize contextual abuse by all the organizations since the death, there remains a concern. Police officers knew of the perpetrator’s wearing of a knife. Possession of a knife was not recognized in risk assessments and not always recorded by police, nor social services. It was also unclear from police evidence when gang affiliation should be explored and when it would be recognized as a risk. Those around Katrina, knew of her past and present association with gang members; yet this too never seems to have been investigated and identified by police as a risk factor. Evidence was heard from her brother and another witness that her fear of what harm the might do led her not to make a full disclosure of his controlling behaviour to 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 Failure to investigate and identify gang affiliation as a risk factor
Wider context from the report “Concern 1:
Whilst significant steps have been taken to recognize contextual abuse by all the organizations since the death, there remains a concern. Police officers knew of the perpetrator’s wearing of a knife. Possession of a knife was not recognized in risk assessments and not always recorded by police, nor social services. It was also unclear from police evidence when gang affiliation should be explored and when it would be recognized as a risk. Those around Katrina, knew of her past and present association with gang members; yet this too never seems to have been investigated and identified by police as a risk factor . Evidence was heard from her brother and another witness that her fear of what harm the might do led her not to make a full disclosure of his controlling behaviour to 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 Insufficient Child Safety Unit workforce capacity to fulfil safeguarding responsibilities safely
Wider context from the report “Concern 2:
The workload pressures in the Child Safety Units of the MPS were considerable and cited by officers who had been disciplined as reasons for some failures. However data presented to the court by the MPS did not reassure that the MPS would be able to establish a CSU workforce of sufficient capacity to enable officers to fulfil their safeguarding role effectively and safely .
” 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 Present the Public Protection review findings to the MPS Management Board in January 2022.
Verbatim wording from the response “The review is considering a number of options that could be initiated in a relatively short period of time to address some key findings across the MPS. These include a drive to fill current vacancies and review different ways of working aimed at reducing workloads on CSU investigators, their line management and an increase in staffing numbers. In January 2022, the findings from the review will be presented to the MPS Management Board comprising of the Commissioner, Deputy Commissioner and Assistant Commissioners. The final decision as to whether any of the options provided can be pursued, will be made by the Management Board.” Source location 2021-0388-Response-from-Metropolitan-Police_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage relevant academics and support their research into considering knife carrying and gang membership in domestic-abuse risk assessment.
Verbatim wording from the response “The MPS will engage positively with the relevant experts and assist where possible in any research undertaken by the academics. The MPS’ Lead Responsible Officer for Domestic Abuse will be writing proactively to both academics offering his support. If consideration is to be given to introducing a new category to the DASH risk assessment tool, then the College of Policing will need to be closely involved in these discussions.” Source location 2021-0388-Response-from-Metropolitan-Police_Published
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 Public Protection demand, systems, productivity, vacancies, working methods and staffing capacity across the MPS.
Verbatim wording from the response “The Deputy Assistant Commissioner for Local Policing requested a broad review of Public Protection within the Metropolitan Police Service (MPS), which is linked to the MPS’s drive to improve outcomes for victims. The work has revealed a significant increase in demand, particularly in relation to reports of Domestic Abuse.” Source location 2021-0388-Response-from-Metropolitan-Police_Published
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 MPS Management Board will decide whether reviewed CSU staffing and workload options can be pursued.
Verbatim wording from the response “The review is considering a number of options that could be initiated in a relatively short period of time to address some key findings across the MPS. These include a drive to fill current vacancies and review different ways of working aimed at reducing workloads on CSU investigators, their line management and an increase in staffing numbers. In January 2022, the findings from the review will be presented to the MPS Management Board comprising of the Commissioner, Deputy Commissioner and Assistant Commissioners. The final decision as to whether any of the options provided can be pursued, will be made by the Management Board.” Source location 2021-0388-Response-from-Metropolitan-Police_Published
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 CSU safeguarding capacity is not solely a staffing-numbers issue; systems efficiency and effectiveness also require consideration.
Verbatim wording from the response “It should be noted that the issue is not solely down to numbers of officers in this area and that as part of the review, efficiency and effectiveness in our systems to manage demand and productivity are being explored.” Source location 2021-0388-Response-from-Metropolitan-Police_Published
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 Any new DASH risk-assessment category requires the College of Policing to be closely involved.
Verbatim wording from the response “The MPS will engage positively with the relevant experts and assist where possible in any research undertaken by the academics. The MPS’ Lead Responsible Officer for Domestic Abuse will be writing proactively to both academics offering his support. If consideration is to be given to introducing a new category to the DASH risk assessment tool, then the College of Policing will need to be closely involved in these discussions.” Source location 2021-0388-Response-from-Metropolitan-Police_Published
Open published response
3 Aug 2021 Emma Day · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 11 Failure to identify all children when sharing risk information View source Failure to record the duration and conditions of protective orders View source Failure to require escalation of domestic-violence concerns beyond immediate risk View source Failure to include the Non-Molestation Order in the Merlin Report View source Lack of safety netting for escalation of risk View source Inadequate caseworker training on the wider domestic-violence risk context View source Lack of guidance on accepting a caller’s assessment of domestic-violence risk View source Lack of a procedure for responding to threats and passing information to other authorities View source Lack of a system for direct entry of protective orders on the Police National Computer View source Failure of case-record access and handover of key domestic-violence risk information View source Failure to hold or know protective-order conditions and arrest powers View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emma Day · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emma Day died in the street on 26 May 2017 from multiple stab wounds and was found to have been unlawfully killed. The report describes a history of domestic violence, coercive and controlling behaviour, threats to her life and protective orders that had expired shortly before her murder. Principal concerns included failures to share and record risk information, inadequate domestic-violence training and guidance, and a system failure in handling reports of domestic violence within the Child Maintenance Service.
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 identify all children when sharing risk information
Wider context from the report “3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report, and when shared with Lambeth CSC only one of the children was mentioned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record the duration and conditions of protective orders
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order , nor did there appear to be any safety netting if the situation escalated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to require escalation of domestic-violence concerns beyond immediate risk
Wider context from the report “d) A caseworker who learnt from a caller of domestic violence was only required to escalate for consideration of signposting or reporting to police if there was an immediate risk of violence , not necessarily if the worker was concerned or an immediate risk was likely to eventuate in the future , in particular on reapplying for maintenance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to include the Non-Molestation Order in the Merlin Report
Wider context from the report “3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report , and when shared with Lambeth CSC only one of the children was mentioned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of safety netting for escalation of risk
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order, nor did there appear to be any safety netting if the situation escalated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate caseworker training on the wider domestic-violence risk context
Wider context from the report “b) Training of caseworkers at the time on domestic violence was focused on domestic violence as a criterion to grant waiver of the fee and did not provide information about the wider definition, the reluctance to self-declare or the available services to be signposted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on accepting a caller’s assessment of domestic-violence risk
Wider context from the report “e) Nevertheless in relation to 16th May, Ms Lilley expected case workers to pick up the degree of risk from a report of past threat to kill and escalate and Mr Gilchrist thought the response of the case worker inadequate, as there was a specific request to continue the maintenance claim in the knowledge of a specific threat. But the guidance at the time was silent as to whether to accept the caller’s assessment of risk . I concluded that staff would likely be uncertain of their duties .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for responding to threats and passing information to other authorities
Wider context from the report “f) Asked about the Domestic Homicide Report’s reference to systemic issues, Mr Gilchrist’s own words were that in May 2017 is where the system fell down. There should be a threat procedure and how to initiate it and pass information to other authorities
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for direct entry of protective orders on the Police National Computer
Wider context from the report “4. The Domestic Homicide Review recommended (R24) that the Home Office work with the Ministry of Justice to implement a system whereby protective orders can be input directly to the Police National Computer . It was not clear whether all State bodies that needed to were able to make entries themselves on the Police National Computer Conflicting evidence was heard, but one police officer stated that R24 had not been adopted , and to do so would be welcomed by other agencies and that without this change there might be missed opportunities to save lives .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of case-record access and handover of key domestic-violence risk information
Wider context from the report “The Coroner concluded that there was a system failure in Child Maintenance Service of Department of Work and Pensions in handling reports of domestic violence.
a) There was no mutual access of case records or system of handing on key risk information between CMO and CMS and so the eliciting of domestic violence risks relies upon repeated self-reporting by a victim .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to hold or know protective-order conditions and arrest powers
Wider context from the report “2. Lambeth Children’s Social Care (CSC) had no copy nor knew conditions of either Order, nor that there was a power of arrest . There seem to be steps taken by the CSC to consider action to mitigate the risk posed by the perpetrator in light of these Orders.
” Open source report
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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 Send MASH sergeants instructions to record non-molestation orders in MERLIN before sharing reports with local authorities.
Verbatim wording from the response “On 26th August 2021, communication was sent to all MASH sergeants asking them to place details of any non-molestation orders found during their research, on to MERLIN before sharing with the Local Authority and for this to be disseminated to all of their officers and researchers. As a reminder, this communication will be followed up in a meeting with MASH sergeants in September 2021 and included in the notes of the meeting that will be circulated.” Source location 2021-0263-Response-from-Metropolitan-Police_Published
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 MASH arrangements to improve risk identification, information sharing and collective safeguarding assessment across London.
Verbatim wording from the response “In June 2021, the MPS commenced a review of MASH with the strategic aim to improve the identification of risk to both children and vulnerable adults across London, and to work in partnership with statutory agencies to transform the collective response to information sharing and collective assessment within the MASH teams. It focuses on a consistent and connective approach to referral and agency activity which prioritises risk over volume; thereby improving the safeguarding response to London’s vulnerable people. During this review, consideration will be given to include details of non-molestation orders to be placed in MERLIN reports and passed to partners so that they can be made aware and report any potential breaches.” Source location 2021-0263-Response-from-Metropolitan-Police_Published
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 Follow up instructions on recording non-molestation orders at a MASH sergeants’ meeting and circulate the meeting notes.
Verbatim wording from the response “On 26th August 2021, communication was sent to all MASH sergeants asking them to place details of any non-molestation orders found during their research, on to MERLIN before sharing with the Local Authority and for this to be disseminated to all of their officers and researchers. As a reminder, this communication will be followed up in a meeting with MASH sergeants in September 2021 and included in the notes of the meeting that will be circulated.” Source location 2021-0263-Response-from-Metropolitan-Police_Published
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 Permission for non-police agencies to enter protective orders on the Police National Computer falls outside the MPS’s authority.
Verbatim wording from the response “PNC is the primary source of information for operational policing in the UK. Access to PNC for non-police organisations can only be authorised by the Police Information Access Panel which is made up of a cross section of senior Home office and police leaders who meet to consider each application. Therefore, the MPS is not in a position to comment on whether other agencies should be given permission to enter protective orders on to PNC.” Source location 2021-0263-Response-from-Metropolitan-Police_Published
Open published response
30 Apr 2021 Rohan Dayal Singh · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure to maintain accurate records of clinical observations View source Tolerance of inaccurate and misleading clinical record keeping View source Failure of searches to detect and remove dangerous contraband View source Failure to undertake required intermittent observations View source Failure to complete relevant documentation after rapid tranquillisation View source Failure to monitor patients following rapid tranquillisation View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rohan Dayal Singh · 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
Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.
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 maintain accurate records of clinical observations
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable , staff accepted that they had failed to undertake observations and made false records , further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” Open source report × Source evidence
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 Tolerance of inaccurate and misleading clinical record keeping
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” Open source report × Source evidence
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 searches to detect and remove dangerous contraband
Wider context from the report “1. Rohan Singh died on a mental health ward, following his death he was found to be in possession of number of prohibited items including controlled drugs and a bracelet consisting of a ligature and a blade. Before admission into hospital, Rohan had been subject to a personal search by police officers when the bracelet was seized. During Rohan’s admission his property was subjected to a search and later he himself was searched for contraband, despite these steps he retained dangerous contraband.
” Open source report × Source evidence
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 undertake required intermittent observations
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” Open source report × Source evidence
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 complete relevant documentation after rapid tranquillisation
Wider context from the report “3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation . The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed.
” Open source report × Source evidence
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 monitor patients following rapid tranquillisation
Wider context from the report “3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation. The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed.
” Open source report
26 Feb 2021 Mr Joseph Agnew · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness View source Failure to train officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable” View source Failure of post-incident performance review and organisational learning processes View source Failure to train officers on when to refer an intoxicated person for medical attention View source Lack of a safe referral facility for acutely intoxicated homeless people found on buses View source Failure to train officers to effectively monitor breathing and recognise dangerous breathing patterns View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Joseph Agnew · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Joseph Agnew suffered an out-of-hospital cardiac arrest after being removed from a bus and left in a bus shelter, was later found unresponsive, and died five days after admission with a devastating brain injury. The report raised concerns about police training and assessment of intoxicated people with reduced responsiveness, including recognising snoring and monitoring breathing, post-incident learning, and the lack of a safe referral facility for acutely intoxicated homeless people found on buses.
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 recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness
Wider context from the report “2. For the attention of CoLP, MPS and College of Policing:
No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness , nor how to monitor breathing. My independent expert in A&E gave evidence that snoring indicates partial airway obstruction . He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention . The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing. He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing.
” Open source report × Source evidence
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 officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable”
Wider context from the report “1. For the attention of CoLP and College of Policing:
CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable” . A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention.
” Open source report × Source evidence
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 post-incident performance review and organisational learning processes
Wider context from the report “3. For the attention of the MPS:
Two MPS officers who attended the scene gave evidence that they would do nothing different even in hindsight. No evidence was presented as to the post incident performance reviews and individual learning , and there is uncertainty about the adequacy of the corporate process of learning from incidents . There is a lack of assurance to the public that the risks related to the decisions of these officers or other incidents have been mitigated for the future .
” Open source report × Source evidence
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 officers on when to refer an intoxicated person for medical attention
Wider context from the report “1. For the attention of CoLP and College of Policing:
CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable”. A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention .
” Open source report × Source evidence
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 safe referral facility for acutely intoxicated homeless people found on buses
Wider context from the report “4. For the attention of the Mayor of London:
Evidence was heard that whilst the police can refer chronic rough sleepers to charities, there is no facility to which police can refer acutely intoxicated homeless people found on buses . It was reported that such facilities do exist elsewhere and that they create a place of safe refuge where monitoring can be effectively conducted. The potential of such a facility to save lives is drawn to the attention of the Mayor.
” Open source report × Source evidence
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 officers to effectively monitor breathing and recognise dangerous breathing patterns
Wider context from the report “2. For the attention of CoLP, MPS and College of Policing:
No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness, nor how to monitor breathing . My independent expert in A&E gave evidence that snoring indicates partial airway obstruction. He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention. The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing . He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing .
” Open source report
18 Feb 2021 Mr Kevin Clarke · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 9 Failure to balance detainee and wider risks before restraint decisions View source Inadequate supervision and collective leadership during challenging incidents View source Failure to define and apply criteria for releasing restraints View source Failure to provide effective continuous Safety Officer monitoring of detainee health and safety View source Inadequate health-professional input into police officer training View source Failure of paramedic leadership and risk assessment in detention situations View source Inadequate police training in detainee health and safety monitoring View source Failure of police and paramedics to obtain and exchange clinical advice on conveyance decisions View source Failure to provide adequate briefings for supervisory risk assessment View source See 6 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. 8
Action
Deliver the National ABD 2021 training package and require all officers to complete it.
Stated plannedThe respondent said that this action was planned when they made their response on 22 February 2021. View source
Action
Review restraint-removal policy during medical emergencies and carriage methods for individuals.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 February 2021. View source
Action
Train supervisors to identify themselves, liaise with the Safety Officer and obtain an incident and subject-welfare briefing on arrival.
Stated plannedThe respondent said that this action was planned when they made their response on 22 February 2021. View source
Action
Form a Police Power and Encounters Unit of subject-matter experts to scrutinise use of force and develop organisational learning on officer safety.
Stated plannedThe respondent said that this action was planned when they made their response on 22 February 2021. View source
Action
Expand first-aid casualty monitoring practice and assessment to all scenarios, including responsive-casualty deterioration and abnormal breathing-rate recognition.
Stated completedThe respondent said that this action was complete when they made their response on 22 February 2021. View source
Action
Train officers and staff to balance restraint risks, identify the Safety Officer, and require the Safety Officer to direct health, welfare and safety monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 22 February 2021. View source
Action
Introduce scenario-based officer-safety training with supplementary content on force, restraint, de-escalation, awareness, communication, stress and reflective practice.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 February 2021. View source
Action
Produce and publish an emergency life-support aide-memoir containing relevant vital-sign information for course participants.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 February 2021. View source See 5 more actions
×
AI-generated summary
Mr Kevin Clarke · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Kevin Clarke, a 35-year-old man with complex mental health problems, was found by police in a disturbed state on 9 March 2018, restrained, and later suffered a fatal cardiac arrest in an ambulance. The report identified concerns about inappropriate restraint, inadequate monitoring and dynamic risk assessment, unsuitable conveyance and positioning, insufficient clinical assessment, and weaknesses in training, leadership and supervision by police and ambulance 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 Failure to balance detainee and wider risks before restraint decisions
Wider context from the report “3. The protocols of the MPS require a Safety Officer to monitor the detainee’s health and safety in restraint situations. Evidence heard suggested that this was either not carried out or was ineffective. No officer challenged the decision to cuff the detainee when he started to get up and the Safety Officer at the time agrees he did not consider whether his illness made the decision unreasonable , as laid out in ACPO guidance. An officer agreed that the risks of restraint to the detainee were not balanced against the risks to everyone from not restraining . The Safety Officer at the head changed several times, making any monitoring of trend difficult and for a critical period the most inexperienced officer was the Safety Officer, who was unaware of the benefits of looking at gums or nails. At the time he was escorted, the Safety officer agreed that the face could not be observed as it was hidden by a hood. The risks are further augmented by the MPS submission that it is not always possible to identify a safety officer in all 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 Inadequate supervision and collective leadership during challenging incidents
Wider context from the report “4. There was serious inadequacy of supervision . The initial scene was managed by “collective leadership”, where decision making seemed to emerge without discussion . An experienced serjeant who arrived after the initial restraint, alleged she had conducted a risk assessment, without getting an adequate briefing on the circumstances of his restraint. She was unable in questioning to identify any situation in which restraints should be released due to the length of restraint, unless directed by a paramedic or emerged from mania. She asserted that she knew that whatever her officers had done prior to her arrival, she could trust that they made the right decision.
The steps that have been taken by the MPS and LAS have begun to address the concerns, but do not provide sufficient assurance of mitigation of risks to the lives of future detainees. Whilst policies and corporate commitments have acknowledged the challenges and agreed approaches, the dominance of the primacy of police officer safety in comparison with the attention to detainee health officer training and the weaknesses in leadership and supervision of both police and ambulance service staff in managing challenging incidents continue to create future risks to lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to define and apply criteria for releasing restraints
Wider context from the report “4. There was serious inadequacy of supervision. The initial scene was managed by “collective leadership”, where decision making seemed to emerge without discussion. An experienced serjeant who arrived after the initial restraint, alleged she had conducted a risk assessment, without getting an adequate briefing on the circumstances of his restraint. She was unable in questioning to identify any situation in which restraints should be released due to the length of restraint , unless directed by a paramedic or emerged from mania. She asserted that she knew that whatever her officers had done prior to her arrival, she could trust that they made the right decision .
The steps that have been taken by the MPS and LAS have begun to address the concerns, but do not provide sufficient assurance of mitigation of risks to the lives of future detainees. Whilst policies and corporate commitments have acknowledged the challenges and agreed approaches, the dominance of the primacy of police officer safety in comparison with the attention to detainee health officer training and the weaknesses in leadership and supervision of both police and ambulance service staff in managing challenging incidents continue to create future risks to lives.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective continuous Safety Officer monitoring of detainee health and safety
Wider context from the report “3. The protocols of the MPS require a Safety Officer to monitor the detainee’s health and safety in restraint situations. Evidence heard suggested that this was either not carried out or was ineffective . No officer challenged the decision to cuff the detainee when he started to get up and the Safety Officer at the time agrees he did not consider whether his illness made the decision unreasonable, as laid out in ACPO guidance. An officer agreed that the risks of restraint to the detainee were not balanced against the risks to everyone from not restraining. The Safety Officer at the head changed several times, making any monitoring of trend difficult and for a critical period the most inexperienced officer was the Safety Officer, who was unaware of the benefits of looking at gums or nails . At the time he was escorted, the Safety officer agreed that the face could not be observed as it was hidden by a hood . The risks are further augmented by the MPS submission that it is not always possible to identify a safety officer in all 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 Inadequate health-professional input into police officer training
Wider context from the report “1. Evidence was adduced that the police officer training programmes are run by a specialist in officer safety, the core being Officer Safety Training, and another module being Emergency Life Support (ELS) and a bolt on of ABD Training. The focus of ELS is upon action in the event of a cardiac arrest, so that there is little attention to given to health and safety of the detainee in non-emergency situations and an inadequate input by health professionals . It is illustrated by the officer who said that he had not been taught how to measure vital signs as part of monitoring a detainee. The expert consultant physician who viewed the video of restraint observed a highly abnormal fast breathing rate, but none of the officers had noticed this at the time.
” Open source report × Source evidence
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 paramedic leadership and risk assessment in detention situations
Wider context from the report “2. Despite organization protocols and the MoU there was a conspicuous lack of leadership, risk assessment or challenge on health and safety of the detainee by the paramedic , who appeared to have insufficient seniority or experience to know what to do in a detention situation . Equally there was a lack of expectation or request by police for her input and advice. My expert physician opined that if the detainee was to be moved, he wouldn’t recommend standing him and walking him, which would make things worse. Yet the paramedic recalls no professional dialogue between police and paramedics about the critical conveyance decision, says she left it to them to decide, although preferring a safer method and then later changes her evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate police training in detainee health and safety monitoring
Wider context from the report “1. Evidence was adduced that the police officer training programmes are run by a specialist in officer safety, the core being Officer Safety Training, and another module being Emergency Life Support (ELS) and a bolt on of ABD Training. The focus of ELS is upon action in the event of a cardiac arrest, so that there is little attention to given to health and safety of the detainee in non-emergency situations and an inadequate input by health professionals. It is illustrated by the officer who said that he had not been taught how to measure vital signs as part of monitoring a detainee . The expert consultant physician who viewed the video of restraint observed a highly abnormal fast breathing rate, but none of the officers had noticed this at the time .
” Open source report × Source evidence
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 paramedics to obtain and exchange clinical advice on conveyance decisions
Wider context from the report “2. Despite organization protocols and the MoU there was a conspicuous lack of leadership, risk assessment or challenge on health and safety of the detainee by the paramedic, who appeared to have insufficient seniority or experience to know what to do in a detention situation. Equally there was a lack of expectation or request by police for her input and advice . My expert physician opined that if the detainee was to be moved, he wouldn’t recommend standing him and walking him, which would make things worse. Yet the paramedic recalls no professional dialogue between police and paramedics about the critical conveyance decision , says she left it to them to decide , although preferring a safer method and then later changes her evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate briefings for supervisory risk assessment
Wider context from the report “4. There was serious inadequacy of supervision. The initial scene was managed by “collective leadership”, where decision making seemed to emerge without discussion. An experienced serjeant who arrived after the initial restraint, alleged she had conducted a risk assessment, without getting an adequate briefing on the circumstances of his restraint . She was unable in questioning to identify any situation in which restraints should be released due to the length of restraint, unless directed by a paramedic or emerged from mania. She asserted that she knew that whatever her officers had done prior to her arrival, she could trust that they made the right decision.
The steps that have been taken by the MPS and LAS have begun to address the concerns, but do not provide sufficient assurance of mitigation of risks to the lives of future detainees. Whilst policies and corporate commitments have acknowledged the challenges and agreed approaches, the dominance of the primacy of police officer safety in comparison with the attention to detainee health officer training and the weaknesses in leadership and supervision of both police and ambulance service staff in managing challenging incidents continue to create future risks to lives.
” 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 Deliver the National ABD 2021 training package and require all officers to complete it.
Verbatim wording from the response “The training schedule for April to September 2021 includes a specific lesson on Acute Behavioural Disorder (ABD) as well as a mandate for all officers to complete the National ABD 2021 package created by the MPS, endorsed by IMSAP and published by the College of Policing. The College of Paramedics and Association of Ambulance Chief Executives have been consulted during the creation of this package.” Source location 2021-0046-Response-from-MPS-Redacted
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 restraint-removal policy during medical emergencies and carriage methods for individuals.
Verbatim wording from the response “The MPS is conducting a review of both policy on restraint removal (or otherwise) during a medical emergency as well as carriage methods of individuals. Work has already begun in terms of identification and initial testing of carriage equipment, namely the Megamover® (a compact, portable unit used to transport or transfer patients from areas inaccessible to stretchers). Following a recent event this year in the Thames Valley Police area, as part of their investigation the IOPC are looking into the use of FLACS (Flexible Life and Carry System) used by officers to assist with carrying the detainee. This is under scrutiny with direction being given from the National Police Chiefs Council (NPCC) that its use is suspended pending further investigation.” Source location 2021-0046-Response-from-MPS-Redacted
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 Train supervisors to identify themselves, liaise with the Safety Officer and obtain an incident and subject-welfare briefing on arrival.
Verbatim wording from the response “It is the responsibility of the Safety Officer to look after the health, welfare and safety of the subject prior to the arrival of the supervisor. In the delivery of officer safety training from April to September 2021, supervisors will be informed of the requirement that upon arrival at the scene of an incident, they need to clearly identify themselves, their role and to liaise with the Safety Officer to be briefed on the circumstances of the incident including the welfare of the subject.” Source location 2021-0046-Response-from-MPS-Redacted
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 Form a Police Power and Encounters Unit of subject-matter experts to scrutinise use of force and develop organisational learning on officer safety.
Verbatim wording from the response “In autumn 2021, the MPS Police Power and Encounters Unit (PPEU) will be formed and will see Subject Matter Experts (SMEs) from across business groups come together to holistically deal with issues such as those identified in your report. This new unit will consist of SMEs from the Officer Safety Unit, Specialist Firearms Command, Continuous Policing Improvement Command for Stop and Search and the Directorate of Professional Standards. This team will have the capacity to reactively and proactively engage with supervisors and support them in scrutinising their officers’ use of force.” Source location 2021-0046-Response-from-MPS-Redacted
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 Expand first-aid casualty monitoring practice and assessment to all scenarios, including responsive-casualty deterioration and abnormal breathing-rate recognition.
Verbatim wording from the response “Since the inquest into the death of Mr Clarke, the MPS has made a number of changes to the delivery of first aid training. Although the training has always consisted of monitoring the casualty, including the pulse and breathing rate, the practice of this in the classroom was limited and mainly carried out during the unresponsive breathing casualty scenarios. This training is now included in all scenarios and especially when monitoring responsive casualties in relation to signs of deterioration. The training now includes the ‘goalposts of life’ which state that the breathing rate should be between 10 and 30 breaths per minute and anything outside of this is a medical emergency. During classroom training the monitoring of the casualty is now fully practised and assessed as a learning outcome.” Source location 2021-0046-Response-from-MPS-Redacted
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 Train officers and staff to balance restraint risks, identify the Safety Officer, and require the Safety Officer to direct health, welfare and safety monitoring.
Verbatim wording from the response “MPS officer safety training now contains a reminder to all officers and staff, through classroom training delivery and practical sessions, that all use of force needs to be justified and needs to take into account all factors including the balance of risk of restraint to the subject, officers and the wider public. This training includes an additional requirement for the Safety Officer at the scene to identify themselves using terminology equal to:” Source location 2021-0046-Response-from-MPS-Redacted
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 Introduce scenario-based officer-safety training with supplementary content on force, restraint, de-escalation, awareness, communication, stress and reflective practice.
Verbatim wording from the response “The unit will act as an initial point of contact for all MPS units that want to develop learning around individual incidents or wider trends. It will also be responsible for identifying potential risks and emerging opportunities and issues regarding officer safety; Taser and stop and search across the MPS, nationally and internationally, and proactively and pre-emptively addressing these in the MPS.
Scenario based training is being introduced into officer safety training from April to September 2021 with the intention of incorporating a largely scenario based, uplifted package from October 2021. The training will also include supplementary material to solidify key learning outcomes, including:” Source location 2021-0046-Response-from-MPS-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and publish an emergency life-support aide-memoir containing relevant vital-sign information for course participants.
Verbatim wording from the response “We are currently in the process of producing an aide memoir which provides the relevant vital information. It is anticipated that this will be published in May 2021 and will be available to anyone who undertakes emergency life support training. I have attached a copy of the draft (Appendix A).” Source location 2021-0046-Response-from-MPS-Redacted
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 Once healthcare professionals attend, they take primary care of the casualty and officers follow their instructions regarding medical assistance.
Verbatim wording from the response “Officers and staff are instructed that once a healthcare professional is at the scene of the incident, the healthcare professional takes primary care of the casualty. The officer or member of staff should provide a handover to the healthcare professional using the pneumatic ATMIST (Age, Sex, Name, Time, Mechanism of injury, Injuries or Illness identified, Signs and Symptoms and Treatment given) which provides a framework for the information required by the healthcare professional. Officers and staff are instructed to call an ambulance because the casualty requires medical assistance beyond the first aid the officer or member of staff can provide. They are instructed that the paramedic may ask them to assist them when they arrive, and that they should follow their instructions.” Source location 2021-0046-Response-from-MPS-Redacted
Open published response
27 Nov 2020 Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to pass relevant incident and vulnerability information to ambulance and hospital staff View source Confusion among police officers about how Merlin recording should work in practice View source Failure to request police-control enquiries or searches of police systems View source Failure to create a Merlin record of potential vulnerability and need for assistance View source Failure to learn from incidents and change practice View source See 2 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
Agnès Blandine Marthe MARCHESSOU · 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
Agnès Marchessou had experienced fragile mental health for four or five years before her death. After her arrest on 4 July 2020, she was knocked over by a bus on 8 July and taken to hospital. The principal concerns were that police did not pass key information about the incident and her stated reasons for stepping into the road to ambulance or hospital staff, did not promptly make relevant enquiries or record her potential vulnerability, and showed confusion about the required process.
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 pass relevant incident and vulnerability information to ambulance and hospital staff
Wider context from the report “The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms Marchessou to hospital, nor to any of the doctors or nurses at the hospital.
2. Ms Marchessou told the police officers that she had blacked out and could not remember what had happened, then that she thought she had stepped into the road as the result of a panic attack. She also said that she had stepped in front of the bus because she was upset about being denied contact with her children.
The police officers did not pass on the crucial information that Ms Marchessou said she had stepped in front of the bus because she was upset about being denied contact with her children, either to the emergency ambulance crew or to the treating doctors or nurses.
” Open source report × Source evidence
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 among police officers about how Merlin recording should work in practice
Wider context from the report “6. The police officer giving evidence was aware of the view of the Directorate of Professional Standards (DPS) regarding the failure to create a Merlin, expressed in its report on the police handling of the incident on 8 July, but he seemed very confused about how that should work in practice .
If he is confused, even after police have taken him through the DPS report, then other police officers may also be confused.
” Open source report × Source evidence
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 request police-control enquiries or searches of police systems
Wider context from the report “3. The two police officers waited with Ms Marchessou at the hospital for well over two hours, but did not at any point during that time radio police control to ask for any enquiries or searches of police systems to be made .
Such information could have been potentially extremely helpful to those treating Ms Marchessou.
” Open source report × Source evidence
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 create a Merlin record of potential vulnerability and need for assistance
Wider context from the report “4. When the police officers returned to the police station, they did make a search themselves and discovered that she had been arrested for domestic violence. However, they did not make a Merlin record of her potential vulnerability and need for assistance .
” Open source report × Source evidence
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 learn from incidents and change practice
Wider context from the report “The police officer defended all of his actions robustly. I could not see that he had learnt anything as a result of these events or that anything about his practice would change in the future.
” 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 Improve officers’ sharing of vital incident information with colleagues, ambulance crews and medical staff.
Verbatim wording from the response “Officer 1 interviewed the bus driver at the scene of the collision whilst Officer 2 dealt with Ms Marchessou in the ambulance. This would be normal practice where two parties were involved, with each officer initially dealing with their casualty, witness or other party involved. The senior officer has discussed this incident in detail with Officer 1, providing him with the opportunity to reflect on the decisions he made. It was evident from their discussion that the officer was reflective as he recognised that he would deal with a similar incident differently next time. He would now relay the bus driver’s account to his colleague who was dealing with Ms Marchessou at the scene and subsequently provide this information to the medical staff at the scene and at the hospital.” Source location 2020-0255-Letter-from-Metropolitan-Police-Redacted.pdf
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 Merlin Toolkit advising officers when to complete reports and requiring Vulnerability Assessment Framework-based risk assessment.
Verbatim wording from the response “The MPS will shortly be introducing a Merlin Toolkit, which will provide advice and guidance on the circumstances in which reports should be completed. This also references the Vulnerability Assessment Framework (VAF) which should be used as the basis for assessment for all officers. This assessment is based on appearance, behaviour, communication/capacity of the victim and whether the victim is in danger and the environment/circumstances they are in. The MPS considers that this action will support officers in making appropriate decisions in respect of completing Merlin Reports for vulnerable people.” Source location 2020-0255-Letter-from-Metropolitan-Police-Redacted.pdf
Open published response
12 Nov 2020 Chelsie Violet Greatorex · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Delays in contacting complainants seeking support View source Inadequate support for complainants seeking assistance View source Failure to conduct child sexual assault investigations through a specialist officer or team View source Delays in investigation and progression of sexual assault cases View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Chelsie Violet Greatorex · 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
Chelsie Violet Greatorex took an overdose of prescribed medication on 10 March 2020 and died later that day despite emergency treatment. The report describes concerns about her anxiety as a complainant in a sexual assault case, delays in the investigation, the lack of specialist handling despite her being a child when the alleged assault occurred, and limited support after she contacted 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 Delays in contacting complainants seeking support
Wider context from the report “d. When Ms Greatorex sought support from the MPS, no contact was made for four days , even then, the extent of the support was an email with the contact details of a borough psychological support service.
” Open source report × Source evidence
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 support for complainants seeking assistance
Wider context from the report “d. When Ms Greatorex sought support from the MPS, no contact was made for four days, even then, the extent of the support was an email with the contact details of a borough psychological support service .
” Open source report × Source evidence
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 child sexual assault investigations through a specialist officer or team
Wider context from the report “b. Despite the fact that Ms Greatorex was a child when the events of the allegation took place, the investigation was not conducted by a specialist officer or 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 Delays in investigation and progression of sexual assault cases
Wider context from the report “c. Delays in the investigation were identified ,
• despite naming the suspect and their place of study, no interview took place for over 3 months .
• a decision to prosecute was not arrived at until late December 2020 .
• A court hearing was not listed until January 2020 .
” 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 Trial and roll out the THRIVE+ vulnerability assessment framework for assessing and reviewing victim and witness risk.
Verbatim wording from the response “In order to provide additional support for victims and/or witnesses throughout the entire investigative process, the MPS has introduced a THRIVE+ vulnerability assessment which is currently being trialled and is anticipated to be rolled out across the MPS in April 2021. It is a set of principles and a framework to assess the type of policing response or investigation required for a particular set of circumstances. THRIVE covers: Threat – Harm – Risk – Investigation – Vulnerability – Engagement + Prevention/Intervention. The framework is a tool which aligns to and enhances the National Decision Model and includes the assessment and ongoing review of risk during investigations. It also provides a common language around risk to improve information sharing and decision-making.” Source location 2021-0018-Response-from-MPS-Redaction
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 the vulnerability tool into monthly Offender Management Meetings to identify and prioritise vulnerable-victim cases requiring management intervention.
Verbatim wording from the response “The observations about the length of the investigation and failure of management systems to adequately prioritise Ms Greatorex’s case are being addressed with the introduction of a new product, the vulnerability tool, which has been developed for Basic Command Units’ monthly Offender Management Meetings which prioritise outstanding named suspect cases when the victim has been identified as being the subject of some form of vulnerability. This allows for management intervention and looks across all offence types to identify cases where progress should be prioritised for the benefit of victims where an element of vulnerability has been identified.” Source location 2021-0018-Response-from-MPS-Redaction
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 North East Basic Command Unit Response Support Team as a training and investigative advice resource for response officers.
Verbatim wording from the response “The MPS recognises that as the investigation was not considered complex, it should have been completed in a quicker timeframe. The MPS have therefore made improvements in the supervision and team structures of response teams to support less experienced officers with their investigations. A Response Support Team was set up on North East Basic Command Unit on 23rd September 2020 and blends together resources from Emergency Response Policing Teams, Local Resolution Teams, Criminal Investigation Departments and probationary officers and their mentors. The Response Support Team functions as a training unit and allows for a steady improvement of officers investigative skills and point of contact for advice.” Source location 2021-0018-Response-from-MPS-Redaction
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 There was little indication that the complainant was very low or required support beyond what would normally be considered for a complainant facing trial.
Verbatim wording from the response “The DPS SIU Investigation Report details a number of occasions when Ms Greatorex reached out to the investigating officer about feeling anxious and low. They appear to have formed a trusting relationship and when Ms Greatorex appeared to become particularly low, the investigating officer offered Ms Greatorex advice and a referral to a support agency. However, Ms Greatorex reassured the investigating officer that she was fine. On the day Ms Greatorex was informed of the date of the trial, there was little to suggest to the officer that she was feeling very low or in need of any further support other than that would be normally considered during a difficult time for any complainant in a case such as this.” Source location 2021-0018-Response-from-MPS-Redaction
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 timeliness of the prosecution decision and court listing lay with the Crown Prosecution Service and Her Majesty’s Courts Service.
Verbatim wording from the response “The timeliness from when the decision to prosecute and the court hearing lies with the CPS and Her Majesty’s Courts Service (HMCS). The suspect for this allegation was interviewed on 5th November 2019 leading to a submission of the evidential file to the Crown Prosecution Service (CPS) on 26th November 2019. The investigating officer made further contact with the CPS on 18th December 2019 regarding the decision on a charging authority and seeking to expedite the case. The CPS authority was granted on 27th December 2019. The suspect was served charges on 2nd January 2020 with a first court appearance provided for the end of the month.” Source location 2021-0018-Response-from-MPS-Redaction
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 allegation was considered non-complex, so specialist investigation was not required and responsibility appropriately remained with a Response Team officer.
Verbatim wording from the response “The allegation Ms Greatorex made was considered at the outset by specialist officers and it was decided that due to the non-complex nature of the investigation, it would remain with a Response Team officer to investigate. The MPS General Investigation Policy states that “Where there is a requirement for ownership of crime investigations by the initial investigating officer, there may be occasions where the characteristics of specific investigations identify themselves as serious and/or complex. It is important that this is identified as soon as possible so that the most appropriate investigating unit is assigned to that investigation dependent on the seriousness and/or complexity. If serious and/or complex characteristics are present, then CID should be approached to take on that investigation”.” Source location 2021-0018-Response-from-MPS-Redaction
Open published response
12 Nov 2020 Imane Bouasbia · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to communicate expressed suicidal intent in the handover View source Failure to complete a self-harm or suicide risk assessment View source Failure to provide an adequately expedited and direct response to suicidal thoughts communicated by text View source
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. 4
Action
Trial the THRIVE+ vulnerability assessment framework to assess and document vulnerability, including suicidal thoughts, and support ongoing risk review and information sharing.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 December 2020. View source
Action
Introduce a mandatory enhanced SOIT risk assessment covering suicide, cultural complexities and honour-based violence, with police-indices review, CRIS recording and supervisor escalation.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2020. View source
Action
Require SOIT and investigating officers to notify supervisors of concerning victim contact, agree and document a response, and make immediate telephone contact.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2020. View source
Action
Publish an Operational Notice requiring staff to review police indices before victim contact, communicate identified vulnerabilities, and record them on the CRIS report.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2020. View source See 1 more action
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AI-generated summary
Imane Bouasbia · 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
Imane Bouasbia was sexually assaulted on 1 January 2020 and subsequently expressed suicidal thoughts to police. On 3 January 2020, she stepped in front of a moving Central Line tube train at Newbury Park Station and was killed instantly. The principal concerns were failures to communicate her suicidal thoughts, complete a self-harm or suicide risk assessment, and respond adequately to her text message indicating suicidal thoughts.
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 communicate expressed suicidal intent in the handover
Wider context from the report “a. The failure of Officer 1 to effectively communicate to Officer 2 either verbally or in the CRIS handover, that Ms Bouasbia had expressed the view that she wished to end her own life following the attack she sustained on 1st Jan 2020.
” Open source report × Source evidence
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 complete a self-harm or suicide risk assessment
Wider context from the report “b. The failure of Officer 2 to complete a risk assessment of Ms Bouasbia regarding thoughts of self-harm or suicide .
” Open source report × Source evidence
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 an adequately expedited and direct response to suicidal thoughts communicated by text
Wider context from the report “c. The police reaction to Ms Bouasbia’s text message at of 3rd January 2020 indicating suicidal thoughts was limited to a non-expedited instruction on a CAD action . The only response to Ms Bouasbia was a further text message rather than a telephone call .
” 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 Trial the THRIVE+ vulnerability assessment framework to assess and document vulnerability, including suicidal thoughts, and support ongoing risk review and information sharing.
Verbatim wording from the response “The MPS has introduced a THRIVE+ vulnerability assessment, which is currently being trialled and is anticipated to be rolled out across the organisation in April 2021. It is a set of principles and a framework to assess the type of policing response or investigation required for a particular set of circumstances. THRIVE covers: Threat – Harm – Risk – Investigation – Vulnerability – Engagement + Prevention/Intervention. The framework is a tool that aligns to, and enhances, the National Decision Model and includes the assessment and ongoing review of risk during investigations. It also provides a common language around risk to improve information sharing and decision-making.” Source location 2020-0234-Response-from-MPS-Redacted.pdf
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 Introduce a mandatory enhanced SOIT risk assessment covering suicide, cultural complexities and honour-based violence, with police-indices review, CRIS recording and supervisor escalation.
Verbatim wording from the response “The MPS has introduced a newly enhanced SOIT risk assessment that specifically covers suicide, cultural complexities and concerns around honour-based violence. It also mandates that the SOIT officer review all police indices including the CAD. The new risk assessment is mandatory for all SOIT officers to complete before speaking to a complainant and must be recorded on the CRIS report and brought to the attention of a supervisor if there is anything of concern.” Source location 2020-0234-Response-from-MPS-Redacted.pdf
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 Require SOIT and investigating officers to notify supervisors of concerning victim contact, agree and document a response, and make immediate telephone contact.
Verbatim wording from the response “Upon reflection, the SOIT officer accepts that she should have contacted Ms Bouasbia by telephone to speak directly with her. On 21st December 2020, the MPS addressed this by e-mailing all SOIT officers and Public Protection Department managers with the instruction that SOIT and investigating officers must inform a supervising officer if they receive any contact from a victim that causes them concern. A course of action must be agreed and documented on the CRIS report or CAD message and immediate contact made with the victim by telephone. In addition, SOIT officers must ensure their work mobile telephone recorded answer message provides alternative contact numbers should the SOIT officer be off duty or uncontactable and the caller needs reassurance.” Source location 2020-0234-Response-from-MPS-Redacted.pdf
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 an Operational Notice requiring staff to review police indices before victim contact, communicate identified vulnerabilities, and record them on the CRIS report.
Verbatim wording from the response “To immediately address the lessons learned prior to the full introduction of THRIVE+, on 18th December 2020 an Operational Notice was published on the MPS internal website informing all staff, including SOIT officers, that they must review all police indices, including the CAD, prior to contact with the victim. Any identified vulnerabilities must be communicated to the investigating officer or their supervisor and noted on the CRIS report. This will also be addressed in future Continuous Professional Development days for all officers, commencing in February 2021 for SOIT officers.” Source location 2020-0234-Response-from-MPS-Redacted.pdf
Open published response
10 Feb 2020 Ms Kerry Aldridge · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Referral to Crisis Resolution and Home Treatment Teams depending on officers' recognition of urgency View source Insufficient mental health training for Sexual Offences Investigation Trained officers View source Lack of established links between police Safeguarding teams and NHS mental health teams 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
Ms Kerry Aldridge · 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
Ms Kerry Aldridge was a student police officer who died by suicide after jumping into the path of a train at Sydenham Railway Station on 6 April 2019. The report raised concerns about the lack of established links between police Safeguarding Teams and NHS mental health teams, and about the need for further mental health training and access to non-urgent advice for officers.
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 Referral to Crisis Resolution and Home Treatment Teams depending on officers' recognition of urgency
Wider context from the report “During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health. ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support.
It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent , which may be a difficult judgment for officers, without professional mental health advice .
” Open source report × Source evidence
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 mental health training for Sexual Offences Investigation Trained officers
Wider context from the report “During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health . ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support.
It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent, which may be a difficult judgment for officers, without professional mental health advice.
” Open source report × Source evidence
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 established links between police Safeguarding teams and NHS mental health teams
Wider context from the report “During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health. ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support.
It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent, which may be a difficult judgment for officers, without professional mental health advice.
” Open source report
29 Jan 2020 Thiago Araujo · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Lack of support or education for families and carers managing emotionally unstable personality disorder View source Failure to make arrangements to address risks when closing crisis team referrals View source Lack of a process for families to escalate concerns to prevent delivery of hazardous packages View source Failure to inform families about the facility for reopening crisis team support View source Delays of 14 days in securing mental health act assessments View source Failure to act on an inpatient admission plan following identification of acute suicide risk View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thiago Araujo · 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
Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.
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 support or education for families and carers managing emotionally unstable personality disorder
Wider context from the report “3. Family and carers of patients diagnosed with emotionally unstable personality disorder do not receive support or education upon management of this diagnosis from Camden and Islington NHS Trust, unless the patient has been received for treatment by the personality disorder service .
” Open source report × Source evidence
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 arrangements to address risks when closing crisis team referrals
Wider context from the report “1. On 24 January 2020 Mr Araujo had discharged himself from psychiatric inpatient care he was to be supervised by the Camden and Islington NHS trust crisis team. Mr Araujo failed to engage with the crisis team and following a meeting on 30 January 2020 the crisis team closed Mr Araujo’s referral . In the course of this closure no arrangements were made to address the risks presented by Mr Araujo .
” Open source report × Source evidence
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 process for families to escalate concerns to prevent delivery of hazardous packages
Wider context from the report “6. In the days leading to Mr Araujo’s death his family became aware that he had made an online purchase of ████████ which was to be delivered to his father’s home address. Despite raising these issues with Camden and Islington NHS trust, the Metropolitan police and employees of the post office there appeared to be no process available to the family to escalate their concerns to prevent delivery of this package .
” Open source report × Source evidence
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 families about the facility for reopening crisis team support
Wider context from the report “2. Following Mr Araujo’s death it has become clear that the closure of his case by the crisis team was not permanent, and had Mr Araujo or his family approached the crisis team to reopen his case, steps could have been taken to reinstate crisis team support . Mr Araujo’s family were unaware of this facility .
” Open source report × Source evidence
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 of 14 days in securing mental health act assessments
Wider context from the report “5. In evidence the community recovery team indicated that a factor in their inaction was the knowledge that arranging a section 135 mental health act 1983 warrant assessment would take two weeks . Such an assessment requires actions by an approved mental health practitioner from the local authority, two section 12 mental health act approved doctors, the assistance of the Metropolitan police and the local magistrates court to secure a warrant. A delay of 14 days in securing a mental health act assessment is in my opinion unacceptable .
” Open source report × Source evidence
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 act on an inpatient admission plan following identification of acute suicide risk
Wider context from the report “4. By 4 February 2020 the Camden and Islington community recovery team identified an acute risk of suicide in Mr Araujo, faced with his non-compliance with community treatment they considered an admission into inpatient care . No actions were taken to affect this plan .
” 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 policies and procedures guiding police preparation and planning of section 135 Mental Health Act warrants.
Verbatim wording from the response “The current MPS policies and procedures governing the framework, operational and tactical guidance for Police Officers and Staff, were updated in May 2020. The guidance specifically assists Basic Command Unit Operations’ Room Staff involved in the preparation and planning of warrants under section 135(1) and 135(2) of the Mental Health Act with responding to AMHP requests.” Source location 2021-0132-Response-from-Metropolitan-Police-Redacted.pdf
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 police lacked lawful powers to intercept the package because communications interception powers did not cover these circumstances.
Verbatim wording from the response “The interception of communications (including postal services) is governed, in general terms, by the Investigatory Powers Act 2016, supported by the Codes of Practice associated with this.” Source location 2021-0132-Response-from-Metropolitan-Police-Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local Authorities are responsible for arranging Mental Health Act assessments and ensuring sufficient Approved Mental Health Professionals are available.
Verbatim wording from the response “The Mental Health Act 1983 (Codes of Practice), stipulate that responsibilities for arranging Mental Health Act Assessments lie with Local Authorities, who must ensure there are sufficient Approved Mental Health Professionals (AMHP) available to carry out their roles under the Act. This includes assessing patients to decide whether an application for detention should be made.” Source location 2021-0132-Response-from-Metropolitan-Police-Redacted.pdf
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 relevant Mental Health Trust must explain delays in securing Mental Health Act warrants because the warrant application process is not conducted by police.
Verbatim wording from the response “Any delay in securing a Mental Health Act warrant and subsequent assessment would be for the relevant Mental Health Trust to respond to in detail, as the warrant application process is not conducted by the MPS. However, I believe it would assist HM Coroner, by explaining the processes in place for securing police assistance in such matters.” Source location 2021-0132-Response-from-Metropolitan-Police-Redacted.pdf
Open published response
20 Nov 2019 Nimo Younis · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 8 Lack of a practical ward plan for taking escalation action with available resources View source Lack of clarity between the MPS and trusts about required information and ensuing police action View source Lack of ward staff understanding of actions required to prompt police progression View source Lack of ward staff understanding of key information required by the MPS View source Failure to promptly and fully utilise patients’ friends in missing-person searches View source Lack of ward staff understanding of MPS actions in response to absent-without-leave reports View source Failure to account for different organisational definitions of the same terms View source Failure to provide MPS decision makers with all information held by the MPS View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Nimo Younis · 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
Nimo Younis was detained in a psychiatric intensive care unit and was granted unescorted leave on 24 January 2019, but did not return. She was found at a friend's home the following day after hanging herself. The concerns included shortcomings in communication and understanding between ward staff and the police, the escalation and handling of the missing-person enquiry, the information provided to police decision-makers, and the use of the patient's friends in searching for her.
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 a practical ward plan for taking escalation action with available resources
Wider context from the report “3. C&I ward staff did not have a practical plan as to how to take that action with the resources at their disposal .
” Open source report × Source evidence
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 clarity between the MPS and trusts about required information and ensuing police action
Wider context from the report “7. Whether or not there is agreement between the MPS and any trust about who should be doing what, there must be a clarity about what information the MPS needs in order to make the best decisions and what action the MPS will then take .
” Open source report × Source evidence
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 staff understanding of actions required to prompt police progression
Wider context from the report “2. C&I ward staff did not have a proper understanding of what action the MPS required others to take in order to prompt the police to progress the matter further .
” Open source report × Source evidence
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 staff understanding of key information required by the MPS
Wider context from the report “4. C&I ward staff did not have a proper understanding of what key information they needed to provide the MPS in order to trigger a police missing person enquiry, or to escalate an existing enquiry.
” Open source report × Source evidence
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 promptly and fully utilise patients’ friends in missing-person searches
Wider context from the report “5. C&I ward staff did not promptly or fully utilise the significant potential of their patient’s friends , who were ultimately the route by which Nimo Younis was found, and who would certainly have acted sooner if they had appreciated the lack of action being taken - whatever the reason for that lack of action.
” Open source report × Source evidence
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 staff understanding of MPS actions in response to absent-without-leave reports
Wider context from the report “1. C&I ward staff did not have a proper understanding of what action the MPS would take in what circumstances , following the report of a patient absent without leave.
” Open source report × Source evidence
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 account for different organisational definitions of the same terms
Wider context from the report “This needs to include a recognition that different organisations may have different definitions of the same terms .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MPS decision makers with all information held by the MPS
Wider context from the report “6. The MPS decision makers, particularly the night time duty inspector, did not have all the information that the MPS held when they were making decisions . Evidence was given that this was a resourcing issue on that particular night and of course it is difficult to legislate for that, but creative thinking may be utilised to address such an issue.
” Open source report
1 Nov 2019 Xavier Thomas and 10 others · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 7 Counter-terrorism investigation concerns View source Emergency response concerns for terrorist attacks View source Concerns about rental vehicles used in terrorist attacks View source Communications concerns View source Protective security concerns View source Concerns about locating casualties View source Medical equipment and training concerns 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. 15
Action
Train intelligence-assessment staff under the National Standards of Intelligence Management, including trace checks and intelligence development.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2019. View source
Action
Review legal provisions that may impose protective-security duties and provide resulting useful guidance to counter-terrorism security advisers where available.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2019. View source
Action
Continue expanding protective-security advice, training products and access channels for audiences ranging from the public to large corporations.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2019. View source
Action
Disseminate updates and advice on hostile-vehicle mitigation, national barrier assets and other evolving protective-security capabilities to relevant policing and security networks.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2019. View source
Action
Implement revised intelligence-handling processes, including national database recording, direct routing and escalation of intelligence matched to counter-terrorism investigations.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2019. View source
Action
Conduct a trial of the London Emergency Services Contact Centre by deploying fire and ambulance representatives to the Specialist Operations Room, testing working practices and running a seven-day live trial.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2019. View source
Action
Upgrade hotline technology with automated answering and messaging facilities and add supervisory checks to intelligence handling.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2019. View source
Action
Implement revised marauding-terrorist-attack operating procedures and Operation Plato guidance emphasizing flexible zone management and deployment of non-specialist responders.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2019. View source
Action
Continue joint training and exercising with emergency-service partners on flexible marauding-terrorist-attack response, including hot and warm zone operations.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2019. View source
Action
Review the crowded-places policy, delivery model and prioritisation process to introduce greater flexibility and ensure sites remain appropriately identified for protective-security advice.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2019. View source
Action
Continue reviewing marauding-terrorist-attack procedures and preparedness using learning from major incidents and exercises.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2019. View source
Action
Provide mandatory emergency lifesaving, firearms first-aid and continuation training, including advanced medical skills and realistic exercises for armed officers.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2019. View source
Action
Conduct national assurance visits to verify that revised marauding-terrorist-attack procedures and Operation Plato guidance are embedded in local policies and practices.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2019. View source
Action
Provide accredited counter-terrorism security adviser training, mentoring and continuing professional development covering available protective-security mitigations.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2019. View source
Action
Equip armed response vehicles with first-aid kits matched to officer training and roll out access to tourniquets and haemostatic wound-packing products.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2019. View source See 12 more actions
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AI-generated summary
Xavier Thomas and 10 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 3 June 2017, three attackers carried out vehicle and knife attacks at London Bridge and Borough Market, killing eight victims: Xavier Thomas, Christine Archibald, Sara Zelenak, James McMullan, Sébastien Bélanger, Alexandre Pigeard, Kirsty Boden and Ignacio Echeverría Miralles de Imperial. The report identifies substantive concerns relating to protective security, counter-terrorism investigations, emergency response, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
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 Counter-terrorism investigation concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations , emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” Open source report × Source evidence
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 Emergency response concerns for terrorist attacks
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks , communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” Open source report × Source evidence
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 Concerns about rental vehicles used in terrorist attacks
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks .
” Open source report × Source evidence
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 Communications concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications , locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” Open source report × Source evidence
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 Protective security concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security , counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” Open source report × Source evidence
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 Concerns about locating casualties
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties , medical equipment and training, and rental vehicles used in terrorist attacks.
” Open source report × Source evidence
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 Medical equipment and training concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training , and rental vehicles used in terrorist attacks.
” 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 Train intelligence-assessment staff under the National Standards of Intelligence Management, including trace checks and intelligence development.
Verbatim wording from the response “32. All staff working in intelligence assessment have completed NSIM assessor training which provides guidance on trace checks and development of intelligence. If for whatever reason (such as a missing “selector”) analysed intelligence is not matched with a subject in a CT investigation then sophisticated systems are in place for the matter to be escalated. Due to sensitivities involved in relation to this form of intelligence handling, it would be inappropriate to include further details within this document.” Source location 2019-0332-Response-by-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 Review legal provisions that may impose protective-security duties and provide resulting useful guidance to counter-terrorism security advisers where available.
Verbatim wording from the response “20. As outlined in MC3, there is an absence of specific protective security legislation. There is also an absence of case law or guidance in this area. Consequently, provision of clear, definitive guidance for the CTSA network is challenging. Ultimately we can provide as much CT advice as we want but absent a clear legal duty, implementation of that advice is optional. NaCTSO is currently reviewing the various legal provisions which might impose a duty in the public and private sector, but we can only provide (further) advice to the CTSA network internally. Providing legal advice directly to public authorities or others would fall outside the scope of our role.” Source location 2019-0332-Response-by-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 expanding protective-security advice, training products and access channels for audiences ranging from the public to large corporations.
Verbatim wording from the response “14. To address this challenge NaCTSO is seeking to expand both the advice and training we provide and how that advice is delivered. Since 2017 NaCTSO has worked hard to expand the range of products available and sought to adapt these to multiple audiences. The strategic approach is to reach as many people as possible with protective security advice. As outlined above, this ranges from CT awareness suitable for all members of the public, to detailed bespoke security advice appropriate for large corporations with professional security expertise. We will continue to grow and develop the advice and accessibility of these measures.” Source location 2019-0332-Response-by-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 Disseminate updates and advice on hostile-vehicle mitigation, national barrier assets and other evolving protective-security capabilities to relevant policing and security networks.
Verbatim wording from the response “25. Hostile Vehicle Mitigation (HVM) and the National Barrier Asset (NBA) represent an evolving capability that is managed centrally within NaCTSO by the National Vehicle Threat Mitigation Unit (NVTMU). All CTSAs and officers working in CT policing are briefed on HVM and NBA capability. As set out above this is covered by inputs at the CTSA annual training event and as part of the formal CTSA training.” Source location 2019-0332-Response-by-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 revised intelligence-handling processes, including national database recording, direct routing and escalation of intelligence matched to counter-terrorism investigations.
Verbatim wording from the response “A learning point in relation to the call handling was identified by Lord Anderson and this has been implemented. Intelligence handling systems have been reviewed, and new processes are in place to ensure intelligence is recorded and disseminated appropriately. ATH technology has been upgraded including an automated answering system and messaging facility. SO15 has placed an extra level of supervision into the process of intelligence handling from the hotline which will ensure that in the event that a human and supervisory error occurs again this will be picked up by the extra supervisory check and the intelligence will then be passed on to the appropriate team” Source location 2019-0332-Response-by-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 Conduct a trial of the London Emergency Services Contact Centre by deploying fire and ambulance representatives to the Specialist Operations Room, testing working practices and running a seven-day live trial.
Verbatim wording from the response “60. Despite the above the MPS continues to seriously consider these matters to see whether there might be opportunity to improve communication between the emergency services. Work is underway to trial a “London Emergency Services Contact Centre”. This will involve representatives from the LFB and LAS being deployed within the Specialist Operations Room. A table top exercise will be conducted with real CADs to finalise working practices followed by a real life 7 day trial early in 2020.” Source location 2019-0332-Response-by-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 Upgrade hotline technology with automated answering and messaging facilities and add supervisory checks to intelligence handling.
Verbatim wording from the response “A learning point in relation to the call handling was identified by Lord Anderson and this has been implemented. Intelligence handling systems have been reviewed, and new processes are in place to ensure intelligence is recorded and disseminated appropriately. ATH technology has been upgraded including an automated answering system and messaging facility. SO15 has placed an extra level of supervision into the process of intelligence handling from the hotline which will ensure that in the event that a human and supervisory error occurs again this will be picked up by the extra supervisory check and the intelligence will then be passed on to the appropriate team” Source location 2019-0332-Response-by-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 revised marauding-terrorist-attack operating procedures and Operation Plato guidance emphasizing flexible zone management and deployment of non-specialist responders.
Verbatim wording from the response “33. As recognised within MC13, changes were made to the MTA Joint Operating Procedures (JOPs) following the 2017 attacks. The changes reflected the broader range of attack methodology experienced and the applicability of the guidance to a wider range of circumstances than the previous Marauding Terrorist Firearms Attack (MTFA) guidance, which it replaced.” Source location 2019-0332-Response-by-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 joint training and exercising with emergency-service partners on flexible marauding-terrorist-attack response, including hot and warm zone operations.
Verbatim wording from the response “38. There has been, and continues to be, a significant amount of training and exercising conducted across the country on the response to a MTA. Individual police forces are regularly conducting joint MTA training and exercising with their local emergency service partners. CTPHQ agrees that it is important to ensure that this continues and regularly reminds forces of the importance of this. The matters the Chief Coroner raises at MC13 are reflected in this work.” Source location 2019-0332-Response-by-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 Review the crowded-places policy, delivery model and prioritisation process to introduce greater flexibility and ensure sites remain appropriately identified for protective-security advice.
Verbatim wording from the response “13. Any system of prioritisation will require an assessment criteria which will result in risk based inclusion and exclusion. NaCTSO accepts that flexibility in this approach is very important and as such has been working closely with the government to review the crowded places policy and delivery model.” Source location 2019-0332-Response-by-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 marauding-terrorist-attack procedures and preparedness using learning from major incidents and exercises.
Verbatim wording from the response “37. The MTA JOPs and Operation Plato guidance are regularly reviewed, drawing on learning from major incidents and exercises. This is an ongoing process. The current edition of the MTA JOPs is the fifth edition to be produced, reflecting a continuous process of reviewing procedures and preparedness. We are satisfied that there is no learning from the 2017 attacks which requires further changes to the current edition of the MTA JOPs and Operation Plato guidance.” Source location 2019-0332-Response-by-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 Provide mandatory emergency lifesaving, firearms first-aid and continuation training, including advanced medical skills and realistic exercises for armed officers.
Verbatim wording from the response “43. In the MPS all officers up to the rank of Chief Inspector have to complete standard emergency lifesaving training once a year. The training includes (but is not limited to) inputs on the use of tourniquets, defibrillators, compression bandages, dealing with cuts and lacerations, knife wounds and other penetrating trauma.” Source location 2019-0332-Response-by-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 Conduct national assurance visits to verify that revised marauding-terrorist-attack procedures and Operation Plato guidance are embedded in local policies and practices.
Verbatim wording from the response “36. CTPHQ staff have undertaken a national programme of assurance visits to all police forces (including the MPS and CoLP) to ensure that the new MTA JOPs and Operation Plato guidance have been fully embedded within local policies, procedures and practices.” Source location 2019-0332-Response-by-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 Provide accredited counter-terrorism security adviser training, mentoring and continuing professional development covering available protective-security mitigations.
Verbatim wording from the response “23. The CTSA network undertakes a comprehensive training programme which takes a minimum of two years to complete. This course is accredited to City and Guilds level and courses are delivered by both NaCTSO and CPNI trainers. All CTSAs must attain this standard and are supported and mentored until this is achieved. Some CTSAs also opt to continue to a further graduate level qualification. Both courses cover the security mitigations that are available in protective security. The course content is regularly updated and those undertaking that task will be fully briefed on all relevant matters including the Chief Coroner’s report.” Source location 2019-0332-Response-by-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 Equip armed response vehicles with first-aid kits matched to officer training and roll out access to tourniquets and haemostatic wound-packing products.
Verbatim wording from the response “50. It is a nationally mandated requirement that all ARVs carry a suitably equipped first aid kit commensurate with the level of training of the officers crewing the vehicle. In August 2018 advice was provided to forces that consideration should be given to ensuring that all ARV officers have immediate access to tourniquets and haemostatic wound packing products. The Chief Coroner will recall the evidence from Dr Wrigley that tourniquets are being “rolled out” for use by police officers across London.” Source location 2019-0332-Response-by-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 Security-board adoption is not led by the protective-security unit and is better addressed by government.
Verbatim wording from the response “22. MC5 poses two recommendations. The majority of the first section sits with NaCTSO. With regards to the second section and the adoption of security boards, NaCTSO is likely to have a role but would not be the lead agency responsible. As such this sits outside the scope of this response and is better addressed by the government.” Source location 2019-0332-Response-by-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 proposed control-room communications technology issue should be considered by the NPCC operational communications portfolio through the Emergency Services Network Programme.
Verbatim wording from the response “53. This is a technical issue and one that should be considered by the NPCC Operational Communications in Policing (OCiP) portfolio as part of the Emergency Services Network Programme (ESNP).” Source location 2019-0332-Response-by-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 further changes to the current marauding-terrorist-attack procedures or national guidance are required based on learning from the 2017 attacks.
Verbatim wording from the response “37. The MTA JOPs and Operation Plato guidance are regularly reviewed, drawing on learning from major incidents and exercises. This is an ongoing process. The current edition of the MTA JOPs is the fifth edition to be produced, reflecting a continuous process of reviewing procedures and preparedness. We are satisfied that there is no learning from the 2017 attacks which requires further changes to the current edition of the MTA JOPs and Operation Plato guidance.” Source location 2019-0332-Response-by-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 Permanent embedding of ambulance and fire representatives in police control rooms is not considered sufficiently beneficial; existing coordinated communication arrangements are relied upon instead.
Verbatim wording from the response “57. The ‘core’ Joint Emergency Services Interoperability Principles (JESIP), the MTA JOPs and the Operation Plato national guidance all stress the importance of effective communication, sharing of information and joint working between the three emergency services. These documents identify the critical importance of establishing an initial ‘tri-service’ communication link between the control rooms, subsequent co-location of on-scene commanders and the establishment of combined tactical and strategic coordinating groups as soon as practicable during a MTA. This was the case during the London Bridge attacks.” Source location 2019-0332-Response-by-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 Definitive guidance for counter-terrorism security advisers is currently limited by the absence of clear legislation, case law and guidance.
Verbatim wording from the response “20. As outlined in MC3, there is an absence of specific protective security legislation. There is also an absence of case law or guidance in this area. Consequently, provision of clear, definitive guidance for the CTSA network is challenging. Ultimately we can provide as much CT advice as we want but absent a clear legal duty, implementation of that advice is optional. NaCTSO is currently reviewing the various legal provisions which might impose a duty in the public and private sector, but we can only provide (further) advice to the CTSA network internally. Providing legal advice directly to public authorities or others would fall outside the scope of our role.” Source location 2019-0332-Response-by-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 Existing training, briefings and centrally managed capability updates already address awareness of protective-security equipment and infrastructure.
Verbatim wording from the response “23. The CTSA network undertakes a comprehensive training programme which takes a minimum of two years to complete. This course is accredited to City and Guilds level and courses are delivered by both NaCTSO and CPNI trainers. All CTSAs must attain this standard and are supported and mentored until this is achieved. Some CTSAs also opt to continue to a further graduate level qualification. Both courses cover the security mitigations that are available in protective security. The course content is regularly updated and those undertaking that task will be fully briefed on all relevant matters including the Chief Coroner’s report.” Source location 2019-0332-Response-by-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 Providing legal advice directly to public authorities or others falls outside the protective-security unit’s role.
Verbatim wording from the response “20. As outlined in MC3, there is an absence of specific protective security legislation. There is also an absence of case law or guidance in this area. Consequently, provision of clear, definitive guidance for the CTSA network is challenging. Ultimately we can provide as much CT advice as we want but absent a clear legal duty, implementation of that advice is optional. NaCTSO is currently reviewing the various legal provisions which might impose a duty in the public and private sector, but we can only provide (further) advice to the CTSA network internally. Providing legal advice directly to public authorities or others would fall outside the scope of our role.” Source location 2019-0332-Response-by-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 It is not possible to provide bespoke protective-security advice to every crowded place, so advice must remain prioritised and proportionate.
Verbatim wording from the response “6. As it is not possible to deliver bespoke advice to every crowded place, access to guidance works on a process of scaled options and differing delivery mechanisms. It is important to note that CT security measures for crowded places do not only begin when a site is identified as a “priority site”. A huge amount of work has been and is being done across the sector. Free security advice is available to everyone as envisaged by the Lord West report. This is delivered in particular by NaCTSO and the Centre for the Protection of National Infrastructure (CPNI).” Source location 2019-0332-Response-by-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 ambulance service retains lead responsibility for casualty management during marauding-terrorist attacks.
Verbatim wording from the response “51. It should be noted that the primary role of armed police officers during a MTA will be to identify, locate and confront subjects in order to neutralise the threat. The provision of first aid may be a secondary role for armed officers once the threat has been neutralised, or where there is sufficient armed capacity to enable some armed officers to support other lifesaving activity. It is important that this role is not confused with that of the ambulance service.” Source location 2019-0332-Response-by-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 Technical limitations currently prevent all three emergency services from having full control-room visibility of one another’s assets.
Verbatim wording from the response “55. Work is currently underway, led by Chief Constable Simon Chesterman on behalf of NPCC, to enable all police force control rooms to have visibility of armed officers who arrive into their force area to provide operational support. However this is a complex technical area and the identification of a viable and affordable solution is challenging.” Source location 2019-0332-Response-by-Metropolitan-Police-Service
Open published response
25 Sep 2019 Anna Eli Hedman · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 3 Insufficient duration and rushed delivery of training for part-time call handlers View source Failure of training to emphasize preservation of life View source Insufficient post-training coaching and mentoring View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Anna Eli Hedman · 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
Anna Eli Hedman was found drowned in a bath at a hotel while intoxicated with cocaine, against a background of psychological illness and drug misuse. The court found gross failures in the police call handler’s prioritisation of preservation of life and failure to call an ambulance, but found these were not causative of the death. Concerns included short and rushed training for part-time call handlers, insufficient emphasis on preservation of life, and inadequate post-training coaching and mentoring.
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 duration and rushed delivery of training for part-time call handlers
Wider context from the report “1. That the training offered to police officers becoming part-time call handlers is too short and rushed , especially in relation to call coding .
” Open source report × Source evidence
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 training to emphasize preservation of life
Wider context from the report “2. That the training does not emphasize preservation of 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 post-training coaching and mentoring
Wider context from the report “3. That the post training coaching/mentoring is insufficient .
” Open source report
27 Jun 2019 Edir Frederico Araujo DA COSTA · Prevention of Future Deaths report East London
View report summary
Concerns raised 10 Failure to follow the procedure for updating CADs about life-threatening deterioration View source Failure to recognise agonal breaths View source Inadequate systems for supervisors to monitor mandatory training attendance View source Excessive noise levels in the communications command centre View source Failure to ensure that a safety officer takes control of restraint View source Inadequate guidance and procedures for CS spray use when a person has an item in their mouth View source Insufficient police officer awareness of plastic bag and choking risks View source Failure to designate an officer to lead communication and monitor condition View source Inadequate understanding of the safety officer role in a street setting View source Failure to maintain police officers’ mandatory Emergency Life Support training View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edir Frederico Araujo DA COSTA · 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
Edir Frederico Araujo DA COSTA died after his airway became obstructed by a plastic bag containing drugs while he was being restrained by police. The report identified concerns about emergency life-support training, supervision and safety-officer roles during restraint, risks associated with plastic bags and CS spray, recognition of agonal breathing, and communication with the ambulance 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 follow the procedure for updating CADs about life-threatening deterioration
Wider context from the report “(7) The controller who was communicating with the LAS received information that Mr Da Costa had stopped breathing. She did not use the correct procedure to update the LAS in relation to this life threatening deterioration . The MPS are requested to review the operation of the procedure for updating CADs and to take any necessary action to ensure that staff are fully aware of the correct procedure to be adopted.
” Open source report × Source evidence
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 agonal breaths
Wider context from the report “(5) The evidence at the Inquest revealed that agonal breaths were likely to have been missed . The officer provided the description of the breaths as looking like “yawning.” The independent expert stated that these were, beyond reasonable doubt, agonal breaths. The MPS is requested to review the training to officers around the recognition of agonal breaths. Within the training, the MPS may wish to incorporate the helpful descriptions provided by the officer 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 Inadequate systems for supervisors to monitor mandatory training attendance
Wider context from the report “(1) The evidence at the Inquest revealed that not all police officers are up to date with mandatory Emergency Life Support training. In addition, the current system in place makes it difficult for supervisors to check whether members of their team have received mandatory training . I request that the working group, driven by Met training, review the attendance of officers at mandatory ELS training and review the systems in place for supervisors to monitor attendance. I request that in doing so they consider the concerns raised by Inspector BC in his evidence at 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 Excessive noise levels in the communications command centre
Wider context from the report “(6) Evidence was heard at the Inquest that errors were made in communicating information to the LAS . This was in part due to the noise levels within the communication’s command centre for the London Borough of Newham. The MPS is requested to carry out an immediate review into the noise levels within the communication command centre and to take steps to reduce noise levels as far as possible. The longer term plans that the MPS have put in place to review their communications command centre is very much welcomed but it is considered that interim, proportionate measures should be explored.
” Open source report × Source evidence
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 that a safety officer takes control of restraint
Wider context from the report “(2) The evidence at the Inquest did not provide assurance that a safety officer had taken control of the restraint or that one officer was taking the lead in communicating with Mr Da Costa and/or monitoring his condition. In addition, the officers who gave evidence considered that the role of the safety officer mainly applied to restraint in a controlled custody setting. The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidance and procedures for CS spray use when a person has an item in their mouth
Wider context from the report “(4) The evidence given at the Inquest hearing revealed a concern that the use of CS spray, when a person has something in their mouth, could increase the risk of a complete airway obstruction . The MPS is requested to review the guidance and procedures in place for officers, in relation to the use of CS spray where a person is believed to be holding items in their mouth.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient police officer awareness of plastic bag and choking risks
Wider context from the report “(3) The Inquest heard that it is well documented that members of the public may swallow plastic bags to evade arrest or conceal evidence. Placing plastic bags in the mouth raises a very high risk of choking. Police officers should be aware of these risks . The MPS are requested to review the training provided to police officers to ensure they are fully informed about the specific risks around the use of plastic bags and the associated risk of choking.
” Open source report × Source evidence
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 designate an officer to lead communication and monitor condition
Wider context from the report “(2) The evidence at the Inquest did not provide assurance that a safety officer had taken control of the restraint or that one officer was taking the lead in communicating with Mr Da Costa and/or monitoring his condition . In addition, the officers who gave evidence considered that the role of the safety officer mainly applied to restraint in a controlled custody setting. The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate understanding of the safety officer role in a street setting
Wider context from the report “(2) The evidence at the Inquest did not provide assurance that a safety officer had taken control of the restraint or that one officer was taking the lead in communicating with Mr Da Costa and/or monitoring his condition. In addition, the officers who gave evidence considered that the role of the safety officer mainly applied to restraint in a controlled custody setting . The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain police officers’ mandatory Emergency Life Support training
Wider context from the report “(1) The evidence at the Inquest revealed that not all police officers are up to date with mandatory Emergency Life Support training . In addition, the current system in place makes it difficult for supervisors to check whether members of their team have received mandatory training. I request that the working group, driven by Met training, review the attendance of officers at mandatory ELS training and review the systems in place for supervisors to monitor attendance. I request that in doing so they consider the concerns raised by Inspector BC in his evidence at 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 Phase in double-ear headsets for First Contact and Despatch staff, prioritising occupational-health and line-management referrals.
Verbatim wording from the response “On 19th August 2019 further communication was circulated to all team Duty Officers offering double ear headsets to staff within the First Contact and Despatch environment, which assists in reducing outside noise. The issuing of these headsets will be phased with priority in the first instance being given to those supported by an Occupational Health referral and line management.” Source location 2019-0211-Response-by-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 agonal-breathing video clips into Emergency Life Support training.
Verbatim wording from the response “On 4th July 2019 Sue Warner tasked the MPS Clinical Panel and the National Clinical Panel to identify appropriate video clips which demonstrate agonal breathing which can be shown during ELS (Emergency Life Support) training. The same request was made to the National Police Chiefs Council’s First Aid Forum on 18th July 2019. From 1st October 2019 these video clips will be introduced into the new Emergency Life Support programme to support the existing training.” Source location 2019-0211-Response-by-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 Progress an external-system change to produce and circulate monthly training-compliance reports to senior managers.
Verbatim wording from the response “Recognising that the current electronic training system ‘PSOP’ has some limitations on the data being provided to supervisors, a request for a change with our external partner is being progressed to allow a monthly compliance package to be produced and circulated to senior managers. In the interim, the MPS is re-introducing a paper ‘Form 250C’ training card to be carried by all officers which will be stamped with the date of their last attendance at an approved Officer Safety Training/Emergency Life Support training session. This will make the information more accessible for officers and supervisors to check compliance. As a shorter term measure I have also issued local data packs to enable police commanders to readily understand which of their officers are in need of up-to-date training.” Source location 2019-0211-Response-by-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 consult on National Personal Safety Manual medical-implications guidance concerning irritant spray and airway risk before publication.
Verbatim wording from the response “The OST refresher training programme will include lessons to reference consideration of tactics when faced with a person intent on trying to swallow drugs, assessing all tactical options and justification, accounting and recording of which options were considered as well as used. This is in line with wider existing National Decision Model training. Module 4 of the NPSM (entitled Medical Implications) is currently under review to reflect the irritant position and will state there is no current conclusive study confirming irritant spray as a causative factor, however care should be taken. Consultation with stakeholders will take place prior to publication.” Source location 2019-0211-Response-by-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 Relocate dispatch-floor printers and install sound-reducing screening around them.
Verbatim wording from the response “As a result of the review, it was identified that printers on the despatch floor were contributing to the noise levels and as such have been moved to an area furthest away from the Operators. On 2nd August 2019 sound reducing screening was erected around printers to further mitigate noise distraction to all staff on the operational floor.” Source location 2019-0211-Response-by-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 Add tactical-option assessment, justification, and recording guidance for suspected swallowed drugs to refresher training.
Verbatim wording from the response “The OST refresher training programme will include lessons to reference consideration of tactics when faced with a person intent on trying to swallow drugs, assessing all tactical options and justification, accounting and recording of which options were considered as well as used. This is in line with wider existing National Decision Model training. Module 4 of the NPSM (entitled Medical Implications) is currently under review to reflect the irritant position and will state there is no current conclusive study confirming irritant spray as a causative factor, however care should be taken. Consultation with stakeholders will take place prior to publication.” Source location 2019-0211-Response-by-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 Remind duty officers to manage non-operational discussions on operational floors.
Verbatim wording from the response “Communication was circulated on 12th August 2019 to all team duty officers to remind Despatch Controllers and First Contact Supervisors to manage non-operational discussions on the operational floors. Although it is almost impossible to create a completely sterile noise working environment, this intervention by team Duty Officers should help mitigate further noise distraction.” Source location 2019-0211-Response-by-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 Drive strategic work to reduce officers overdue for mandatory Emergency Life Support and Officer Safety Training.
Verbatim wording from the response “I lead a strategic group to address this challenge and I have been supported by Commander ████████ from ‘Front Line Policing’. Together we have significantly reduced the number of officers who are in need of training. In addition, new issue personal protective equipment is not being given to officers until they are suitably trained and in-date. Corporate communications have been published and the matter discussed personally with the Commissioner in her regular MPS-wide on-line questions and answer sessions. On 12th July 2019 a news item was published on the MPS intranet site confirming this instruction to all officers.” Source location 2019-0211-Response-by-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 Reintroduce paper training cards recording officers’ latest approved Officer Safety or Emergency Life Support training attendance.
Verbatim wording from the response “Recognising that the current electronic training system ‘PSOP’ has some limitations on the data being provided to supervisors, a request for a change with our external partner is being progressed to allow a monthly compliance package to be produced and circulated to senior managers. In the interim, the MPS is re-introducing a paper ‘Form 250C’ training card to be carried by all officers which will be stamped with the date of their last attendance at an approved Officer Safety Training/Emergency Life Support training session. This will make the information more accessible for officers and supervisors to check compliance. As a shorter term measure I have also issued local data packs to enable police commanders to readily understand which of their officers are in need of up-to-date training.” Source location 2019-0211-Response-by-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 Issue local training data packs enabling commanders to identify officers requiring up-to-date training.
Verbatim wording from the response “Recognising that the current electronic training system ‘PSOP’ has some limitations on the data being provided to supervisors, a request for a change with our external partner is being progressed to allow a monthly compliance package to be produced and circulated to senior managers. In the interim, the MPS is re-introducing a paper ‘Form 250C’ training card to be carried by all officers which will be stamped with the date of their last attendance at an approved Officer Safety Training/Emergency Life Support training session. This will make the information more accessible for officers and supervisors to check compliance. As a shorter term measure I have also issued local data packs to enable police commanders to readily understand which of their officers are in need of up-to-date training.” Source location 2019-0211-Response-by-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 Explore incorporating Officer Safety and Emergency Life Support training into team rosters as rostered duty.
Verbatim wording from the response “In the longer term, the MPS is actively exploring opportunities for OST and ELS training to be built into team rosters making it a rostered tour of duty (as opposed to the self-service system currently in place). This work is expected to deliver improvements from April 2020.” Source location 2019-0211-Response-by-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 Include significant-deterioration CAD procedures in initial call-handler training and October personal-development training days.
Verbatim wording from the response “To this effect, on 2nd August 2019 a reminder was circulated to all staff via a weekly MetCC Operational update bulletin. This policy is emphasised in MetCC initial call handler training and included in the next Personal Development Days (training days) in October 2019. It must be stated however that although on this occasion the policy was not correctly complied with, it is the experience of Team Duty Officers and Met Grip Chief Inspectors that no previous issues have been identified and that the policy has been adhered to.” Source location 2019-0211-Response-by-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 communications-centre noise levels and identify sources requiring mitigation.
Verbatim wording from the response “A physical review at Bow MetCC took place on 11th July 2019 and was followed up on 30th July 2019 by Mike Chinchen from the Strategic Health and Safety Department. Sound testing revealed that there were no current issues. All entry doors into Despatch and First Contact floors were checked for opening and closure noise. There was negligible noise generated upon opening or closing any of the doors. However an inspection has now been carried out by a contracted maintenance provider to check hinges. They have been found to be in working order and unable to be adjusted further to reduce noise. A separate order was raised on 3rd August 2019 to replace all doors for silent or near silent opening or closure and are expected to be delivered within three to four weeks.” Source location 2019-0211-Response-by-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 Circulate a bulletin reminding staff to create a new CAD for significant patient deterioration and update the LAS.
Verbatim wording from the response “To this effect, on 2nd August 2019 a reminder was circulated to all staff via a weekly MetCC Operational update bulletin. This policy is emphasised in MetCC initial call handler training and included in the next Personal Development Days (training days) in October 2019. It must be stated however that although on this occasion the policy was not correctly complied with, it is the experience of Team Duty Officers and Met Grip Chief Inspectors that no previous issues have been identified and that the policy has been adhered to.” Source location 2019-0211-Response-by-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 Replace MetCC doors with silent or near-silent opening and closing doors.
Verbatim wording from the response “A physical review at Bow MetCC took place on 11th July 2019 and was followed up on 30th July 2019 by Mike Chinchen from the Strategic Health and Safety Department. Sound testing revealed that there were no current issues. All entry doors into Despatch and First Contact floors were checked for opening and closure noise. There was negligible noise generated upon opening or closing any of the doors. However an inspection has now been carried out by a contracted maintenance provider to check hinges. They have been found to be in working order and unable to be adjusted further to reduce noise. A separate order was raised on 3rd August 2019 to replace all doors for silent or near silent opening or closure and are expected to be delivered within three to four weeks.” Source location 2019-0211-Response-by-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 Add safety-officer role reminders and incident evidence requirements to the Officer Safety Training refresher package.
Verbatim wording from the response “The current training for the role of the safety officer covers environments to include custody and street settings. The practice of instructing officers to take the lead when they are controlling the head of a subject works well. The safety officer has a better communication and monitoring ability with the subject of the restraint and all other officers have the training to “speak up, speak out”. This method ensures everyone present is responsible for the subject’s safety. We will however include this reminder in the OST refresher training package from 1st October 2019. This new package will incorporate a presentation delivered by MPS trainers reminding officers of the importance of identifying themselves as the safety officer throughout the incident. In addition, they must provide evidence as to what action they took throughout the incident referencing when they were the safety officer.” Source location 2019-0211-Response-by-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 Recommend implementing the identified noise-mitigation measures across all MetCC sites.
Verbatim wording from the response “A recommendation will be made to implement all the above actions at all MetCC sites and the work will be overseen by MetCC Buildings Manager, Marissa Howard.” Source location 2019-0211-Response-by-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 Withhold newly issued personal protective equipment from officers until their mandatory training is current.
Verbatim wording from the response “I lead a strategic group to address this challenge and I have been supported by Commander ████████ from ‘Front Line Policing’. Together we have significantly reduced the number of officers who are in need of training. In addition, new issue personal protective equipment is not being given to officers until they are suitably trained and in-date. Corporate communications have been published and the matter discussed personally with the Commissioner in her regular MPS-wide on-line questions and answer sessions. On 12th July 2019 a news item was published on the MPS intranet site confirming this instruction to all officers.” Source location 2019-0211-Response-by-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 Sound testing identified no current noise issues in the communications centre, although further mitigation measures were nevertheless implemented.
Verbatim wording from the response “(6) Evidence was heard at the Inquest that errors were made in communicating information to the LAS. This was in part due to the noise levels within the communications command centre for the London Borough of Newham. The MPS is requested to carry out an immediate review into the noise levels within the communications command centre and to take steps to reduce noise levels as far as possible. The longer term plans that the MPS have put in place to review their communications command centre is very much welcomed but it is considered that interim, proportionate measures should be explored.” Source location 2019-0211-Response-by-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 Evidence that CS spray worsens airway obstruction was theoretical and unsupported by firm evidence; further medical research was therefore being pursued.
Verbatim wording from the response “The MPS has considered the expert testimony of ████████ provided at the Inquest during which he said that “…it is theoretically possible that CS spray in those circumstances could perhaps make airway obstruction worse” (page 201 of transcript dated 29th May 2019). To emphasise that he was making a theoretical point only, he further added “I am not an expert on CS spray, it is something I have looked up …. There is to my knowledge no firm evidence for what I am saying, it is a rational opinion (pages 200-201 of the court transcript dated 29th May 2019).” Source location 2019-0211-Response-by-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 Current safety officer training already covers both custody and street settings, although refresher training will reinforce the role in street incidents.
Verbatim wording from the response “(2) The evidence at the Inquest did not provide assurance that a safety officer had taken control of the restraint or that one officer was taking the lead in communicating with Mr Da Costa and/or monitoring his condition. In addition, the officers who gave evidence considered that the role of the safety officer mainly applied to restraint in a controlled custody setting. The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise).” Source location 2019-0211-Response-by-Metropolitan-Police
Open published response
23 May 2019 Tyereece Johnson · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1 Failure to pass relevant rider age information to tactical decision-makers 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
Tyereece 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
Tyereece Johnson, aged 16, died following a collision with a police vehicle while driving a moped with two passengers. The report raised concern that the approximate age of the moped riders was not passed to the Police Control Centre, despite witnesses considering it relevant to risk assessment and tactical decision-making.
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 pass relevant rider age information to tactical decision-makers
Wider context from the report “The first CAD messages gave an approximate age of the riders of the moped (aged 15 to 16). However this was not passed on to the team in the Police Control Centre who were formulating tactics to bring the moped to a stop. All witnesses from the police control room and police helicopter agreed that the age of the riders was a relevant factor to take into account when formulating a risk assessment in order to inform their tactical decision making .
(However I did not find that it caused or contributed to the death in this instance.)
” 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 Ensure Pan London courses and refresher training include information and intelligence-gathering instruction.
Verbatim wording from the response “The MPS considers that the changes implemented since 2016 are sufficient, however as a result of this Regulation 28 Report to Prevent Future Deaths, MetCC led by Superintendent Gary Warby in charge of Service Delivery, will take the following action;” Source location 2019-0166-Response-by-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 the pod’s roles and responsibilities to maximise information and intelligence opportunities by 31 October 2019.
Verbatim wording from the response “The MPS considers that the changes implemented since 2016 are sufficient, however as a result of this Regulation 28 Report to Prevent Future Deaths, MetCC led by Superintendent Gary Warby in charge of Service Delivery, will take the following action;” Source location 2019-0166-Response-by-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 six-role police pursuits and follows pod supporting risk assessment and information gathering.
Verbatim wording from the response “Since 2016 a number of changes have been made within Met Command and Control (MetCC). There is now a dedicated pod for police pursuits and follows as occurred here, which consists of the following six roles;” Source location 2019-0166-Response-by-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 Consider whether to introduce a mandatory checklist of information sources at the start of pursuits.
Verbatim wording from the response “The MPS considers that the changes implemented since 2016 are sufficient, however as a result of this Regulation 28 Report to Prevent Future Deaths, MetCC led by Superintendent Gary Warby in charge of Service Delivery, will take the following action;” Source location 2019-0166-Response-by-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 dedicated pursuits pod and its resources are considered sufficient to address the concern, although its practices will be reviewed further.
Verbatim wording from the response “In the last couple of years MetCC has created a dedicated police pursuits pod. This contains the necessary resources to support the Pan London Supervisor, who has overall control of pursuits/follows, with the information and intelligence required so risk assess the incident using the National Decision Model. MetCC believes this is sufficient to address the matter of concern raised by the Coroner, however they seek to improve their practices further and will conduct a review of the roles and responsibilities contained within the pod to ensure they maximise all available information and intelligence opportunities. This review will be completed within the next four months.” Source location 2019-0166-Response-by-Metropolitan-Police
Open published response
15 Jan 2019 Ms Catherine Anne Horton · Prevention of Future Deaths report London (South)
View report summary
Concerns raised 2 Failure to complete a Safe and Well check before closing a missing person investigation View source Insufficient staffing capacity for missing person enquiries View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ms Catherine Anne Horton · 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
Ms Catherine Anne Horton, a patient with paranoid schizophrenia detained under section 3 of the Mental Health Act 1983, died by hanging in July 2017, with the death occurring sometime between 16 and 24 July. The report identified failures in ward observation, recording and risk assessment, leadership, the police information pack, and the execution of a section 135(2) warrant. It also raised concerns about a missing-person investigation being incorrectly closed before a Safe and Well check, in the context of staff shortages and pressure of work.
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 complete a Safe and Well check before closing a missing person investigation
Wider context from the report “There were multiple failures in the days leading up to Ms Horton’s death. During the evidence it was made clear that a mistake was made in relation to closing a missing person investigation relating to the deceased (before a Safe and Well check had been undertaken) . This occurred at a time when staffing was low and the expectations of the Officer or Officers working on particular days was well above what was achievable. Particularly, on the day the investigation was incorrectly closed was one where the unit was dealing with 28 missing person enquiries.
I strongly suspect that resources are stretched in every department of the MPS. However, the missing persons’ unit may not be seen as readily as other departments as a life-saving department. Of course it is because of the vulnerable nature of the persons missing and I am told that Croydon has the highest figures of missing persons in Europe. At the time of Ms Horton’s death, an error was made that coincided with staff being re-located elsewhere and the senior officer giving evidence said that the error was made due to pressure of work.
I have sufficient concern about a wider issue which warrants the writing of this Prevent Future Death Report (CJA 2009, Schedule 5, Paragraph 7; Regulation 28 Coroners (Investigations) Regulations 2013) to be sent more centrally.
” Open source report × Source evidence
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 staffing capacity for missing person enquiries
Wider context from the report “There were multiple failures in the days leading up to Ms Horton’s death. During the evidence it was made clear that a mistake was made in relation to closing a missing person investigation relating to the deceased (before a Safe and Well check had been undertaken). This occurred at a time when staffing was low and the expectations of the Officer or Officers working on particular days was well above what was achievable . Particularly, on the day the investigation was incorrectly closed was one where the unit was dealing with 28 missing person enquiries .
I strongly suspect that resources are stretched in every department of the MPS . However, the missing persons’ unit may not be seen as readily as other departments as a life-saving department. Of course it is because of the vulnerable nature of the persons missing and I am told that Croydon has the highest figures of missing persons in Europe. At the time of Ms Horton’s death, an error was made that coincided with staff being re-located elsewhere and the senior officer giving evidence said that the error was made due to pressure of work .
I have sufficient concern about a wider issue which warrants the writing of this Prevent Future Death Report (CJA 2009, Schedule 5, Paragraph 7; Regulation 28 Coroners (Investigations) Regulations 2013) to be sent more centrally.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update policies and standard operating procedures for missing-person risk assessments, investigations and interviews with returned missing people.
Verbatim wording from the response “The MPS has reviewed and updated its policies and standard operating procedures for on-going risk-assessments, investigations and interviews with returning missing people. Interviews with returned or found missing people are aimed at prevention of further missing episodes. Information that could prevent the person going missing again, along with any other information affecting their welfare, is disseminated to our policing and partner agencies, which allows for early intervention.” Source location 2019-0143-Response-by-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 Establish BCU Safeguarding Hubs with senior safeguarding leadership and flexible deployment of officers to MPUs during periods of high demand.
Verbatim wording from the response “Under the delivery of this new policing model for London, each BCU has established an MPU that is resourced according to local demand. Each MPU works to a set of minimum standards of operational procedure, staffing levels, skills and supervision. The responsibility of implementing the model and operational delivery lies with local leadership teams, ultimately BCU Commanders. This does however involve balancing available resources at times against operational demand, and flexing resources to respond to peaks and critical issues. The BCU Commanders are best placed to make decisions where vacancies are held, taking into account all the risks being dealt with by the BCU as a whole and by Safeguarding the most vulnerable in particular.” Source location 2019-0143-Response-by-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 Provide 24-hour staffing for safeguarding investigation teams through a corporate shift pattern.
Verbatim wording from the response “The MPS has invested significantly in safeguarding focused police officer posts as part of the new BCU model, which has resulted in an increase of dedicated MPU officers. The MPUs are now integrated with local command and control functions via a local operations room in each BCU that monitors live and incoming risk at all times. Any new missing person who comes to the notice of police will continue to be risk assessed and monitored by the emergency response team Duty Inspector. Any high-risk missing person will immediately be passed to the Safeguarding MPU under the direction of a Detective Inspector who will utilise all relevant and available resources to ensure priority actions are addressed. Safeguarding investigation teams across London are resourced 24 hours a day following the implementation of a corporate shift pattern.” Source location 2019-0143-Response-by-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 the BCU policing model, incorporating MPUs into twelve BCUs to provide greater resilience and consistency.
Verbatim wording from the response “The structure, working practices and resourcing of MPS Missing Persons Units (MPUs) have changed significantly since 2017. The MPS has now implemented a programme to incorporate thirty two boroughs into twelve Basic Command Units (BCUs), providing resilience and consistency across London to help the MPS meet its financial and operational challenges. The design of the new MPUs under this programme is intended to resolve some of the historic issues that have been raised which involves an investment of additional posts into MPUs across the MPS. Considering the financial constraints the MPS is operating within, we believe this to be a significant commitment to what is acknowledged as an area of risk.” Source location 2019-0143-Response-by-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 Conduct three-month and full reviews of the BCU model and provide recommendations to address identified risks and improve the model.
Verbatim wording from the response “Following the implementation of BCUs, led by the Assistant Commissioner for Frontline Policing, the Deputy Assistant Commissioner for Local Policing will conduct a three month review of their progress; this provides the opportunity to check that all the elements of the BCU including MPUs are working effectively. This will be followed by a full review (June to September 2019) and recommendations will be provided on how to further improve the model taking into account pressures that have been experienced and address any risks or issues that have been identified.” Source location 2019-0143-Response-by-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 Increase dedicated MPU staffing through additional safeguarding-focused police officer posts across the MPS.
Verbatim wording from the response “The structure, working practices and resourcing of MPS Missing Persons Units (MPUs) have changed significantly since 2017. The MPS has now implemented a programme to incorporate thirty two boroughs into twelve Basic Command Units (BCUs), providing resilience and consistency across London to help the MPS meet its financial and operational challenges. The design of the new MPUs under this programme is intended to resolve some of the historic issues that have been raised which involves an investment of additional posts into MPUs across the MPS. Considering the financial constraints the MPS is operating within, we believe this to be a significant commitment to what is acknowledged as an area of risk.” Source location 2019-0143-Response-by-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 Increase staffing in the South Area MPU and plan a further increase in staffing levels.
Verbatim wording from the response “South Area (SN) BCU incorporates the boroughs of Croydon, Sutton and Bromley. The South Area MPU has had an uplift of officers with a plan to increase staffing levels further in the near future. High risk missing person cases should attract a BCU response and a senior detective within the Safeguarding Hub will lead the investigation. There are currently some challenges regarding the investigation of low and medium graded missing person reports before they reach the MPU, however this is now being addressed as a matter of urgency.” Source location 2019-0143-Response-by-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 Local BCU leadership, ultimately BCU Commanders, is responsible for implementing the policing model and making operational staffing decisions.
Verbatim wording from the response “Under the delivery of this new policing model for London, each BCU has established an MPU that is resourced according to local demand. Each MPU works to a set of minimum standards of operational procedure, staffing levels, skills and supervision. The responsibility of implementing the model and operational delivery lies with local leadership teams, ultimately BCU Commanders. This does however involve balancing available resources at times against operational demand, and flexing resources to respond to peaks and critical issues. The BCU Commanders are best placed to make decisions where vacancies are held, taking into account all the risks being dealt with by the BCU as a whole and by Safeguarding the most vulnerable in particular.” Source location 2019-0143-Response-by-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