19 Dec 2018 Kurt Cochran and 5 others · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 18 Lack of consistent and up-to-date national protective security advice View source Failure of supervisory systems to audit ADAM System use View source Failure to record reasons for closing a Subject of Interest View source Lack of clear required intervals for officers to access the ADAM System View source Inadequate training for lone-actor and multi-actor marauding attacks View source Failure to provide revised Post Instructions directly to relevant officers View source Insufficient time for officers to access the ADAM System and review Post Instructions View source Failure to brief officers on the rationale for changes to Post Instructions View source Failure of Post Instructions to be clear and readily interpretable View source Inadequate coordinated training of AFOs, unarmed officers and security officers View source Lack of consistent pre-rental vehicle checks and enquiries View source Lack of regular supervisory audits of policing at the Palace of Westminster View source Lack of armed police protection at a vulnerable public entrance to the Parliamentary Estate View source Lack of periodic audit of Tactical Firearms Reviews View source Failure of Post Instructions to be consistent with tactical plans, orders and practices View source Lack of guidance on removing unconscious persons or bodies from navigable water View source Failure of officers to register for and access the ADAM System View source Insufficient facilities for officers to access the ADAM System View source See 15 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. 10
Action
Maintain mandatory ADAM registration and regular access, with supervision checks, compliance reporting, and live audit functionality.
Stated completedThe respondent said that this action was complete when they made their response on 20 December 2018. View source
Action
Review and revise post instructions with counter-terrorism specialists, senior managers, and lawyers to remove ambiguity.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 December 2018. View source
Action
Review whether officers’ standby time is sufficient for accessing and refreshing post instructions at the scheduled challenge meeting.
Stated plannedThe respondent said that this action was planned when they made their response on 20 December 2018. View source
Action
Ensure the PaDP OFC Sergeant explains the rationale for post-instruction changes to AFOs.
Stated plannedThe respondent said that this action was planned when they made their response on 20 December 2018. View source
Action
Email post-instruction changes directly to all PaDP officers, requiring read confirmations and auditing compliance.
Stated completedThe respondent said that this action was complete when they made their response on 20 December 2018. View source
Action
Complete the ongoing network upgrade to increase officer access to terminals across PaDP sites.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 December 2018. View source
Action
Expand officer-safety training with scenario-based preparation for lone-actor and multi-actor marauding attacks, sharing it with relevant MPS commands.
Stated plannedThe respondent said that this action was planned when they made their response on 20 December 2018. View source
Action
Maintain a static armed post of two AFOs at Carriage Gates during Parliamentary sitting hours.
Stated completedThe respondent said that this action was complete when they made their response on 20 December 2018. View source
Action
Introduce twice-yearly external supervisory audits of policing by officers outside the PaDP command, beginning in summer 2019.
Stated plannedThe respondent said that this action was planned when they made their response on 20 December 2018. View source
Action
Deliver joint annual training and regular exercises for armed, unarmed, and security personnel with Parliamentary partners.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 December 2018. View source See 7 more actions
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AI-generated summary
Kurt Cochran and 5 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 22 March 2017, Khalid Masood drove a vehicle across Westminster Bridge, fatally injuring Kurt Cochran, Leslie Rhodes, Aysha Frade and Andreea Cristea, before fatally stabbing PC Keith Palmer at the Palace of Westminster. The report raised concerns about the protection of public entrances, officers’ access to and understanding of Post Instructions, use of the ADAM System, supervision and training, and wider protective security measures.
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 consistent and up-to-date national protective security advice
Wider context from the report “MC14: I suggest that the Secretary of State for the Home Department asks the authorities responsible for preparing and delivering advice on protective security to consider whether any further work can usefully be done on this subject, particularly in preparing and delivering consistent and up-to-date national advice . I also suggest that TfL considers whether there is any further work it can do to improve protective security on major roadways and bridges in the capital, in response to national advice and known threats.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 supervisory systems to audit ADAM System use
Wider context from the report “MC6: It was a matter of concern that officers were unaware of their Post Instructions and that supervisory systems had not identified limited usage of the ADAM System . I therefore suggest that the MPS considers auditing use of the ADAM System periodically , by checks to confirm use at sufficiently regular intervals over the period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 reasons for closing a Subject of Interest
Wider context from the report “MC16: I suggest that the Security Service considers whether it would be practicable and beneficial to introduce a procedure whereby any decision to close a person as a Subject of Interest is recorded with brief reasons .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clear required intervals for officers to access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given . Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system . Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 training for lone-actor and multi-actor marauding attacks
Wider context from the report “MC9: I suggest that the MPS reviews the adequacy of training of officers stationed in the Parliamentary Estate to ensure it includes lone actor and multi-actor marauding 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 Failure to provide revised Post Instructions directly to relevant officers
Wider context from the report “MC1: I suggest that the MPS gives consideration to providing revised Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices (as well as their being accessible through ADAM) and to providing them in a way that requires the recipient to respond indicating safe receipt. I was concerned that, when Post Instructions were updated, they were apparently not emailed or provided in hard copy to relevant officers directly . The system relied upon officers’ use of the ADAM System, which was sporadic . I am aware from the submissions of the MPS that, since the attack, an update is sent to all relevant officers advising them of a revision of Post Instructions and telling them to view the new version on ADAM. The MPS has provided a copy of an example email, which was sent on 11 October 2018. However, it may be valuable for the MPS to go further than this by supplying revised instructions directly to the officers and in requiring an acknowledgement of safe receipt is sent back by the officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for officers to access the ADAM System and review Post Instructions
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals). I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 brief officers on the rationale for changes to Post Instructions
Wider context from the report “MC10: I suggest that the MPS considers the possibility of the firearms assessor / adviser briefing officers as to the rationale for any changes to their Post Instructions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 Instructions to be clear and readily interpretable
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions , and some officers when presented with them found it difficult to interpret parts . It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate. It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices, security can be undermined.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 coordinated training of AFOs, unarmed officers and security officers
Wider context from the report “MC8: I suggest that the MPS, with the Parliamentary Authorities, reviews the adequacy of training to ensure that it involves AFOs, unarmed officers and security officers and their co-ordination .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 consistent pre-rental vehicle checks and enquiries
Wider context from the report “MC18: I recommend that the Department for Transport and the British Vehicle Rental & Leasing Association consider introducing a Code of Practice (or at least guidance) on checks to be carried out and/or enquiries made before vehicles are rented .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 regular supervisory audits of policing at the Palace of Westminster
Wider context from the report “MC7: I suggest that the MPS considers instituting regular supervisory audits of policing at the Palace of Westminster (and perhaps other parts of the Parliamentary Estate), preferably by officers outside the PaDP Command.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 armed police protection at a vulnerable public entrance to the Parliamentary Estate
Wider context from the report “MC5: It was a matter of concern that, at the time of the attack, one of the most vulnerable and public entrances to the Parliamentary Estate was not protected by armed police . In my view, the MPS should consider (a) imposing a standing order that there should be armed officers stationed at all open public entry points to the Palace of Westminster (and possibly to some other buildings on the Parliamentary Estate) and (b) introducing a provision that this standing order may only be varied with the written approval of an officer of very senior rank.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 periodic audit of Tactical Firearms Reviews
Wider context from the report “MC11: I suggest that the MPS considers a periodic audit of Tactical Firearms Reviews .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 Instructions to be consistent with tactical plans, orders and practices
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions, and some officers when presented with them found it difficult to interpret parts. It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate . It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices , security can be undermined.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 removing unconscious persons or bodies from navigable water
Wider context from the report “MC17: I suggest that the Maritime and Coastguard Agency considers whether it or some other body could provide guidance on the removal of unconscious persons or bodies from the water close to those operating on navigable rivers and canals .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 officers to register for and access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given. Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system. Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 facilities for officers to access the ADAM System
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals) . I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” 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 Maintain mandatory ADAM registration and regular access, with supervision checks, compliance reporting, and live audit functionality.
Verbatim wording from the response “12. Compliance has substantially improved and the proportion of officers on the PaDP command who have now registered on ADAM is 100%. This is a mandatory element of the induction course into the command which takes place in the first week of joining PaDP. This sets the tone around knowledge requirements when officers arrive at PaDP. For existing officers, separate instructions have been issued around registering and logging into the ADAM system regularly. In addition, there is a separate regime of supervision checks conducted on posts to check that officers are aware of the post instructions and complying with them. These checks are recorded, analysed and produced in a performance report by the IDT. In addition, PaDP has developed a ‘Skills Loss Policy’ to enable officers to be exited from the Command where there is a loss of confidence due to a failure to comply with instructions.” Source location 2018-0304-Response-by-Metropolitan-Police
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise post instructions with counter-terrorism specialists, senior managers, and lawyers to remove ambiguity.
Verbatim wording from the response “19. It is accepted that different opinions were expressed at the inquests as to whether post instructions were “open to interpretation” or not. To the extent that there was uncertainty and a lack of precision in the wording of a small number of post instructions relating for example to phrases such as “short patrol”, this has been addressed and such wording is no longer used.” Source location 2018-0304-Response-by-Metropolitan-Police
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review whether officers’ standby time is sufficient for accessing and refreshing post instructions at the scheduled challenge meeting.
Verbatim wording from the response “15. AFOs have periods of standby time between posts of at least one hour, but this can be two hours or more. Officers are aware of their postings three weeks in advance and this time must be used to refresh and improve familiarity with post instructions. All officers are reminded of the need to refresh their knowledge when they come on duty and sign to accept their postings for the day. An agenda item will be raised at the next challenge meeting on 01.03.19 as to whether this time is sufficient. This has also been raised with supervisors on the PaDP command.” Source location 2018-0304-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 Ensure the PaDP OFC Sergeant explains the rationale for post-instruction changes to AFOs.
Verbatim wording from the response “41. The newly appointed PaDP OFC Sergeant with responsibility for internal tactical advice will ensure that AFOs fully understand not only relevant changes to post instructions but also the rationale behind the changes. This will happen as and when post instructions change.” Source location 2018-0304-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 Email post-instruction changes directly to all PaDP officers, requiring read confirmations and auditing compliance.
Verbatim wording from the response “3. Following the inquests, a great deal of work has been carried out within PaDP in relation to the ADAM system, post instructions and auditing compliance. A temporary system has been introduced whereby officers sign a form before they take over a post so that they have read the post instructions and are aware of their role. This must be completed before an officer can sign out a firearm. Changes to post instructions are now emailed directly to all officers on PaDP, not just supervisors (see para 7 below). Further improvements will be made following the introduction of a digital system currently on trial called AIRBOX (see para 6 below). All Sergeants and Inspectors have been briefed on their operational responsibilities for supervision of officers on posts. Supervisors are set performance targets for post knowledge checks on every shift.” Source location 2018-0304-Response-by-Metropolitan-Police
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the ongoing network upgrade to increase officer access to terminals across PaDP sites.
Verbatim wording from the response “17. As stated above, a bespoke IT solution is being developed for the command as a priority. It is anticipated that this will include the use of hand held devices upon which post instructions can be viewed.” Source location 2018-0304-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 Expand officer-safety training with scenario-based preparation for lone-actor and multi-actor marauding attacks, sharing it with relevant MPS commands.
Verbatim wording from the response “MC9: I suggest that the MPS reviews the adequacy of training of officers stationed in the Parliamentary Estate to ensure it includes lone actor and multi actor marauding attacks.” Source location 2018-0304-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 Maintain a static armed post of two AFOs at Carriage Gates during Parliamentary sitting hours.
Verbatim wording from the response “23. At the time of Masood’s attack, Carriage Gates should have been protected by two AFOs in accordance with the post instructions. Steps have since been taken to ensure that this entrance has a static armed post (two AFOs) at the gates and the gates are always protected by at least this number of armed officers during sitting hours. This was introduced as a result of a new tactical assessment which was conducted immediately after the attacks. The Chief Coroner will also be aware of what he observed on the site visit and the Sir Jon Murphy report.” Source location 2018-0304-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 twice-yearly external supervisory audits of policing by officers outside the PaDP command, beginning in summer 2019.
Verbatim wording from the response “30. The review of risk assessments for posts is conducted by a Tactical Advisor from MO19. As explained in the response to MC4 above, an additional OFC Sergeant post has been created within the PaDP command to review posts on an ongoing basis in addition to the tactical advice received from MO19.” Source location 2018-0304-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 Deliver joint annual training and regular exercises for armed, unarmed, and security personnel with Parliamentary partners.
Verbatim wording from the response “32. All armed and unarmed officers on the PaDP command undergo joint officer safety training and emergency life support training every year.” Source location 2018-0304-Response-by-Metropolitan-Police
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual hard copies and mass email distribution of post instructions are restricted by document security and email limitations.
Verbatim wording from the response “8. It is not possible to provide individual hard copies of post instructions to all officers due to the security sensitivity of these documents. There are also restrictions upon emailing such documents to large groups. The MPS has introduced the procedure detailed above as a means of ensuring compliance without compromising security.” Source location 2018-0304-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 The MPS lacks a standing-order system capable of precisely and effectively delivering the recommended control for public entrances.
Verbatim wording from the response “25. The MPS does not have a relevant system of “standing orders” which could precisely and effectively deliver that which the Chief Coroner has recommended. However, the Commissioner recognises and accepts the rationale behind recommendation MC5.” Source location 2018-0304-Response-by-Metropolitan-Police
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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 Joint training with security officers requires assistance from the Parliamentary authorities, with implementation to be negotiated jointly.
Verbatim wording from the response “36. Joint training with security officers will require assistance from the Parliamentary authorities, who we are in discussion with. The MPS will negotiate with the Parliamentary authorities to ensure that this recommendation is implemented. There are joint exercises scheduled for March and July 2019.” Source location 2018-0304-Response-by-Metropolitan-Police
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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 existing armed-policing model protects all open public entrances to the Parliamentary Estate while Parliament is sitting.
Verbatim wording from the response “26. The present armed policing model ensures that all open public entrances to the Parliamentary Estate are protected by armed guards when Parliament is sitting.” Source location 2018-0304-Response-by-Metropolitan-Police
Open published response
20 Nov 2018 Suleyman Yalcin · Prevention of Future Deaths report North London
View report summary
Concerns raised 3 Police under-resourcing View source Inadequate police terminology for describing the urgency of situations View source Insufficient refresher training in emergency response driving 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
Suleyman Yalcin · 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 December 2017, a police van responding to an incident collided with Suleyman Yalcin as he crossed Seven Sisters Road, causing fatal injuries. The substantive concerns were insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology to communicate the urgency of the incident.
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 Police under-resourcing
Wider context from the report “2, Police under resourcing
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 terminology for describing the urgency of situations
Wider context from the report “3, Inadequate police terminology to describe the urgency of the situation to which the driver was responding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 refresher training in emergency response driving
Wider context from the report “1, Insufficient refresher training in emergency response driving given to the driver of the van.
” 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 Continuously review officer availability to respond to incidents across Basic Command Units.
Verbatim wording from the response “This policing restructure allows us to make best use of our available resources and the BCU’s will constantly review the availability of officer to respond to incidents.” Source location 2018-0368-Response-by-Metropolitan-Police2
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain mandatory emergency response driving refresher training for all MPS officers every three to five years under the revised driving policy.
Verbatim wording from the response “████████ was a qualified response driver under the MPS Driving Policy and training regime in place prior to 1st October 2015. The regime in place at the time comprised of ‘check tests’ being conducted by qualified officers. ████████ completed this in line with the then policy. He is due to receive his next refresher training later this year in accordance with the new MPS Driving Policy, which adheres to the College of Policing’s Roads Policing and Police Driving Learning Programme. All MPS officers now undertake refresher training every 3 to 5 years. I trust that this new regime of refresher training addresses your matter of concern.” Source location 2018-0368-Response-by-Metropolitan-Police2
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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 Basic Command Unit model to enable flexible deployment of resources across borough boundaries.
Verbatim wording from the response “The MPS seeks to balance available resources at times against operational demand, and flexing resources to respond to peaks and critical issues. Since 2017 the MPS has undergone a significant restructure with the implementation of the Basic Command Unit (BCU) model with the final phase being completed in February 2019. The responsibility of implementing the model and operational delivery lies with local” Source location 2018-0368-Response-by-Metropolitan-Police2
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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 call handlers and dispatchers to clarify the reason and specific needs for urgent requests and record them in the Computer Aided Despatch system.
Verbatim wording from the response “Since DAC Martin’s response dated 6th February 2019 I have been updated that our Command and Control Centre (MetCC) informed all call handlers to remind them to always clarify the reason for their request and record this on the Computer Aided Despatch system. This issue has also been incorporated into their professional development days (training days) which started on 5th February 2019. Call despatch courses now include a session on clarifying terminology in these situations.” Source location 2018-0368-Response-by-Metropolitan-Police2
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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 staff to seek further clarification when necessary to justify an urgent assistance request.
Verbatim wording from the response “Whilst we recognise the use of MPS terminology, we will seek to remind our staff that if required, further clarification should be sought to justify the request. The MPS are committed to enhancing our training and this will be incorporated in Met CC professional development days and initial training for all operational staff.” Source location 2018-0368-Response-by-Metropolitan-Police
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continuously review resourcing and demand across the Metropolitan Police Service to maintain operational effectiveness.
Verbatim wording from the response “At the inquest, the jury heard that the police van involved in the collision with Mr Yalcin was travelling from Hackney Borough to an incident in Haringey. Police vehicles have always responded to requests to support colleagues in neighbouring boroughs during serious incidents. Resourcing and demand across the MPS is constantly reviewed to maintain operational effectiveness; this flexibility is essential in preventing crime and keeping London safe.” Source location 2018-0368-Response-by-Metropolitan-Police
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the programme integrating 32 boroughs into 12 Basic Command Units to provide operational resilience and consistency.
Verbatim wording from the response “The MPS has implemented a programme to incorporate thirty two boroughs into 12 Basic Command Units (BCUs), providing resilience and consistency across London to help the MPS meet its financial and operational challenges.” Source location 2018-0368-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 Deliver three- to five-year refresher training to response, covert advanced and advanced car drivers, completing the current five-year cycle by October 2020.
Verbatim wording from the response “Prior to 2015, drivers were locally assessed by an experienced advanced driver who was qualified as an MPS driving assessor. In 2015 the Roads Policing and Police Driving Learning Programme set out national learning standards for police driving, including the delivery of driver refresher training. On 1st October 2015, the MPS Driving School introduced a three to five year refresher training course for all response car, covert advanced car and advanced car drivers; this is delivered by a suitably trained driving instructor and complies with the nationally recognised APP. By October 2020, this group of drivers will have received refresher training by the MPS Driving School which will complete the five year cycle.” Source location 2018-0368-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 Incorporate enhanced training on urgent-request clarification into Met Command and Control professional development days and initial training for operational staff.
Verbatim wording from the response “Whilst we recognise the use of MPS terminology, we will seek to remind our staff that if required, further clarification should be sought to justify the request. The MPS are committed to enhancing our training and this will be incorporated in Met CC professional development days and initial training for all operational staff.” Source location 2018-0368-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 The BCU structure, resource flexibility and continuing availability reviews are considered sufficient to manage police resourcing against operational demand.
Verbatim wording from the response “The MPS seeks to balance available resources at times against operational demand, and flexing resources to respond to peaks and critical issues. Since 2017 the MPS has undergone a significant restructure with the implementation of the Basic Command Unit (BCU) model with the final phase being completed in February 2019. The responsibility of implementing the model and operational delivery lies with local” Source location 2018-0368-Response-by-Metropolitan-Police2
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 Implementation and operational delivery of the BCU model rests with local leadership teams, ultimately BCU commanders.
Verbatim wording from the response “The MPS seeks to balance available resources at times against operational demand, and flexing resources to respond to peaks and critical issues. Since 2017 the MPS has undergone a significant restructure with the implementation of the Basic Command Unit (BCU) model with the final phase being completed in February 2019. The responsibility of implementing the model and operational delivery lies with local” Source location 2018-0368-Response-by-Metropolitan-Police2
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 phrase “on the hurry up” is recognised language for requesting assistance, so the MPS does not propose changing it.
Verbatim wording from the response “The use of the terminology ‘on the hurry up’, is a recognised use of language to request additional support and assistance at the scene of an incident. It is MetCC’s responsibility to command and control police radio communications; this involves clarifying the reasons for the request and deploying units according to urgency, risk and operational priorities. The MPS does not propose to a change in the language, but clarity as to the specific needs is now incorporated into the revised training above.” Source location 2018-0368-Response-by-Metropolitan-Police2
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 revised MPS driving policy requires refresher training every three to five years and is considered sufficient to address the training concern.
Verbatim wording from the response “████████ was a qualified response driver under the MPS Driving Policy and training regime in place prior to 1st October 2015. The regime in place at the time comprised of ‘check tests’ being conducted by qualified officers. ████████ completed this in line with the then policy. He is due to receive his next refresher training later this year in accordance with the new MPS Driving Policy, which adheres to the College of Policing’s Roads Policing and Police Driving Learning Programme. All MPS officers now undertake refresher training every 3 to 5 years. I trust that this new regime of refresher training addresses your matter of concern.” Source location 2018-0368-Response-by-Metropolitan-Police2
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 Cross-borough deployment, demand reviews and BCU restructuring provide sufficient flexibility and resilience to address police resourcing pressures.
Verbatim wording from the response “At the inquest, the jury heard that the police van involved in the collision with Mr Yalcin was travelling from Hackney Borough to an incident in Haringey. Police vehicles have always responded to requests to support colleagues in neighbouring boroughs during serious incidents. Resourcing and demand across the MPS is constantly reviewed to maintain operational effectiveness; this flexibility is essential in preventing crime and keeping London safe.” Source location 2018-0368-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 The terminology was not inadequate because the National Decision Model requires drivers to assess risk regardless of the wording used.
Verbatim wording from the response “The term “on the hurry up” is a widely used term within the police service and means assistance is required as quickly as possible due to officers being involved in a volatile or dangerous situation, for themselves and/or members of the public. The Road Traffic Regulation Act 1984 and The Traffic Signs Regulations and General Directions 2016 exempt emergency vehicles being used for police purposes from:” Source location 2018-0368-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 The van driver was appropriately trained to exceed the statutory speed limit during an emergency response.
Verbatim wording from the response “The driver of the police van was appropriately trained to drive above the statutory speed limit, whilst responding to an emergency request for assistance. He was consequently acting in accordance with legislation, the College of Policing APP and the MPS Police Driver and Vehicle Policy.” Source location 2018-0368-Response-by-Metropolitan-Police
Open published response
29 Oct 2018 Mr Thomas Patrick McAuley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to provide prison doctors access to uploaded prison case history notes View source Failure to ensure universal availability of DPMFs to health care staff View source Failure to ensure sufficient time for reception nurses to review DPMFs View source Failure of police doctors to communicate directly with prison health care staff or transfer medical information between doctors View source Failure to establish a fail-safe mechanism for medical staff in prison to see and consider custody assessments and records View source Failure to provide DPMFs to health care staff View source Unavailability of DPMFs in prison wings View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Thomas Patrick McAuley · 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 Thomas Patrick McAuley was found dead in his prison cell on 23 August 2017. The medical cause of death was bronchopneumonia, with chronic bronchitis and alcohol and drug dependence also recorded. The inquest identified concerns about clinical information from police custody not being available to all prison clinical staff and a lack of clinical observations during the first five days of methadone treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prison doctors access to uploaded prison case history notes
Wider context from the report “3. An Oxleas manager said that the case history notes from the prison were uploaded onto PNomis, but a prison doctor did not think he had access to this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure universal availability of DPMFs to health care staff
Wider context from the report “4. A representative of Oxleas HC reported that a new process required a nurse to tick a box when the DPMF was uploaded onto the medical records, but there was no evidence that the DPMF is universally available to health care staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 sufficient time for reception nurses to review DPMFs
Wider context from the report “1. The reception nurse said that she would have had access to DPMFs but does not always have time to look at these . The DPMF was not available in the wings.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 doctors to communicate directly with prison health care staff or transfer medical information between doctors
Wider context from the report “5. There was no evidence that police doctors communicated directly with health care staff in prison , or arranged for transfer of medical information between doctors . (The police doctors were not called).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 establish a fail-safe mechanism for medical staff in prison to see and consider custody assessments and records
Wider context from the report “6. In conclusion, there is no assurance that doctors attending in custody, the prison service and those providing health care in prisons have established a fail-safe mechanism of ensuring that medical assessments on vulnerable individuals and records from custody are seen and considered by medical staff in prison .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 DPMFs to health care staff
Wider context from the report “2. A manager of the drug addiction services in the prison said that health care staff were not always given the DPMF .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 DPMFs in prison wings
Wider context from the report “1. The reception nurse said that she would have had access to DPMFs but does not always have time to look at these. The DPMF was not available in the wings .
” 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 Complete installation of the N3 connection and associated hardware across all MPS custody suites to provide healthcare professionals access to NHS Summary Care Records.
Verbatim wording from the response “The MPS has been working in partnership with the NHS to introduce an electronic medical record system (EMRS) for several years. The EMRS is expected to allow a better facilitation of healthcare information on an electronic platform. Information will be shared across police, prison and potentially court services and may include mental health, physical health and medication information, where appropriate agreements are in place. The first stage of implementing the communication network (N3) and the hardware into all MPS custody suites has been completed. The N3 connection provides healthcare professionals in MPS custody suites with access to NHS Summary Care Records and is required for an EMRS. The full implementation has been inadvertently delayed due to factors beyond the control of the MPS, however it is now likely that delivery could be achieved within a year.” Source location 2018-0309-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 Continue training and partnership working to improve medical-information handover and management of detainee health risks.
Verbatim wording from the response “The MPS will continue to attach all relevant medical information to the PER when detainees leave our custody suites to highlight any increased health risks. We are committed to continual training and partnership working and in the short-term it is anticipated by April 2019 the new PER will be introduced, which will seek to address limitations on the current PER. The MPS has also supported the dissemination of the learning opportunities presented by your report through engagement with NOMS. NHS England and HMPPS leads in the preparation of this response and as a result, we have been invited to evaluate and comment on the ePER. The MPS will be introducing the EMRS platform, hopefully within one year, which will enable the medical assessments and treatments of vulnerable individuals to be considered by medical staff in prison.” Source location 2018-0309-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 Attach relevant medical information to the Person Escort Record when detainees leave custody, including information identifying increased health risks.
Verbatim wording from the response “Prior to departure, custody staff complete a Person Escort Record (PER) and give the form to SERCO officers. If the detainee has been assessed by a Health Care Professional (HCP) in custody, the HCP will complete a Detained Person’s Medical Form (DPMF). The purpose of the DPMF is to highlight areas of medical concern to custody staff, and to provide, where necessary, a chronological medical report relating to a detainee’s period of detention. The information contained in the DPMF together with a risk assessment contribute to the safe and effective detention of the detainee. The MPS Custody Policy states that the DPMF (where applicable) is to be included in the documentation attached to the PER and should be referred to in the ‘escort handover’ page.” Source location 2018-0309-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 the revised Person Escort Record with additional health, social-care and risk information for transfers between partner agencies.
Verbatim wording from the response “There is currently work in progress to change the PER to mitigate such risks when transferring a detainee between partner agencies. HMPPS are leading on this project, which includes attaching additional documentation and notes to highlight the increased risks to partner agencies. The new PER will contain additional health and social care information, which will mitigate the identified risks when vulnerable people are being transferred between the police escort contractors and HMPPS custody. It is anticipated that this project will be completed and delivered by April 2019.” Source location 2018-0309-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 HMPPS leads the project to change the Person Escort Record and mitigate risks when detainees transfer between partner agencies.
Verbatim wording from the response “There is currently work in progress to change the PER to mitigate such risks when transferring a detainee between partner agencies. HMPPS are leading on this project, which includes attaching additional documentation and notes to highlight the increased risks to partner agencies. The new PER will contain additional health and social care information, which will mitigate the identified risks when vulnerable people are being transferred between the police escort contractors and HMPPS custody. It is anticipated that this project will be completed and delivered by April 2019.” Source location 2018-0309-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 NHS England and HMPPS are developing the electronic Person Escort Record, including medication information.
Verbatim wording from the response “There is also further work being undertaken by NHS England and HMPPS to develop an electronic version of the PER (ePER) with information regarding medications included. The ePER is being used in five prisons and is being piloted by Surrey Police. The MPS understand that, by the time the new PECS contract is operational (late 2020) the product will be fully digital. In the interim period, whilst these innovations are taking place, the MPS will continue to ensure that any relevant medical information available on NSPSIS is also recorded in the PER.” Source location 2018-0309-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 Prison-service actions concerning DPMF access and availability fall beyond the MPS’s responsibility to influence.
Verbatim wording from the response “Matters 1-4 relate to actions of the prison service and are beyond the responsibility of the MPS to influence. Matters 5-6 raise issues relating specifically to police handover of detainees and sharing of medical information; we have responded to these below:” Source location 2018-0309-Response-by-Metropolitan-Police
Open published response
29 Oct 2018 Rosario CORDERO-SANZ · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 8 Inadequate understanding of the missing person process among special police officers View source Inadequate understanding of section 136 Mental Health Act and mental health issues among special police officers View source Failure to consider and communicate ambulance involvement when clinically indicated View source Failure to use language support to obtain information from non-native English speakers View source Failure to actively listen and recheck Merlin records when new identifying information is obtained View source Failure to obtain direct or supported assessment of a person when access is challenged by concerns about police uniforms View source Inadequate CAD operator competence in partial-name wildcard searches View source Unavailability of mobile access to police computer systems for special police officers View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rosario CORDERO-SANZ · 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
Rosario (known as Charo) Cordero-Sanz died after jumping in front of a train at Bethnal Green Underground Station on 14 July 2018. The concerns included gaps in special police officers’ access to information, understanding of missing-person and mental-health procedures, communication with a non-native English-speaking friend, and the failure to identify her as a high-risk missing person.
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 Inadequate understanding of the missing person process among special police officers
Wider context from the report “2. In addition, the jury heard as follows.
- The three police officers did not appear to have an in depth understanding of the misper process .
- They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues.
- They did not consider using language line to assist them in obtaining information from the non native English speaking friend, with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices.
- Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves, or call for the assistance of a plain clothes colleague, or suggest that they speak to the friend who was sitting inside with her.
- Nobody thought of calling an ambulance that night, save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else.
I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 section 136 Mental Health Act and mental health issues among special police officers
Wider context from the report “2. In addition, the jury heard as follows.
- The three police officers did not appear to have an in depth understanding of the misper process.
- They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues .
- They did not consider using language line to assist them in obtaining information from the non native English speaking friend, with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices.
- Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves, or call for the assistance of a plain clothes colleague, or suggest that they speak to the friend who was sitting inside with her.
- Nobody thought of calling an ambulance that night, save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else.
I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and communicate ambulance involvement when clinically indicated
Wider context from the report “2. In addition, the jury heard as follows.
- The three police officers did not appear to have an in depth understanding of the misper process.
- They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues.
- They did not consider using language line to assist them in obtaining information from the non native English speaking friend, with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices.
- Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves, or call for the assistance of a plain clothes colleague, or suggest that they speak to the friend who was sitting inside with her.
- Nobody thought of calling an ambulance that night , save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else .
I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to use language support to obtain information from non-native English speakers
Wider context from the report “2. In addition, the jury heard as follows.
- The three police officers did not appear to have an in depth understanding of the misper process.
- They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues.
- They did not consider using language line to assist them in obtaining information from the non native English speaking friend , with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices.
- Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves, or call for the assistance of a plain clothes colleague, or suggest that they speak to the friend who was sitting inside with her.
- Nobody thought of calling an ambulance that night, save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else.
I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 actively listen and recheck Merlin records when new identifying information is obtained
Wider context from the report “3. The three special police officers who attended late that Friday evening / early Saturday morning were described as kind, and clearly demonstrated concern, but ultimately they did not know that they were dealing with a high risk missing person. Without tablets or a mobile data terminal, they had no means of checking this themselves.
The jury found that the special sergeant and the CAD operator did not actively listen to one another . This meant that the Merlin system was not checked again after officers had obtained Ms Cordero-Sanz’s full name , missing the opportunity to match her details with those reported earlier and to identify her as a high risk misper.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 obtain direct or supported assessment of a person when access is challenged by concerns about police uniforms
Wider context from the report “2. In addition, the jury heard as follows.
- The three police officers did not appear to have an in depth understanding of the misper process.
- They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues.
- They did not consider using language line to assist them in obtaining information from the non native English speaking friend, with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices.
- Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves , or call for the assistance of a plain clothes colleague , or suggest that they speak to the friend who was sitting inside with her .
- Nobody thought of calling an ambulance that night, save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else.
I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 CAD operator competence in partial-name wildcard searches
Wider context from the report “4. There was not a full understanding among the CAD operators of how to search with only part of a name e.g. CORDERO* as a wild card . This seems a significant omission in the understanding of those fulfilling that role.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 mobile access to police computer systems for special police officers
Wider context from the report “1. MPS special police officers are not issued with tablets as regular officers are , yet the three on duty who attended on Friday night / Saturday morning were given one of the police vans that is not equipped with an on board computer . This meant that they could not check details on police computer systems themselves . Instead, they had to radio for assistance.
” 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 Roll out 100 pool tablet devices for Metropolitan Special Constabulary officers across frontline policing.
Verbatim wording from the response “In September 2018, the MPS committed to the purchase and issuing of one hundred tablet devices, to be used as pool devices for MSC officers. The allocation of tablets across the MPS has been designated according to budgetary and operational demands. The roll out of these devices was completed in November 2018 and they have now been evenly distributed within frontline policing across the footprint of the MPS. Data usage is currently being collated, with the intention of increasing the pool size in the future. It is to be highlighted that the use of a tablet in an operational situation may benefit officers, however this is a relatively recent addition and officers are expected to use their police radios where tablets are not available. We have addressed this issue with the officers directly.” Source location 2018-0307-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 Launch and operate a mental-health and wellbeing campaign providing training, awareness and support to officers.
Verbatim wording from the response “In general terms the MPS response to incidents involving people with mental illness has evolved significantly over the last few years and continues to do so. We are committed to continual training and partnership working which has been incorporated into the annual officer safety training programme for all officers, including MSC. MSC officers are provided with mental health training in their foundation course which includes awareness of signs, symptoms and legislation. The MPS has launched a mental health and wellbeing campaign, which includes training, awareness and support for all officers. MSC are also incorporated into the Home Office funded MIND Blue Light Champion Programme, whereby selected MSC officers, alongside regular officers, are trained as mental health champions.” Source location 2018-0307-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 local learning addressing communication and active-listening failures involving Metropolitan Special Constabulary officers and the CAD operator.
Verbatim wording from the response “• The second CAD operator’s (call despatch) mistake was not related to wild card searches either. His error was not to check Ms Cordero-Sanz’s name and its phonetic spelling with the officers at the scene. However it is acknowledged that CAD operators have numerous demands placed on them at any one time and are generally dealing with multiple calls. This was a failure of communication and active listening, and has been dealt with by way of local learning for the MSC officers and the second CAD operator.” Source location 2018-0307-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 support for Metropolitan Special Constabulary practical learning.
Verbatim wording from the response “• The three police officers did not appear to have an in depth understanding of the misper process.
On their initial foundation course, all MSC officers receive training on how to deal with a missing person and are expected to be conversant with changes in legislation and policy. The MPS is satisfied that the level of training provided is sufficient for MSC officers. If a MSC officer, or indeed any police officer, is unsure of how to deal with an incident they should seek supervisory advice at the scene. In light of this incident, all MSC coordinators who are experienced police constables supporting the MSC, have been tasked to review the support of MSC practical learning.” Source location 2018-0307-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 Continue mental-health training and partnership working through annual officer safety training.
Verbatim wording from the response “In general terms the MPS response to incidents involving people with mental illness has evolved significantly over the last few years and continues to do so. We are committed to continual training and partnership working which has been incorporated into the annual officer safety training programme for all officers, including MSC. MSC officers are provided with mental health training in their foundation course which includes awareness of signs, symptoms and legislation. The MPS has launched a mental health and wellbeing campaign, which includes training, awareness and support for all officers. MSC are also incorporated into the Home Office funded MIND Blue Light Champion Programme, whereby selected MSC officers, alongside regular officers, are trained as mental health champions.” Source location 2018-0307-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 Disseminate learning from the report and review training for Metropolitan Special Constabulary and regular officers.
Verbatim wording from the response “The MPS has supported the dissemination of the learning opportunities presented by your report and is reviewing training in the context of both the MSC and the regular service. The MPS identifies that an aspiration to patrol MSC officers with regular officers on a regular basis would be unachievable due to competing demands, as well as MSC availability. As a direct result of this incident, CE BCU has put processes in place to ensure that MSC officers are briefed and debriefed at the start and end of their tours of duty and have supervisory support throughout. Commander Muskett, the lead for frontline policing, has directed that this process be implemented across all other BCUs.” Source location 2018-0307-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 Recirculate Language Line access instructions and information about its benefits to Metropolitan Special Constabulary officers.
Verbatim wording from the response “Language Line can be accessed via police Airwave radios at any time and full instructions on how to access this service is readily available on the MPS intranet. Instructions on how to use this and its benefits have been recirculated to the MSC via the duty sheet messaging system. The failures identified within this matter of concern represent individual failings which have been addressed directly with the officers concerned.” Source location 2018-0307-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 Existing foundation training is considered sufficient for special officers handling missing-person incidents.
Verbatim wording from the response “• The three police officers did not appear to have an in depth understanding of the misper process.
On their initial foundation course, all MSC officers receive training on how to deal with a missing person and are expected to be conversant with changes in legislation and policy. The MPS is satisfied that the level of training provided is sufficient for MSC officers. If a MSC officer, or indeed any police officer, is unsure of how to deal with an incident they should seek supervisory advice at the scene. In light of this incident, all MSC coordinators who are experienced police constables supporting the MSC, have been tasked to review the support of MSC practical learning.” Source location 2018-0307-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 Wildcard searches could not have assisted in this case, and Merlin has limited wildcard-search functionality.
Verbatim wording from the response “• Merlin has limited capacity to perform ‘wild card’ searches. It has no Boolean capability and cannot perform searches of terms within a certain distance of other terms; it is the system, and not the operators, that is limited in this way. More importantly, no wild card searches could have assisted in this case, since the CAD operator (call receipt) only had the first name to search on and therefore had no reason to contemplate a wild card search. The spelling was provided phonetically and the CAD operator could not have known that it was wrongly spelled. In any event, it would not have been reasonable to search for ‘Rosareo’ multiple times with every letter in turn replaced with an *.” Source location 2018-0307-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 Suggested scene-assessment actions will not be made mandatory because they may be impracticable or inappropriate in some circumstances.
Verbatim wording from the response “It has been established that the MSC officers who attended the address were not provided with the full details of the call. The informants whom they spoke to did not indicate that Ms Cordero-Sanz was in immediate danger. However it is recognised that if they had obtained more information at the scene utilising Language Line they may have altered their risk assessment and seen her in person. Whilst the suggested considerations have merit, we would not seek to make them mandatory actions as they may not be appropriate or practicable in all circumstances. Had the MSC officers known Ms Cordero-Sanz was a high risk missing person, MPS policy would have required them to physically see her and ensure she was safe and of no danger to herself or others.” Source location 2018-0307-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 Police radios are considered sufficient when tablets are unavailable, so tablets are not required for every special officer.
Verbatim wording from the response “In September 2018, the MPS committed to the purchase and issuing of one hundred tablet devices, to be used as pool devices for MSC officers. The allocation of tablets across the MPS has been designated according to budgetary and operational demands. The roll out of these devices was completed in November 2018 and they have now been evenly distributed within frontline policing across the footprint of the MPS. Data usage is currently being collated, with the intention of increasing the pool size in the future. It is to be highlighted that the use of a tablet in an operational situation may benefit officers, however this is a relatively recent addition and officers are expected to use their police radios where tablets are not available. We have addressed this issue with the officers directly.” Source location 2018-0307-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 Section 136 would not have assisted because it does not apply to people inside private dwellings.
Verbatim wording from the response “S136 Mental Health Act would not have assisted the MSC officers in this particular situation because it does not apply to a person inside a private dwelling.” Source location 2018-0307-Response-by-Metropolitan-Police
Open published response
19 Jul 2018 Jeroen ENSINK · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 19 Failure to create safeguarding notifications for suspected mental health or substance abuse problems View source Lack of police understanding of the CPS Notice of Proposed Discontinuance procedure View source Failure to communicate mental health concerns to the forensic medical examiner View source Failure to accurately record suspected cannabis use View source Failure of custody systems to generate alerts from recorded mental health information View source Lack of a common police understanding of where and when to find required information View source Failure to obtain statements from available witnesses View source Failure to communicate identified mental health concerns to custody staff View source Failure to alert the forensic medical examiner to newly available mental health information View source Failure to review CRIS information before interview View source Failure to record strip-search results View source Failure of custody staff to read relevant detention-log information View source Failure to maintain consistent and accurate recording of alleged weapon threats View source Failure to record force used during arrest View source Failure to investigate a volunteered admission of hammer possession View source Omission of material information from prosecution statements View source Failure to accurately record detainee injuries View source Failure to refer detainees for forensic medical examination on relevant non-substance grounds View source Failure to flag material mental health and assault information on the PNC View source See 16 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
Jeroen ENSINK · 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
Dr Jeroen Ensink was stabbed to death in a wholly unprovoked attack on 29 December 2015. The report identified multiple concerns involving police recording and information-sharing failures, including failures to identify and communicate possible mental health problems and issues in the handling of evidence and custody records.
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 create safeguarding notifications for suspected mental health or substance abuse problems
Wider context from the report “1. Following his arrest on 22 May 2015, no officer created a Merlin in respect of ████████, though his behaviour suggested to both arresting officers the possibility that he was suffering mental health or substance abuse problems. Thus the MASH (multi agency safeguarding hub) was never alerted to his potential need for treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of police understanding of the CPS Notice of Proposed Discontinuance procedure
Wider context from the report “19. There was an almost total lack of understanding among police officers of the detail of the CPS Notice of Proposed Discontinuance procedure , most particularly in terms of who this should go to, who should send it, what actions are then possible and what impact these actions might have .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 mental health concerns to the forensic medical examiner
Wider context from the report “8. Consequently, no mental health concerns were brought to the attention of the FME (forensic medical examiner) who examined ████████, meaning that his mental state examination was more superficial than it would otherwise have been .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 accurately record suspected cannabis use
Wider context from the report “9. Both arresting officers thought there was a possibility that ████████ was under the influence of cannabis. The custody sergeant recorded this as heavy cannabis use , he said because in his experience people who use cannabis use it heavily .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of custody systems to generate alerts from recorded mental health information
Wider context from the report “11. When ████████ sister rang the police station to explain that in Nigeria, her brother had been diagnosed with mental health problems, and to ask that she be permitted to attend during his interview as an appropriate adult, the detention officer recorded this, but the system did not create any sort of alert or pop up .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 common police understanding of where and when to find required information
Wider context from the report “18. There was no common understanding among police officers of who should look where, when, for what : the PNC, the Merlins, the CRIS, the COPA, the detention log, the custody record risk assessments etc.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 obtain statements from available witnesses
Wider context from the report “3. Only one statement was taken, though there were other witnesses on scene .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 identified mental health concerns to custody staff
Wider context from the report “7. Both arresting officers formed the view that ████████ was suffering mental health or substance abuse problems, and both included these two factors in their statements , but the custody sergeant gave evidence that no mental health concerns were brought to his 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 to alert the forensic medical examiner to newly available mental health information
Wider context from the report “13. Consequently, the FME was never alerted to this , and so did not return to re-examine ████████ .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 review CRIS information before interview
Wider context from the report “15. The interviewing officer did not read the CRIS report , and gave evidence that it was not MPS protocol so to do . The CRIS report contained a record of the question mark over ████████ mental health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to record strip-search results
Wider context from the report “14. The booking in custody sergeant recorded authorisation of a strip search, but did not record the result of the search .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of custody staff to read relevant detention-log information
Wider context from the report “12. Neither custody sergeant working that night read the note of the conversation recorded by the detention officer in the detention log.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 consistent and accurate recording of alleged weapon threats
Wider context from the report “4. The custody sergeant who booked ████████ into custody recorded that ████████ had threatened police officers with a knife , though there was no mention of this on the CRIS (crime record information system) report or in the officers’ statements , and both officers gave evidence at inquest that ████████ had not had a bladed article in his possession when they arrested him. This was later found on the windowsill through which he had climbed into the property.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 force used during arrest
Wider context from the report “6. The arresting officers described in evidence a violent struggle with ████████ when they arrested him. He had tried to grab the Taser belonging to one of the officers. Yet the custody sergeant recorded that no force had been used . And this was despite the fact he said that he was under the impression that ████████ had wielded a knife against the officers. He said in evidence this was because the force had been used outside the police station .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 a volunteered admission of hammer possession
Wider context from the report “16. The interviewing officer was surprised when ████████ denied possession of a bladed article in a public place but volunteered possession of a hammer. As a consequence of his surprise, he asked very few questions about this and did not pursue 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 Omission of material information from prosecution statements
Wider context from the report “2. Police officers at the scene of ████████ arrest took a statement in support of the prosecution of the offence of possession of a bladed article in a public place. However, they missed out a line from the statement that the CPS considered was vital to demonstrating ████████ location when he had the knife . This omission was rectified only months later.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 accurately record detainee injuries
Wider context from the report “5. The custody sergeant noted that ████████ had a bruised, bleeding and swollen lip , yet to the custody record question regarding any injuries, he recorded no .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 refer detainees for forensic medical examination on relevant non-substance grounds
Wider context from the report “10. The custody sergeant gave evidence that, had it not been for suspected cannabis use, he would not have called the FME for any other reason .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 flag material mental health and assault information on the PNC
Wider context from the report “17. The PNC (police national computer) was never flagged with a warning that ████████ had mental health problems , either after his arrest, after his sister’s phone call, or after the letter from his Nigerian doctor was presented and scanned onto COPA (case overview and prosecutions application); and was never flagged with a warning that he had assaulted a police officer .
” Open source report
29 Jun 2018 Rashan Jermaine CHARLES · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to recognise that apparent resistance may indicate a struggle to breathe View source Lack of specific training advice on managing public assistance View source Choking without classic visible signs View source Difficulty assessing whether breathing is present and normal 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
Rashan Jermaine CHARLES · 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
Rashan Jermaine Charles entered a convenience store after a foot chase, put a package in his mouth, and was restrained and handcuffed during a struggle. He lost consciousness and suffered cardiac arrest; the recorded medical cause of death was cardiac arrest due to upper airway obstruction by a foreign body during restraint. Concerns included recognising choking when it resembles resistance, assessing breathing in stressful conditions, and managing assistance from members of the public.
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 that apparent resistance may indicate a struggle to breathe
Wider context from the report “When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers.
1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that.
2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick.
3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.)
4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed.
Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate.
Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment.
I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of specific training advice on managing public assistance
Wider context from the report “When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers.
1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that.
2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick.
3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.)
4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed.
Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate.
Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment.
I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Choking without classic visible signs
Wider context from the report “When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers.
1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that.
2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick.
3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.)
4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed.
Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate.
Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment.
I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Difficulty assessing whether breathing is present and normal
Wider context from the report “When updating police officer training, it would seem helpful for those developing policies and protocols to bear the following factors in mind, factors that might not otherwise be evident to police officers.
1. An apparent struggle to resist search or arrest, might in fact be a struggle to breathe, or might become that.
2. Choking is not always accompanied by classic signs such as clutching the throat, coughing, red face or bulging eyes, but can be silent and very quick.
3. It can be extremely difficult to assess whether breathing is present and normal, particularly in a stressful and/or noisy situation. (I heard evidence that, for training purposes, abnormal breathing could possibly in future be simulated by a virtual reality programme.)
4. Members of the public can sometimes give vital assistance, but this assistance might need to be managed.
Analysis of a situation by a member of the public might give helpful insight, but on the other hand might not be accurate.
Even a single member of the public might unwittingly distract an officer, especially in a fast paced environment.
I heard evidence that, at present, MPS training does not include specific advice about how best to utilise members of the public who are willing and able to assist police officers.
” 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 Train officers to manage bystander assistance through practical scenarios and situation-specific decisions using the National Decision Model.
Verbatim wording from the response “The potential value of bystanders in dealing with casualties is recognised within the training given to officers and is explored with various scenarios. These include assisting in placing a subject into the spinal recovery position, crash helmet removal and the delivery of CPR.” Source location 2018-0210-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 Train officers to conduct thorough breathing checks, monitor breathing, open airways and commence CPR when breathing is abnormal or uncertain.
Verbatim wording from the response “The importance of completing a thorough breathing check and regularly monitoring a subject’s breathing is central to ELS training. The training states that if breathing cannot be established because a subject is in the recovery position, they should be turned onto their back to facilitate a full breathing check. It further states that CPR should be commenced if there is any doubt.” Source location 2018-0210-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 Provide recruit and three-yearly refresher training on recognising and treating choking, including cases without classic signs.
Verbatim wording from the response “The Programme Specification states in respect of choking: “An airway obstruction can be recognised by difficulty speaking, attempts to breathe or cough, increasing signs of asphyxia (blueness discolouration to face) and eventual loss of consciousness. Therefore, it is therefore made clear that individuals who are choking they may not be able to breathe or cough.” Source location 2018-0210-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 Deliver ELS training scenarios requiring officers to assess breathing, reposition subjects, recognise noisy breathing and provide CPR.
Verbatim wording from the response “The careful assessment of a subject’s breathing features in one of the training scenarios within the 2018 / 2019 ELS training package. The scenario requires an assessment of a subject’s breathing, and them being re-positioned to assist breathing. The scenario then develops to noisy breathing and onto the delivery of cardiopulmonary resuscitation (CPR).” Source location 2018-0210-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 It is not possible to prescribe how bystanders should be used because situations, backgrounds, training and skills vary.
Verbatim wording from the response “The potential value of bystanders in dealing with casualties is recognised within the training given to officers and is explored with various scenarios. These include assisting in placing a subject into the spinal recovery position, crash helmet removal and the delivery of CPR.” Source location 2018-0210-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 Existing MPS Emergency Life Support training addresses recognition of concealed medical emergencies, choking, abnormal breathing and appropriate first-aid responses.
Verbatim wording from the response “The possibility that an apparent struggle or resistance might mask a medical emergency is firmly established within the MPS’ Emergency Life Support (ELS) training. It is central to training concerning positional asphyxia and Acute Behavioural Disturbance. It has also informed the MPS’ review of guidelines associated with restraint positions. Current work is focusing upon tilting the subject’s head forward to help reduce the risk of concealed objects falling into the airway and causing choking. The revised guidance is currently being peer-reviewed prior to adoption by the MPS. The findings will be shared with the College of Policing to help ensure best practice across England and Wales.” Source location 2018-0210-Response-by-Metropolitan-Police
Open published response
28 Jun 2017 Olaseni Lewis · Prevention of Future Deaths report South London
View report summary
Concerns raised 8 Inadequate definition of prolonged restraint and restraint danger in ABD training View source Lack of defined and understood respective roles and responsibilities between healthcare and police staff View source Failure of ABD training to provide clear and understood recognition guidance View source Lack of guidance and training for failure to achieve control within a given period View source Lack of trained and physically able medical staff View source Lack of clarity about responsibility for assessing compliance View source Failure to follow the policy for closing wards or placing them in special measures when training levels fall below the required level View source Lack of required reading and ready reference on restraint techniques and dangers View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Olaseni Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Olaseni Lewis developed an acute psychotic illness, was admitted to hospital, and was later restrained by police and healthcare staff after becoming agitated. He became unconscious and suffered a cardiac arrest. The concerns included prolonged and disproportionate restraint, inadequate police and healthcare training and communication, unclear responsibilities, and failures to respond appropriately to the medical emergency.
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 Inadequate definition of prolonged restraint and restraint danger in ABD training
Wider context from the report “(3) Police were taught that prolonged restraint was dangerous, but had no idea what “prolonged” meant, and were left to use their own judgement . They also seemed to think that prolonged restraint referred to time spent in a prone position and that as long as the detainee was held on his/her side the danger was ameliorated or removed . The pathological and psychiatric expert evidence clearly indicated that restraint in any position can lead to sudden death in patients who are highly agitated . The jury found that the police training was inadequate in its definition of “prolonged restraint” for people exhibiting signs of ABD .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 defined and understood respective roles and responsibilities between healthcare and police staff
Wider context from the report “(5) There was no training or understanding about the respective roles and responsibilities of healthcare and police staff . There was (and still is) no Memorandum of Understanding .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 ABD training to provide clear and understood recognition guidance
Wider context from the report “(2) Officers had been taught about Acute Behavioural Disturbance (ABD) but most did not recognise that Mr Lewis was suffering from ABD . The training on ABD appeared unnecessarily complicated and was not fully understood by officers . They incorrectly assumed that it was a formal diagnosis of some sort and that healthcare professionals would be able to recognise and treat the condition . An expert psychiatrist indicated that the description might be helpful for police in the community, particularly when the condition is caused by drugs, but it causes difficulty when police and mental health services work together and where the underlying cause is related to mental illness. The question that arose was whether it is necessary to attach a label at all. It might be more easily understood if officers are taught that people who resist restraint and appear to be suffering from mental illness may not respond as expected, and are therefore more vulnerable to die suddenly during restraint.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 and training for failure to achieve control within a given period
Wider context from the report “(4) Police officers were given no advice or training what they could or should do if control was not achieved within a given period of 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 Lack of trained and physically able medical staff
Wider context from the report “(6) The jury concluded that medical staff requested police assistance due to a lack of trained and physically able medical staff . The Trust had a policy for closing wards or placing them in special measures when training levels fell below a given level, but this was not followed and there was a lack of clarity around who was responsible for assessing compliance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 responsibility for assessing compliance
Wider context from the report “(6) The jury concluded that medical staff requested police assistance due to a lack of trained and physically able medical staff. The Trust had a policy for closing wards or placing them in special measures when training levels fell below a given level, but this was not followed and there was a lack of clarity around who was responsible for assessing compliance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 policy for closing wards or placing them in special measures when training levels fall below the required level
Wider context from the report “(6) The jury concluded that medical staff requested police assistance due to a lack of trained and physically able medical staff. The Trust had a policy for closing wards or placing them in special measures when training levels fell below a given level, but this was not followed and there was a lack of clarity around who was responsible for assessing compliance
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 required reading and ready reference on restraint techniques and dangers
Wider context from the report “(1) The court was told that officers are not expected to read Standing Operating Procedures and the Officer Safety Manual , and there is little “required reading” or ready reference for police officers regarding restraint techniques and dangers .
” 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 Embed recognition and emergency treatment of suspected ABD in mandatory, assessed restraint training.
Verbatim wording from the response “In addition, the Officer Safety Training Programme (OST), which is pass/fail and mandatory for all officers below the rank of superintendent, reinforces each of the significant areas of information during the instructor-led modules. For example, the complex issues surrounding the condition that has come to be known as Acute Behavioural Disorder (ABD) forms a golden thread through regularly taught, refreshed and assessed modules within restraint training. In this way, officers become” Source location 2017-0205-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 Maintain an ongoing partnership with independent healthcare experts to inform restraint and officer-safety training.
Verbatim wording from the response “The Independent Medical Science Advisory Panel (IMSAP) is an ad hoc panel of leading independent healthcare professionals who advise the National Policing Lead for Personal Safety Training on medical matters relating to physical restraint and self-defence techniques and equipment. The MPS believes that this on-going partnership helps to ensure that its officers receive the best informed training on what remains a complex condition that can present in very challenging and often violent situations. The benefits of changing this approach, which is firmly embedded in national and MPS training, appear to be unclear and could undo much good work already achieved by the police service with medical partners.” Source location 2017-0205-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 Continue the Mental Health Team’s work supporting development of the national police-healthcare memorandum of understanding.
Verbatim wording from the response “The potential confusion this term may cause when working with other mental health service providers highlighted in your report is however acknowledged. This barrier can be reduced through improved working relations with the police and health care professionals. Work in this area includes the production of the ‘Safer Restraint’ DVD by the MPS in partnership with South London and Maudsley NHS Trust (SLaM) and the ongoing work of the MPS Mental Health Team in support of the national Memorandum of Understanding (MOU) announced by the College of Policing in January 2017 (College of Policing, 2017). The MOU was provided to you as an appendix to ████████ statement dated 26/01/2017.” Source location 2017-0205-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 Produce safer-restraint training material jointly with South London and Maudsley NHS Trust.
Verbatim wording from the response “The potential confusion this term may cause when working with other mental health service providers highlighted in your report is however acknowledged. This barrier can be reduced through improved working relations with the police and health care professionals. Work in this area includes the production of the ‘Safer Restraint’ DVD by the MPS in partnership with South London and Maudsley NHS Trust (SLaM) and the ongoing work of the MPS Mental Health Team in support of the national Memorandum of Understanding (MOU) announced by the College of Policing in January 2017 (College of Policing, 2017). The MOU was provided to you as an appendix to ████████ statement dated 26/01/2017.” Source location 2017-0205-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 Agree and implement a joint police-healthcare protocol covering police support in relevant mental-health settings.
Verbatim wording from the response “5. The service level agreement (SLA) that had been in place since 6 September 2000 between SLaM/BRH and the MPS had fallen out of use by 2010 (C170, Holmes ref D20, pages 7563 – 7576). Although SLAs were agreed between SLaM and various MPS policing boroughs in 2004 - 6, one was not in place with Bromley. Following Mr. Lewis’ death, a new Joint Protocol was agreed between SLaM and relevant MPS policing boroughs (including Bromley), which came into effect in September 2012 (C280, Holmes ref D50, pages 8093 – 8134).” Source location 2017-0205-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 Replace lengthy policing procedures with accessible toolkits, including a live Mental Health Toolkit.
Verbatim wording from the response “At the time of Mr. Lewis’ death in 2010 and at all times subsequently, all MPS SOPs and guidelines on mental health and officer safety have been available to officers on the MPS Intranet. A number of years ago it became accepted that the number and format of SOPs was overly burdensome on officers’ time and it was not realistic to expect them to be familiar with them. To make the guidance easier to access the MPS has reformatted its SOPs into much shorter, and more user-friendly “Toolkits”. The “Toolkits” have been designed to make information easier to locate and comprehend. They contain e- links to related information to provide additional depth and context where required. This change reflects previous learning. The Policing Mental Health SOP has been replaced with a Mental Health Toolkit, which went live in July this year.” Source location 2017-0205-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 A specified restraint time limit will not be introduced because it lacks clinical basis and presents practical timekeeping difficulties.
Verbatim wording from the response “3. The introduction of time limits for prolonged restraint has been subject to much discussion in the police service. Advice from the Independent Medical Science Advisory Panel (IMSAP) was that there is no clinical basis for this due to the ‘many and various physiological factors that would preclude a firm medical basis for such an approach’ (Independent Medical Science Advisory Panel, 2014). The advice further cautioned that the introduction of a time limit could give rise to a misconception that restraint within this time period was safe. Doubts were also raised over the practicalities of accurate time keeping such events.” Source location 2017-0205-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 The sixth concern is directed to South London and Maudsley NHS Foundation Trust rather than the police service.
Verbatim wording from the response “6. The jury concluded that medical staff requested police assistance due to a lack of trained and physically able medical staff. The Trust had a policy for closing wards or placing them in special measures when training levels fell below a given level, but this was followed and there was a lack of clarity around who was assessing compliance.” Source location 2017-0205-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 Existing ABD terminology and embedded training are considered sufficient; changing the approach has unclear benefits and could undo established work.
Verbatim wording from the response “2. It is widely recognised that the status of ABD remains a point of conjecture for many healthcare professionals. The police service in England recognised this but increasing phenomenon in the mid-90s and adopted the American terminology of Excited Delirium in mandatory training. The Senior Coroner heard evidence that the terminology was largely connected to the use of drugs, whereas behaviour manifesting in the same way and raising the same risk of sudden death during or following restraint became known to arise also from the misuse of drink, and/or related to certain health conditions, both physical and mental. Leading pathologists and other healthcare professionals advised the police service to adopt the wider umbrella term of ABD.” Source location 2017-0205-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 Existing training and prompt medical intervention are considered sufficient when officers fail to achieve control within a specified period.
Verbatim wording from the response “4. As outlined above at 3, the advice received from IMSAP is that the attachment of any specified time value to the term “prolonged” would be without a clinical basis. Suggestions during the inquest in relation to the option of leaving Mr. Lewis in mechanical restraints only (i.e. handcuffs and leg restraint) were not supported by the expert evidence, as it would not have removed the basis for resistance/struggling and therefore would not have reduced the risk to life. Police training in respect of all suspected incidents of ABD is clear, consistent and unambiguous. Officers should treat all suspected incidents of ABD as a medical emergency. The emphasis is then on obtaining appropriate and timely medical intervention, whether from LAS or other health partners.” Source location 2017-0205-Response-by-Metropolitan-Police
Open published response
8 Mar 2017 Mr Valdas Jasiunas · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Unavailability of alcohol-withdrawal information leaflets in different languages View source Lack of a specific alcohol-dependency question in custody-suite risk assessments View source Custody-record systems that readily permit errors 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
Mr Valdas Jasiunas · 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 Valdas Jasiunas, who had serious underlying health problems including chronic alcohol liver disease and seizures, was arrested and held in police custody on 1 September 2010. He collapsed in his cell the following morning and died in hospital on 2 September 2010. Concerns included the identification and management of alcohol dependency, erroneous custody-record entries that could provide false reassurance, and communication difficulties where English was not the detainee’s first language.
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 Unavailability of alcohol-withdrawal information leaflets in different languages
Wider context from the report “3. There were some questions marks around the full understanding of Mr Jasiunas as English was not his first language. The Medical Director of the Forensic Healthcare services has confirmed that a very helpful leaflet is now provided to detained persons in custody setting out the signs and symptoms of alcohol withdrawal. The leaflet is not yet available in different languages . The FME stated that in East London, a number of detained persons are of Eastern European origin. The leaflet may well assist in ensuring that relevant signs and symptoms are brought to the attention of custody staff. Availability of the leaflet in the most common presenting languages is likely to ensure that more detained persons are able to understand and communicate significant concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific alcohol-dependency question in custody-suite risk assessments
Wider context from the report “1. It was noted that staff in custody suites have to deal with a large number of detained persons who suffer from alcohol dependency. The risks of withdrawal to those who are alcohol dependent are wide ranging from shakes and tremors to death. In light of the frequency of dealing with detained persons who suffer from alcohol dependency and in light of the severity of the potential risk, it was considered that a specific question in the risk assessment document as to dependency on alcohol should be included . The current risk assessment simply states “are you dependent on drugs or any other substance”. A directly pointed question relating to alcohol is likely to be of greater assistance in ensuring that the risk is clearly identified, assessed and managed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Custody-record systems that readily permit errors
Wider context from the report “2. An erroneous entry was inserted into Mr Jasiunas’ record by an FME. The entry had the effect of providing false assurance to custody staff. The evidence revealed that errors on the custody records are commonplace and that the current design of the system renders errors easily made . Suggestions for improvements of the system included photographs of the detainee on the computer system; more prominent indication of the detainees surname at the top of the medical form; pop-up prompts to remind the healthcare practitioner to ensure that they have identified the correct detainee before prescribing medication; changes to prevent medication from being entered onto a person’s custody record in the absence of an accompanying medical form being completed at the same time.
” Open source report
2 Feb 2017 James Kerry Fox · Prevention of Future Deaths report North London
View report summary
Concerns raised 7 Unavailability of a less lethal firearm for disabling subjects View source Failure to use maximum available protection in firearms incident responses View source Differences and apparent contradictions within police officer training curricula View source Lack of detailed contingency planning at briefings View source Inaccuracy of shots fired at close range View source Lack of standard central national training View source Unavailability of a shield with enhanced ballistic protection and a visible section View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Kerry Fox · 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
James Kerry Fox, who had been suffering from depression and anxiety, was shot by police officers after opening the door of his flat while holding an air weapon pointed in the officers’ direction. The inquest concluded that the death was lawful killing. The principal concerns included the accuracy of close-range shots, the lack of detailed contingency planning, the availability of less-lethal firearms and enhanced ballistic protection, firearms response tactics, and inconsistencies and lack of national standardisation in police firearms training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a less lethal firearm for disabling subjects
Wider context from the report “3, That there is no less lethal firearm available to disable rather than cause fatal injury . A larger calibre less lethal firearm is available for use in other circumstances.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to use maximum available protection in firearms incident responses
Wider context from the report “5, A concern that if the presumption is that every firearm has the potential to kill or cause serious injury to officers, and members of the public, who attend or are present, at a firearms incident then the response to each incident does not utilise that maximum available protection ie, two officer team one with a full length shield and the other carrying a short carbine .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Differences and apparent contradictions within police officer training curricula
Wider context from the report “6, The differences between, and apparent contradictions within the curriculum used for the training of police officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed contingency planning at briefings
Wider context from the report “2, The need for contingency planning. There was no detailed contingency plan formulated at the briefing to cover the very real prospect that Mr Fox might at the very least open his door. It was left to the officers to apply their generic training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inaccuracy of shots fired at close range
Wider context from the report “1, The accuracy of shots fired at close range . A number of shots were fired at close range, (about 1 meter) , resulting in a range if injuries spread over a large area including a gunshot wound to the head.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 standard central national training
Wider context from the report “7, That there is no standard central training provided on a national basis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 a shield with enhanced ballistic protection and a visible section
Wider context from the report “4, That there is no currently available shield with enhanced ballistic protection and a visible section that officer’s might use to safely shelter behind.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide London armed officers with recently purchased enhanced ballistic shields incorporating ballistic-rated observation windows.
Verbatim wording from the response “25. The MPS acknowledges the value of portable ballistic protection (shields), and the ability to see through such protection. As this inquest commenced the MPS had already taken delivery of recently purchased shields of this design, and continues to make them available to armed officers in London. The purchase of these particular shields came about as a result of a general capability review for the MPS in light of the recent global terrorist incidents.” Source location 2017-0014-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 Research and develop less-lethal technologies suitable for police use through UK policing and Home Office collaboration.
Verbatim wording from the response “23. As technology advances it may be possible to revisit the policy with regard to deploying less lethal weapons during certain firearms incidents. However, currently there is no less lethal weapon approved for police use which is guaranteed to incapacitate, and could therefore be considered for use as a primary response against a person believed to be in possession of a firearm. The MPS will continue to in work within the UK policing structure and in conjunction with the Home Office Centre for Applied Science and Technology (CAST), to research and develop all less lethal technologies that are suitable for police use.” Source location 2017-0014-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 MPS firearms training material to make wording explicit and reduce judicial misinterpretation.
Verbatim wording from the response “38. In respect of this particular incident the MPS does not accept there is training delivered to officers contrary to that required or permitted by the NPFTC. It is true to say that some MPS content in respect of a particular formation around a door as a point of entry no longer appears in the relevant section of the NPFTC. The MPS believes this will be rectified when the module in question is reviewed, and is currently working with the College of Policing to ensure this review is completed in a timely fashion. The MPS is also reviewing its own training material to ensure the wording contained is explicit and can be better understood during judicial processes. This is done with the aim to avoid future misinterpretation.” Source location 2017-0014-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 Continue reviewing and developing firearms tactics to prioritise the safety of subjects and officers.
Verbatim wording from the response “46. The MPS recognises that there will be lessons learnt from each and every occasion an officer discharges their weapon. The MPS is committed to continually reviewing and developing tactics to ensure the safety of subjects and officers is of the highest priority.” Source location 2017-0014-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 Work with the College of Policing to complete a timely review of the national firearms training curriculum module.
Verbatim wording from the response “38. In respect of this particular incident the MPS does not accept there is training delivered to officers contrary to that required or permitted by the NPFTC. It is true to say that some MPS content in respect of a particular formation around a door as a point of entry no longer appears in the relevant section of the NPFTC. The MPS believes this will be rectified when the module in question is reviewed, and is currently working with the College of Policing to ensure this review is completed in a timely fashion. The MPS is also reviewing its own training material to ensure the wording contained is explicit and can be better understood during judicial processes. This is done with the aim to avoid future misinterpretation.” Source location 2017-0014-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 Maintain national armed-officer weapon-handling and shooting-accuracy standards, with regular reviews of training sufficiency.
Verbatim wording from the response “11. The MPS continues to maintain national standards in respect of armed officers weapon handling and shooting accuracy, and additionally reviews these standards regularly to ensure officers are trained sufficiently to meet the operational requirement based on threats encountered.” Source location 2017-0014-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 Generic training and rehearsed scenario-based responses are considered sufficient for officers to react appropriately as armed incidents develop.
Verbatim wording from the response “13. Officers are taught to react to circumstances as they unfold and read visual stimulus to inform threat assessment and take appropriate action / reaction. This would be the case for a door unexpectedly opening and a person posing an immediate threat. Armed officers are trained to assess and respond to threat appropriately, and this is a constant feature in training where numerous differing scenarios are rehearsed.” Source location 2017-0014-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 College-led training governance, common standards, good-practice sharing and flexible local delivery are considered the best model for UK firearms training.
Verbatim wording from the response “40. There are 51 separate police forces and law enforcement organisations (E.g. The National Crime Agency) in the UK. These organisations all have differing levels of armed capability. Whilst some Forces operate within a training collaboration, some Forces deliver training independently. The link is provided by the College of Policing who licence training centres, and training delivery is completed with the NPFTC as a guide to ensure common national standards and interoperability.” Source location 2017-0014-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 A full-length shield and carbine are not accepted as the maximum protective configuration for every circumstance because equipment limitations and operational environments vary.
Verbatim wording from the response “31. The full-length enhanced ballistic shield referred to has a weight of more than 30Kg. This prevents most police officers from being able to easily manoeuvre or indeed even hold this equipment for more than a few minutes at a time. This equipment therefore has limitations despite its enhanced protective capabilities. The advantages of greater degrees of ballistic protective equipment have to be balanced with the practicalities of wearing and moving in such equipment. Armed response officers must also be capable of carrying such equipment in vehicles, and responding to incidents quickly and effectively.” Source location 2017-0014-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 The College of Policing owns and manages the national firearms training curriculum, including its content and role-profile requirements.
Verbatim wording from the response “35. The National Police Firearms Training Curriculum (NPFTC) has been developed within a framework of integrated modules and units that together represent a whole programme of skills to be incorporated into armed officer training. The NPFTC is owned and managed by the College of Policing. It determines the training content for all firearms officer and Firearms Commander role profiles. The NPFTC is a reference document that is used to deliver a consistent standard of training, and a nationally understood catalogue of tactical deployments and capabilities for armed policing. The NPFTC is not a training manual for armed police. It is utilised as a guide to provision of common National standards, method of standardised assessment, and performance criteria.” Source location 2017-0014-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 The available evidence does not establish that officers’ shooting accuracy was poor or that the head wound resulted from deliberately aiming at the head.
Verbatim wording from the response “9. It is possible one or both officers’ aim was adversely affected by the requirement to act quickly and instinctively. However, based upon the evidence available, no definite conclusion can be arrived at which would suggest either of the officer’s aim was poor. It is possible and plausible that the movement of James Fox’s body as he was hit may account for the location of the wounds. For example, the wound to head may have been the final shot fired which was directed into the torso but actually hit the head as James Fox fell backwards. Without any detailed and evidentially reliable reconstruction providing a basis for further examination, it would not be a fair conclusion that the officer’s accuracy was poor.” Source location 2017-0014-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 National standards and regular review of armed-officer weapons handling and shooting accuracy are considered sufficient to meet operational requirements.
Verbatim wording from the response “11. The MPS continues to maintain national standards in respect of armed officers weapon handling and shooting accuracy, and additionally reviews these standards regularly to ensure officers are trained sufficiently to meet the operational requirement based on threats encountered.” Source location 2017-0014-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 Less-lethal weapons cannot be used unless approved by the Secretary of State, limiting independent police adoption of new systems.
Verbatim wording from the response “22. In terms of development of technologies, UK police cannot use less lethal weapons unless approved by the Secretary of State. Chief Police officers have a responsibility to ensure that police weaponry is fit for purpose and …where appropriate adopt effective less lethal weapon systems where they might reduce reliance on conventional firearms or ammunition without compromising the safety of police officers or others who might be affected. For this purpose, Chief Officers co-operating with each other (normally through ACPO) should monitor the availability of new weapon systems. The police service should maintain the capability centrally to assess, evaluate and where ACPO regard new weapon systems as suitable for further evaluation and testing they should consult the Secretary of State.⁵” Source location 2017-0014-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 Centralised firearms training for all organisations is currently logistically impracticable and would prevent necessary regional and organisational variations.
Verbatim wording from the response “41. There are regional and organisational variations across the country in respect of detailed content of training, weaponry, and in general capacity and capability. These variations are seen across the world between different law enforcement agencies within the same country. The provision of central training to all organisations requiring it would at present not be logistically possible, and would not allow for regional or organisations variations based upon strategic threat and risk assessments.” Source location 2017-0014-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 Detailed contingency plans for every possible eventuality are impractical because briefings would become excessively long, confusing and difficult to remember.
Verbatim wording from the response “12. During this inquest police officers gave evidence around training received in relation to generic contingencies. Expert evidence was also attested by the Chief Firearms Instructor for the MPS around the impracticality of formulating (either verbal or written) detailed contingency plans for all possible eventualities. If this were to occur operational briefings would be overly long and lose value, as the myriad of contingencies would be confusing and unlikely to be remembered in detail.” Source location 2017-0014-Response-by-Metropolitan-Police
Open published response
8 Nov 2016 Ms Michelle Ann Lawrence · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Insufficient CCTV-monitoring facilities for detainees at risk in custody View source Insufficient PNC character capacity for meaningful risk recording View source Lack of independent investigation into deaths following release from private custody providers View source Failure to ask detainees about concealment View source Unavailability of strip-search facilities in SERCO custody View source Failure to routinely check toilets for concealed items after detainee use 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
Ms Michelle Ann Lawrence · 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 Michelle Ann Lawrence died at home on 2 May 2015 from respiratory failure after taking multiple prescription and illegal sedative drugs, following periods in police and private custody. The principal concerns included failures to identify concealed drugs, limited strip-searching and CCTV facilities, inadequate checking of custody-suite toilets, insufficient detail in risk records, and the lack of independent investigation into deaths following release from private custody providers.
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 CCTV-monitoring facilities for detainees at risk in custody
Wider context from the report “(5) That all custody suites have sufficient facilities for CCTV monitoring of detainees at risk in custody whether held by the State or private custody providers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 PNC character capacity for meaningful risk recording
Wider context from the report “(6) That the number of characters on the PNC where risks are described and highlighted need to be increased to allow sufficient meaningful detail to be recorded to allow accurate risk assessment by staff without having to trawl through multiple electronic documents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 independent investigation into deaths following release from private custody providers
Wider context from the report “(1) That there is no independent investigation into the deaths of persons following release from private providers of custody analogous to the IPCC such that important evidence is lost that upon analysis may be used to learn lessons and thus prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ask detainees about concealment
Wider context from the report “(2) That detainees are currently not asked about concealment . Such questions at booking in by police and on transfer between custody providers and when in consultation with health care professionals would provide an opportunity for some individuals who conceal to be identified either by positive responses to such questions or by allowing staff to assess their credibility. Ms Lawrence had admitted to taking drugs whilst in custody in February 2015.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 strip-search facilities in SERCO custody
Wider context from the report “(3) That facilities for strip searching appear to be virtually non-existent for those in the custody of SERCO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check toilets for concealed items after detainee use
Wider context from the report “(4) That SERCO staff do not appear to routinely check toilets for concealed items after they have been used by detainees .
” Open source report
20 Oct 2016 Susan Sian JONES · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Lack of protocol and training for monitoring members of the public in police stations who are not in police custody View source Failure to treat an unresponsive individual as a medical emergency View source Failure to recognise snoring as a possible sign of life-threatening partial airway obstruction View source Failure of police officers and staff to know the location of the nearest defibrillator View source Failure to pass on and record relevant information about members of the public View source Failure to rouse individuals to assess whether snoring is benign View source Failure to account for alcohol or drug intoxication when assessing snoring View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Susan Sian JONES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Susan Sian Jones suffered a cardiorespiratory arrest at Hornsey Police station while waiting to make a statement about an allegation of historical sexual assault. At inquest, the jury concluded that her death resulted from methadone and alcohol intoxication together with inadequate police policies, procedures and training. The report identified a lack of specific protocol or training for monitoring members of the public in police stations who are not in police custody.
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 protocol and training for monitoring members of the public in police stations who are not in police custody
Wider context from the report “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody . This was acknowledged by the Metropolitan Police Service to be a gap . In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.
• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.
• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie.
• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).
• The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.
• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.
• All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location.
In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 treat an unresponsive individual as a medical emergency
Wider context from the report “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.
• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.
• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie.
• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).
• The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.
• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency .
• All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location.
In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 possible sign of life-threatening partial airway obstruction
Wider context from the report “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.
• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.
• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie.
• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).
• The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.
• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.
• All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location.
In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 officers and staff to know the location of the nearest defibrillator
Wider context from the report “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.
• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.
• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie.
• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).
• The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.
• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.
• All police officers and staff should know the location of the nearest defibrillator . If they are attending a police station for the first time, they should make themselves aware of its location .
In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 on and record relevant information about members of the public
Wider context from the report “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.
• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.
• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie.
• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other ).
• The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.
• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.
• All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location.
In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 rouse individuals to assess whether snoring is benign
Wider context from the report “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.
• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.
• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant. In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking, even when there seems no obvious reason to lie.
• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).
• The only way of determining whether snoring is benign is by rousing , most particularly by waking the individual and determining whether they are able to sit up and hold a conversation .
• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.
• All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location.
In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 alcohol or drug intoxication when assessing snoring
Wider context from the report “I heard evidence at inquest that there is no specific protocol or training regarding the monitoring of members of the public in police stations who are not in police custody. This was acknowledged by the Metropolitan Police Service to be a gap. In seeking to plug this gap by way of policy development, it may be helpful for you to consider the following.
• Snoring is not always a reassuring sign and may indicate a partial airway obstruction. A partial airway obstruction can be life threatening.
• In considering whether snoring is sign for concern, the fact of intoxication by alcohol or drugs or both – even if the individual is capable – is highly relevant . In addition, officers should bear in mind that members of the public sometimes lie about alcohol or drug taking , even when there seems no obvious reason to lie.
• Any relevant information gleaned by officers, for example that an individual is a methadone user, should be passed on to colleagues with responsibility (and preferably recorded in some way or other).
• The only way of determining whether snoring is benign is by rousing, most particularly by waking the individual and determining whether they are able to sit up and hold a conversation.
• The rousing itself may have a therapeutic purpose even over and above its value as a tool of assessment. And an unresponsive individual must be treated as a medical emergency.
• All police officers and staff should know the location of the nearest defibrillator. If they are attending a police station for the first time, they should make themselves aware of its location.
In terms of feedback regarding officer training generally and for the officer who led this resuscitation attempt, I should also point out that after Ms Jones’s cardiorespiratory arrest, the cardiopulmonary resuscitation given was later noted by a paramedic to be extremely effective.
” Open source report
22 Jul 2016 Olawale ADELUSI · Prevention of Future Deaths report West London
View report summary
Concerns raised 1 Absence of an effective system for transmitting information relevant to detained persons’ self-harm risk or mental health assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Olawale ADELUSI · 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
Olawale Adelusi was arrested on 28 October 2014 and, after attempting suicide by hanging at court, was remanded to HMP Wormwood Scrubs, where he was found hanging in his cell on the morning of 3 November. The principal concern was the absence of an effective system for transmitting information relevant to the risk of self-harm and mental health, including information recorded during his police custody and hospital supervision. The inquest jury recorded the failure to transfer information and documentation at each stage as a contributory factor.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Absence of an effective system for transmitting information relevant to detained persons’ self-harm risk or mental health assessment
Wider context from the report “The absence of an effective system to ensure appropriate transmission of all information relevant to assessment of the (i) risk of self-harm or (ii) mental health, of detained persons
BASIS OF CONCERN : –
Whilst in police custody Mr Adelusi had been taken to hospital where he remained under police guard. Police Officers kept a Hospital Guard Supervision Log covering a 6.5 hour period and it recorded that Mr Adelusi had: on several occasions deliberately thrown himself from bed to floor in such a way as to cause concern for his safety; been observed crying on several occasions; been observed banging his head on the floor; spoken of a plot to kill him and of his son having been killed by police; and tried to bite the clinical drip pipe.
On return to the police station, Mr Adelusi was kept under constant supervision and a Constant Supervision Log was maintained by officers over a period of 23 hours in which they recorded that he had been observed: "pushing his thumbs down on to his neck" until he had to be told to desist; urinating in the corner of his cell; whispering to the Forensic Medical Examiner "they've killed him"; again crying and saying "you've killed him"; trying to strangle himself with a vest; kneeling with his head against the floor, crying; and accusing officers of killing his children and asking to see their bodies.
Neither the logs, nor the information recorded in them, was included in Mr Adelusi's Personal Escort Record; nor was that information otherwise transmitted in writing to those responsible for his detention after removal from the police station. Whilst there was evidence of a verbal handover to Escort Personnel, at which some of this information may have been mentioned, no record was made of that conversation.
” 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 initial-course training for new custody staff on the Prisoner Escort Record process.
Verbatim wording from the response “For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:” Source location Olawale-ADELUSIR-1
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 Prisoner Escort Record guidance provided through the Custody Toolkit.
Verbatim wording from the response “For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:” Source location Olawale-ADELUSIR-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a quality-assurance monitoring system to assess the quality of Prisoner Escort Record completion.
Verbatim wording from the response “For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:” Source location Olawale-ADELUSIR-1
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 the Prisoner Escort Record process in the next custody staff training cycle.
Verbatim wording from the response “For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:” Source location Olawale-ADELUSIR-1
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 NOMS owns the PER design and protocols, while national solutions require multi-agency action driven by NOMS and supported by other stakeholders.
Verbatim wording from the response “The design of the form and protocols for its use are the responsibility of NOMS, though the current form and any future versions will be agreed in discussion and agreement with all the stakeholders who use the form. The current PER was first issued in 2009 and its use adopted across all agencies during 2010. The PER is currently used by the police, NOMS, Secure Hospital Estate, the Home Office (for immigration detainees) and the escort contractors. The Metropolitan Police are therefore merely one of a number of users of the system, and whilst we can make suggestions and influence the future development of the system from this position, such changes would need to be made in agreement with all the other participating agencies, and with NOMS.” Source location Olawale-ADELUSIR-1
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The MPS cannot unilaterally change the PER system because changes require agreement from NOMS and all participating agencies.
Verbatim wording from the response “The design of the form and protocols for its use are the responsibility of NOMS, though the current form and any future versions will be agreed in discussion and agreement with all the stakeholders who use the form. The current PER was first issued in 2009 and its use adopted across all agencies during 2010. The PER is currently used by the police, NOMS, Secure Hospital Estate, the Home Office (for immigration detainees) and the escort contractors. The Metropolitan Police are therefore merely one of a number of users of the system, and whilst we can make suggestions and influence the future development of the system from this position, such changes would need to be made in agreement with all the other participating agencies, and with NOMS.” Source location Olawale-ADELUSIR-1
Open published response
4 Jul 2016 Henry David Hicks · Prevention of Future Deaths report London Inner (North)
View report summary
Concerns raised 2 Failure to seek authorisation to continue a police pursuit View source Failure to identify a police pursuit in accordance with the standard operating procedure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Henry David Hicks · 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
Henry David Hicks died after losing control of a moped during a road traffic collision on Wheelwright Street in Islington on 19 December 2014. Two unmarked police cars had been following the moped, and the jury determined that Henry was aware of the police and that this was a police pursuit. The principal concern was that, by implication, the Metropolitan Police Service standard operating procedure for pursuits was not complied with.
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 seek authorisation to continue a police pursuit
Wider context from the report “The driver and operator of police car 1 and the driver and operator of police car 2 (Officers A, B, C & D) all gave evidence in court that they were never in a position to signal to the rider of the moped to pull over, though this was what they wanted to happen.
All four gave evidence that they believed at the time of the collision, and that they still believed at the time of the inquest, that the rider was unaware of police behind him wanting him to stop.
For these reasons the officers said, they did not consider themselves to be in pursuit and therefore did not seek authorisation to continue .
The jury made a determination that Henry Hicks was aware of the police behind him and that this was a police pursuit within the definition of the Metropolitan Police Service standard operating procedure. The jury also made a determination that Henry’s attempt to avoid the police was a contributory factor in the collision.
Whilst I appreciate that we do not know whether, if the police officers had sought authorisation , this would have been granted, and so whether, if they had treated this as a pursuit, the outcome would have been different, it seems to me that this is a matter I must bring to your attention. All four officers gave a proper understanding of the MPS relevant standard operating procedure. However, by implication, the jury did not accept that this SOP was complied with on 19 December 2014.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 a police pursuit in accordance with the standard operating procedure
Wider context from the report “The driver and operator of police car 1 and the driver and operator of police car 2 (Officers A, B, C & D) all gave evidence in court that they were never in a position to signal to the rider of the moped to pull over, though this was what they wanted to happen.
All four gave evidence that they believed at the time of the collision, and that they still believed at the time of the inquest, that the rider was unaware of police behind him wanting him to stop.
For these reasons the officers said, they did not consider themselves to be in pursuit and therefore did not seek authorisation to continue.
The jury made a determination that Henry Hicks was aware of the police behind him and that this was a police pursuit within the definition of the Metropolitan Police Service standard operating procedure . The jury also made a determination that Henry’s attempt to avoid the police was a contributory factor in the collision.
Whilst I appreciate that we do not know whether, if the police officers had sought authorisation, this would have been granted, and so whether, if they had treated this as a pursuit, the outcome would have been different, it seems to me that this is a matter I must bring to your attention. All four officers gave a proper understanding of the MPS relevant standard operating procedure. However, by implication, the jury did not accept that this SOP was complied with on 19 December 2014.
” 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 pursuit guidance following the inquest and retain the existing policy unchanged.
Verbatim wording from the response ““I can say we remain confident in our policy, training and tactics, which are kept under constant review and revision. We reviewed our guidance as a matter of course... following the findings of the recent inquest touching the death of Henry Hicks, the result of which was that the existing policy remains unchanged...If any officer is unsure of the pursuit policy, they should consult their local Safer Driver Manager.”” Source location 2016-0244-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 Review found no systemic issues or specific lessons requiring changes to existing pursuit policy, training or management.
Verbatim wording from the response “Our experts were of like mind, finding nothing, following review, in our wider practices and protocols which were called into question by the particular facts of the current case.” Source location 2016-0244-Response-by-Metropolitan-Police
Open published response
12 Aug 2015 Dean Christian JOSEPH · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Armed Policing Policy failing to describe the effective range of a TASER View source Failure to prevent officers' access to control-log matters outside their personal knowledge during account preparation View source Failure to ask where the incident commander wants the hostage negotiator co-ordinator to meet them View source Unavailability of en-route guidance from trained hostage negotiators View source Failure to ensure a consistent understanding of overt or covert armed containment View source Failure to restrict post-incident officer conferral to timings when writing detailed accounts 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
Dean Christian JOSEPH · 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
Dean Christian JOSEPH broke into his former girlfriend’s home, took her hostage with a knife and remained in the property during an approximately one-and-a-half-hour siege. He was shot by a firearms officer when he moved the knife to the hostage’s throat. Concerns included differing understandings of whether armed containment was overt or covert, the lack of guidance from a trained hostage negotiator for the first officer on scene, possible gaps in guidance about TASER effective range, and shortcomings in post-incident police procedures.
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 Armed Policing Policy failing to describe the effective range of a TASER
Wider context from the report “4. My recollection from the evidence I heard, is that the Armed Policing Policy only describes the maximum range of a TASER, not the effective range . The inclusion of the latter might be helpful.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent officers' access to control-log matters outside their personal knowledge during account preparation
Wider context from the report “5. The post incident management:
• allowed police officers writing their detailed accounts to confer about matters other than simply timings, and
• arranged for the display of the control log for them, which included matters outside the personal knowledge of some of the officers .
It may seem that this is not a matter for a prevention of future deaths report. However, it will always be the case that we, as a society, try to learn lessons from deaths such as Mr Joseph’s, and the learning of any lessons is hampered if the post incident procedure is sub optimal.
In this case, it was clear to me that the version of events given by police officers was doubted to a degree that would not otherwise have been the case, because of the post incident procedure.
• That means that public confidence in the police is eroded, when there may be no substantive reason for this.
• It also caused me to exclude some officers from court when other officers were giving evidence which, all other things being equal, I would much have preferred not to do, because it is generally less helpful in ensuring the most meaningful exploration of events.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 ask where the incident commander wants the hostage negotiator co-ordinator to meet them
Wider context from the report “3. The hostage negotiator co-ordinator felt that it would be useful for the officer in her role to ask when first contacted, “Where does the incident commander want me to meet them?” This is a point which could be included in training. The fact of not asking that question did not appear to have a material impact in this case, but it might in another.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 en-route guidance from trained hostage negotiators
Wider context from the report “2. As you will see from the narrative, the jury noted that there was no guidance from trained hostage negotiators en route , for the local officer who was first on scene. He was attempting to negotiate, though he was untrained as a hostage negotiator. Such guidance might or might not have led to the issuing of an armed challenge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 a consistent understanding of overt or covert armed containment
Wider context from the report “1. Different officers had a different understanding of whether the armed containment was overt or covert .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 restrict post-incident officer conferral to timings when writing detailed accounts
Wider context from the report “5. The post incident management:
• allowed police officers writing their detailed accounts to confer about matters other than simply timings , and
• arranged for the display of the control log for them, which included matters outside the personal knowledge of some of the officers.
It may seem that this is not a matter for a prevention of future deaths report. However, it will always be the case that we, as a society, try to learn lessons from deaths such as Mr Joseph’s, and the learning of any lessons is hampered if the post incident procedure is sub optimal.
In this case, it was clear to me that the version of events given by police officers was doubted to a degree that would not otherwise have been the case, because of the post incident procedure.
• That means that public confidence in the police is eroded, when there may be no substantive reason for this.
• It also caused me to exclude some officers from court when other officers were giving evidence which, all other things being equal, I would much have preferred not to do, because it is generally less helpful in ensuring the most meaningful exploration of events.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the College of Policing to consider whether national armed-policing guidance and firearms training need greater specificity on containment types.
Verbatim wording from the response “The NPCC will also work with the College of Policing to consider whether the APP and/or the National Police Firearms Training Curriculum needs to be more explicit in this area.” Source location 2015-0319-Responses
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 Clarify overt and covert/discreet containment and require commanders to communicate the containment type in firearms training.
Verbatim wording from the response “The MPS, however, will in future make clear in training to both firearms officers and commanders what is meant by overt and covert/discreet containment according to the APP. The MPS will ensure that TFCs are aware of the need to communicate to containment officers what type of containment is being carried out.” Source location 2015-0319-Responses
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 Highlight in training the need to communicate the final meeting point to arriving personnel when a forward reception point accompanies a rendezvous point.
Verbatim wording from the response “The MPS will highlight to TFCs and incident commanders in training the need to consider communicating the final desired meeting point to persons arriving at an incident (including negotiator coordinators) if a forward reception point has been designated alongside an RVP.” Source location 2015-0319-Responses
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 Direct post-incident managers to consult professional standards and the IPCC on proposed account reference materials and record their decisions and reasoning.
Verbatim wording from the response “Further development of best practice has already lead the MPS to direct the post incident manager (PIM) to consult the DPS and the IPCC to decide on what reference materials are proposed to be used by officers when giving their accounts. The PIM is also trained to record his or her decision and reasoning to further promote transparency.” Source location 2015-0319-Responses
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen national guidance on officer separation and clarify its application to prevent inappropriate conferring.
Verbatim wording from the response “It is accepted by the NPCC that when applying national guidance across all police forces and agencies, there is some risk that the guidance will be subject to local interpretation. However, the NPCC has already taken steps to strengthen the guidance (for example, in relation to when separation of officers is necessary to prevent conferring) and to improve clarity on its application. Individual forces are responding positively with training and amendments to local procedure.” Source location 2015-0319-Responses
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 post-incident guidance is sufficient on officer conferring, having been upheld by the Court of Appeal and subsequently clarified.
Verbatim wording from the response “5. The APP provides detailed guidance in relation to the post incident procedure to be followed in cases of death following police contact. The guidance has been developed over several years and draws upon legal advice and learning from previous incidents.” Source location 2015-0319-Responses
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A single prescriptive Taser effective range cannot be specified because effectiveness depends on circumstances including clothing, physique, distance and weather.
Verbatim wording from the response “The MPS and NPCC consider this guidance is clear and adequate. The maximum distance is dictated by the length of the Taser cables (21 feet), so this is the maximum distance at which the weapon has the potential to be effective.” Source location 2015-0319-Responses
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 guidance adequately explains Taser maximum and variable effective range, so adding a prescriptive effective range is unnecessary.
Verbatim wording from the response “4. In respect of the conducted energy device (Taser), the APP currently states that:” Source location 2015-0319-Responses
Open published response
6 Aug 2015 Darren Brown · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Failure to balance vulnerable prospective defendants’ needs and risks when setting bail conditions or restricting support 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
Darren 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
Darren Brown died by suicide on 3 March 2014 at Lambeth Hospital; the medical cause of death was asphyxia due to ligature compression of the neck. The report described mental health issues, limited social support, family bereavements and an imminent court appearance as contributory factors. A principal concern was whether restricting his contact with his mother and sister properly balanced the risks and needs of a highly vulnerable adult against the reasons for restricting family contact.
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 vulnerable prospective defendants’ needs and risks when setting bail conditions or restricting support
Wider context from the report “During the course of the inquest the evidence revealed that he was prevented from contacting his mother or sister and that they were not even aware of the circumstances nor consulted about this decision. The evidence suggested that both the deceased and his relatives regretted the complete cessation of communications.
Mr Brown was an extremely vulnerable adult and professional evidence was heard about his high risk of suicide and his incapacity to make friends and how crucial his reliance was on his mother and sister. The prevention of any communication was a factor which led to his taking his life.
Whilst the details of the offences being investigated were not disclosed to the jury, but were known to the coroner, it is clear that there may have been good reason to restrict contact between members of the family. However the matter of concern is whether in making that decision, proper consideration was given to balancing those needs or risks with the very acute needs of and risks to the deceased .
It is of great public concern that the needs and risks of prospective defendants, who are (not infrequently) suffering from mental health problems and are vulnerable are taken into account in setting bail conditions or making restrictions on support to them . The inquest did not permit exploration of the possible charges or the decisions of the police, mindful of the proper scope of enquiry and the need to respect Convention rights about what may enter the public domain.
” Open source report
21 Jul 2015 Anne Wilson · Prevention of Future Deaths report South London
View report summary
Concerns raised 12 Lack of checklist or question examples for eliciting sufficient welfare concern information View source Lack of guidance on updating involved parties about changes in MPS actions View source Failure to inform the GP when a welfare check request is downgraded View source Lack of guidance on managing additional information received after welfare check closure View source Failure to share the GP’s mobile telephone number with the London Ambulance Service View source Failure to share the final MPS Welfare Check policy with the London Ambulance Service View source Unclear version control for the MPS Welfare Check policy View source Failure of the MPS and LAS to meet to discuss joint working under the welfare checks policy View source Failure to share welfare check policy changes with the London Ambulance Service View source Lack of training for staff handling welfare check requests in the new policy View source Failure to seek further clarification of the GP’s concerns before downgrading a welfare check request View source Lack of guidance on managing welfare checks concerning an individual’s mental health View source See 9 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
Anne Wilson · 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
Anne Wilson had a history of depression, had recently been discharged from psychiatric hospital, and was found deceased in her flat after failing to attend appointments and following concerns raised to the police. The principal concerns were the downgrading of the welfare-check request without informing her GP, inadequate training and guidance under the Metropolitan Police Service welfare-check policy, and failures in communication and joint working between the Metropolitan Police Service and London 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 Lack of checklist or question examples for eliciting sufficient welfare concern information
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 updating involved parties about changes in MPS actions
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the GP when a welfare check request is downgraded
Wider context from the report “(4) The MPS call handler informed Miss Wilson’s G.P that the police would attend Miss Wilson’s flat within the hour however the request for a welfare check was downgraded without informing the G.P of the change in decision or to seek further clarification of his concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on managing additional information received after welfare check closure
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed .
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 share the GP’s mobile telephone number with the London Ambulance Service
Wider context from the report “(5) The MPS did not share the G.P’s mobile telephone number with the LAS causing delay making further contact with the G.P.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 share the final MPS Welfare Check policy with the London Ambulance Service
Wider context from the report “(6) It is unclear what version of the MPS Welfare Check policy is currently in force and a final version has not yet been shared with the LAS despite requests to do so .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 version control for the MPS Welfare Check policy
Wider context from the report “(6) It is unclear what version of the MPS Welfare Check policy is currently in force and a final version has not yet been shared with the LAS despite requests to do so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 the MPS and LAS to meet to discuss joint working under the welfare checks policy
Wider context from the report “(7) The MPS and LAS have joint working arrangements but have yet to meet to discuss joint working arrangements under the MPS Welfare checks policy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 share welfare check policy changes with the London Ambulance Service
Wider context from the report “(1) In 2014 the Metropolitan Police Service (MPS) introduced a new policy for dealing with requests for and attending welfare checks. The precise date of the implementation of the new policy could not be established at inquest. The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that 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 Lack of training for staff handling welfare check requests in the new policy
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 seek further clarification of the GP’s concerns before downgrading a welfare check request
Wider context from the report “(4) The MPS call handler informed Miss Wilson’s G.P that the police would attend Miss Wilson’s flat within the hour however the request for a welfare check was downgraded without informing the G.P of the change in decision or to seek further clarification of his concerns .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on managing welfare checks concerning an individual’s mental health
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Open source report
15 Jul 2015 PAULS RICARDS KALNINS · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 2 Failure of the Merlin database to present key risk information prominently and accessibly View source Lack of current database training for communications officers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
PAULS RICARDS KALNINS · 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
PAULS RICARDS KALNINS, who had a history of depression and had expressed suicidal thoughts, was found hanging in a shed after leaving a location where police had spoken to him. The principal concerns were that the Merlin database did not clearly display key risk information, was difficult to navigate, and that communications officers needed more familiarisation and refresher training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure of the Merlin database to present key risk information prominently and accessibly
Wider context from the report “(1) The communications officer confirmed that he had worked in his role for 15 years, but had little need to obtain data from the Merlin database. Whilst he therefore had access to it, he was not familiar with it. He confirmed that he had last had training in 2011, in relation to the database.
(2) The communications officer said that he did not know where to look for the required details . He explained that the database is complex to navigate . The front screen does not contain any key information relating to risk .
(3) An investigation was carried out by the Directorate of Professional Standards and they found that the communications officer had accessed the correct pages of the database but had failed to see the relevant pieces of information .
(4) The line manager for the communications officer concerned, confirmed that it would “100% assist if key risks come up automatically on the front screen of the Merlin database” .
(5) She confirmed that the communications officers are under a lot of pressure when they provide information to officers on the ground; they do not need to access the Merlin database regularly and have to go through a lot of detail in the database. She agreed that refresher training for communications officers would also be useful.
(6) The investigator from the Directorate of Professional Standards, ████████ also agreed that the Merlin database is a piece of software which could be improved and could be more user-friendly . He agreed that Merlin is an important database and it would be useful to have refresher training.
(7) It was considered that the identification of the grade of risk (low, medium or high) on the front page, together with a brief explanation as to the type of risk posed, is likely to assist in prompting the communications officer to undertake a more detailed search of key parts of the database. ████████ suggested that the warning could be in red.
Having heard all of the above evidence, I consider that if the key risks could be highlighted on the front screen of the Merlin database, this would greatly assist communications officers and reduce risk to vulnerable persons in the future . Mandatory refresher training for communications officers, may also reduce risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of current database training for communications officers
Wider context from the report “(1) The communications officer confirmed that he had worked in his role for 15 years, but had little need to obtain data from the Merlin database. Whilst he therefore had access to it, he was not familiar with it. He confirmed that he had last had training in 2011, in relation to the database .
(2) The communications officer said that he did not know where to look for the required details. He explained that the database is complex to navigate. The front screen does not contain any key information relating to risk.
(3) An investigation was carried out by the Directorate of Professional Standards and they found that the communications officer had accessed the correct pages of the database but had failed to see the relevant pieces of information.
(4) The line manager for the communications officer concerned, confirmed that it would “100% assist if key risks come up automatically on the front screen of the Merlin database”.
(5) She confirmed that the communications officers are under a lot of pressure when they provide information to officers on the ground; they do not need to access the Merlin database regularly and have to go through a lot of detail in the database. She agreed that refresher training for communications officers would also be useful .
(6) The investigator from the Directorate of Professional Standards, ████████ also agreed that the Merlin database is a piece of software which could be improved and could be more user-friendly. He agreed that Merlin is an important database and it would be useful to have refresher training .
(7) It was considered that the identification of the grade of risk (low, medium or high) on the front page, together with a brief explanation as to the type of risk posed, is likely to assist in prompting the communications officer to undertake a more detailed search of key parts of the database. ████████ suggested that the warning could be in red.
Having heard all of the above evidence, I consider that if the key risks could be highlighted on the front screen of the Merlin database, this would greatly assist communications officers and reduce risk to vulnerable persons in the future. Mandatory refresher training for communications officers, may also reduce risk .
” 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 Notify affected staff line managers of the requirement for Merlin refresher training.
Verbatim wording from the response “With this in mind and in direct response to this recommendation, Chief Inspector O’Herlihy contacted all line managers for the affected staff as set out below on the 12th August 2015. This was on the instructions of Operations Superintendent at MET CC ████████” Source location 2015-0278-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 Deliver mandatory Merlin refresher training covering warning flags, unflagged incident details, and compliance monitoring for all current MET CC communications staff.
Verbatim wording from the response “In relation to this area of concern, the Metropolitan Police Service does not intend to make changes to the Merlin database because the functionality identified already exists. However, the importance of this functionality will be part of the training that is set out below, with an intended completion date of 31 March 2016.” Source location 2015-0278-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 No Merlin database changes are intended because the recommended warning functionality already exists in the system.
Verbatim wording from the response “████████ states that if information is correctly input onto the system in the first place, the suggested functionality is already present on the system, and would result in a red warning triangle being prominently visible on the top right of every page of the database entry. Clicking on this triangle takes one directly to the relevant warning text. An internal briefing document with screen shots taken from Mr Kalnins’ real Merlin record has been prepared to illustrate this, but as this contains sensitive personal data which should not be circulated to third parties without permission, it has not been included here. If you wish to have sight of this document, please advise, and we will facilitate this separately.” Source location 2015-0278-Response-by-Metropolitan-Police
Open published response
13 Jul 2015 Viktoria Was · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Insufficient learning from police pursuit deaths View source Failure to provide adequate initial regard, enquiry and ambulance response to injured third parties at pursuit scenes View source Failure to disseminate police pursuit lessons about impacts on third parties to officers promptly View source Failure to require sufficient refresher training and skills updates for police officers 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
Viktoria Was · 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
Viktoria Was died on 6 January 2013, aged 13, after being injured in a road traffic collision while travelling as a rear-seat passenger in a Volkswagen Polo. The concerns included insufficient regard for injured third parties at the scene, inadequate evidence that lessons had been learned from police pursuits, and insufficient refresher training for police 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 Insufficient learning from police pursuit deaths
Wider context from the report “(2) Evidence was placed before me from other unrelated deaths in police pursuits. There was an insufficiency of material to satisfactorily conclude that lessons had been learnt about police pursuits .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 initial regard, enquiry and ambulance response to injured third parties at pursuit scenes
Wider context from the report “(1) At the point of impact and for an unsatisfactory period of time thereafter, there was insufficient regard to Viktoria Was and her family . There were a number of officers immediately at the scene, and all focus appears to have been on the wanted suspect to the exclusion of injured third parties . A call for an ambulance, without further initial enquiry to third parties , whilst the pursuit continued for a number of hours was inadequate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate police pursuit lessons about impacts on third parties to officers promptly
Wider context from the report “(3) Police Officers were not required to attend for sufficient ‘refresher’ training; either at all, at satisfactory intervals, or of a sufficiently rigorous nature. This revealed a gap in continued learning and skills updates. In this regard, I would be concerned to learn if lessons to be learnt from this investigation about the potential impact of police pursuits on third parties were not disseminated to officers as soon as reasonably possible .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 sufficient refresher training and skills updates for police officers
Wider context from the report “(3) Police Officers were not required to attend for sufficient ‘refresher’ training; either at all, at satisfactory intervals, or of a sufficiently rigorous nature . This revealed a gap in continued learning and skills updates . In this regard, I would be concerned to learn if lessons to be learnt from this investigation about the potential impact of police pursuits on third parties were not disseminated to officers as soon as reasonably possible.
” 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 Extend the radio-operator pursuit training package to officers who joined before its introduction, potentially through a revised computer-delivered format.
Verbatim wording from the response “Since its introduction this package has been rolled out to selected elements of the Territorial Policing (uniformed) workforce; and since July 2014 all new recruits to the service have had this input. Steps are in hand to ensure that the officers serving prior to the course introduction, and who have yet to receive the benefit of it, may have an opportunity to take the course in the near future, most likely re-worked as a computer-delivered package.” Source location 2015-0271-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 Develop and deliver pursuit-narration and radio-operator training incorporating risk assessment, stress management, and the ‘A Pursuit’ model.
Verbatim wording from the response “• Development and delivery of a Pursuit Narration training package for in car radio operators for all new recruits.” Source location 2015-0271-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 Embed the National Decision Model in recruit and refresher training, pursuit procedures, and online reference toolkits.
Verbatim wording from the response “A simple mnemonic - ‘COW’ - Casualties, Obstructions, Witnesses - has long been a cornerstone of officer training in the handling of road traffic incidents, reminding first responders of their priorities as they arrive on scene. However, since the tragic death of Ms WAS, further steps have been taken by the MPS to better equip our officers, firstly with the cognitive tools to structure their choices in such difficult circumstances, and subsequently to better evidence these choices in a way which can make their rationale more readily apparent to others. For example, the Metropolitan Police now subscribes to the National Decision Model (NDM), developed by the College Of Policing.” Source location 2015-0271-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 Conduct a scoping exercise to determine resources and training abstractions required for a recurring, formally assessed refresher regime for police drivers.
Verbatim wording from the response “We note however your concerns regarding the ‘…gap in continued learning and skills updates’. We are also mindful of proposed changes to the regulatory framework. Section 19 of the Road Safety Act 2006 seeks to amend Section 87 of the Road Traffic Regulation Act 1984 to regularise the current use by police, fire and ambulance services” Source location 2015-0271-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 There is solid quantitative and qualitative evidence that lessons from Safer Driving 3 improved management of vehicle pursuits.
Verbatim wording from the response “However, according to ████████ Crime Intelligence Analyst with the Directorate of Professional Standards Specialist Investigations Unit, the quantitative evidence that is available, albeit on a very small numerical base, does indeed show a welcome downward trend:” Source location 2015-0271-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 driver assessment drives sufficiently comply with the regulatory regime and check that response-level drivers remain safe and capable.
Verbatim wording from the response “In order to maintain their driving qualification, police drivers in the MPS are currently required to undertake an “Assessment Drive” conducted at a local level, by Advanced Drivers who have themselves been trained to carry out these assessments. Our Driving assessors are highly qualified ‘advanced drivers’ (formerly Level 1), who have attended the MPS Driving School for a 3 day course and are taught how to give feedback on an officers driving. Our current assessments are carried out at Response Car Level, and consist of a ‘normal’ drive which does not make use of any legal exemptions, together with a simulated emergency response drive using appropriate warning equipment and making use of legal exemptions. This is sufficient to comply with the current regulatory regime and, at a practical level, to check that drivers tested at Response Car level are safe and capable.” Source location 2015-0271-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 available evidence does not show officers knowingly prioritised suspect capture over preserving life; their decisions reflected the information available at the time.
Verbatim wording from the response ““This is not a situation where disciplinary proceedings would be suitable. In summary, it would appear that none of the officers saw the VW Polo on their immediate arrival at the scene. ████████ did immediately request an ambulance with regards to the crash. On the arrival at the crash by ████████ immediately started to make off from the scene and ████████ chose to give chase. ████████ had information that the driver of the Peugeot was wanted for a serious assault and may be armed. ████████ chose to also chase ████████ to assist ████████ and based on the increased risk that came with this information. The officers had not seen the VW Polo and their decision making is in line with the National Decision Model.” Source location 2015-0271-Response-by-Metropolitan-Police
Open published response
10 Jun 2015 Darren NEVILLE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to give sufficient consideration to the risk of death associated with prolonged restraint of a person suffering from acute behavioural disturbance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Darren NEVILLE · 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
Darren Neville died after taking cocaine, experiencing acute behavioural disturbance, and being restrained by police. The principal concern was that police did not sufficiently consider the risks of prolonged restraint, including the risk of death, for a person experiencing acute behavioural disturbance; the extent to which this factor caused his death was unclear.
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 give sufficient consideration to the risk of death associated with prolonged restraint of a person suffering from acute behavioural disturbance
Wider context from the report ““Police did not give sufficient consideration to the risks associated with prolonged restraint to a person suffering from acute behavioural disturbance ; more specifically, the risk of death following prolonged restraint . It is unclear the extent to which this single factor caused Darren’s death.”
” 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 Continue fast-tracking learning from the national mental-health restraint expert group into corporate officer-safety training.
Verbatim wording from the response “The MPS is also promoting the newly formed National Mental Health Restraint Expert Reference Group, which is independently chaired by Lord Carlisle. This group of leading experts from partnership groups and organisations has been convened to help ensure a unified response to best practice across the UK. The OST learning outcomes from such groups will continue to be fast-tracked into corporate training as an on-going process of development, in line with College of Policing principles. For these reasons, work is ‘on-going’ from an OST perspective.”” Source location 2015-0220-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 Deliver mandatory officer-safety training covering acute behavioural disorder, de-escalation, safer restraint, positional-asphyxia risks and medical implications of restraint.
Verbatim wording from the response “This resource sits alongside a continuing emphasis on de-escalation tactics in the OST sessions. The classroom element of the current cycle of the mandatory training includes a section called ‘Mental Health - Safety In Mind’, a DVD and tutor led interactive session. This has been developed in conjunction with South London & Maudsley Hospital (SLAM) and the LAS and is aimed at improving the management of a situation involving a person identified as vulnerable. This package discusses the importance of the VAF and ABCDE models; and offers practical guidance on de-escalation tactics using the ‘CARES’ model (see below.)” Source location 2015-0220-Response-by-Metropolitan-Police
Open published response
29 Apr 2015 Finnulla Catherine MARTIN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 13 Failure to obtain the triage record before patient assessment View source Unavailability of triage records of patient attendance View source Failure to ask patients about thoughts of suicide View source Failure to establish the circumstances leading to police involvement and the identity of the caller View source Lack of clarity about protocols for receiving information from police officers accompanying voluntary patients View source Delays in passing family information to the psychiatry liaison team View source Confusion about voluntary attendance of patients with mental health needs accompanied by police View source Failure to record calls from family members to the emergency department View source Failure to characterise urgent police contact as an emergency after a patient leaves hospital View source Failure to obtain collateral history from family members before concluding the interview View source Confusion about voluntary attendance of patients with mental health needs accompanied by police View source Failure to record critical information disclosed to police call handlers View source Failure to ask patients about thoughts of harming another person View source See 10 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
Finnulla Catherine MARTIN · 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
Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.
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 obtain the triage record before patient assessment
Wider context from the report “2. The team then saw a patient without waiting to obtain the triage record created by Whittington Hospital Trust staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 triage records of patient attendance
Wider context from the report “2. I was told at inquest by Camden & Islington that the Whittington had been unable to locate the Whittington triage record of Ms Martin’s attendance , and I did not discover any record of the call made by Ms Martin’s sister to the emergency department that night.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 ask patients about thoughts of suicide
Wider context from the report “3. The doctor did not ask Ms Martin about thoughts of suicide within the context of her earlier declaration that she would die that night.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 establish the circumstances leading to police involvement and the identity of the caller
Wider context from the report “5. He did not address his mind to what had led up to the police being called for Ms Martin, nor who had called them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about protocols for receiving information from police officers accompanying voluntary patients
Wider context from the report “1. It seemed from the evidence I heard that the Camden and Islington Trust psychiatry liaison team (doctor and nurse) operating at Whittington Hospital on the night of 15 November 2015, were not wholly clear about the protocols for receipt of information from police officers bringing patients into hospital on a voluntary basis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 passing family information to the psychiatry liaison team
Wider context from the report “8. The crisis team did not pass on information received from Ms Martin’s sister to the psychiatry liaison team with a sufficient degree of urgency to ensure that this was taken into consideration before the interview with Ms Martin was concluded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Confusion about voluntary attendance of patients with mental health needs accompanied by police
Wider context from the report “2. As I have indicated above, the confusion surrounding voluntary attendance of a patient with mental health needs accompanied by the police , suggests a multi agency discussion and agreement would be beneficial.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 calls from family members to the emergency department
Wider context from the report “2. I was told at inquest by Camden & Islington that the Whittington had been unable to locate the Whittington triage record of Ms Martin’s attendance, and I did not discover any record of the call made by Ms Martin’s sister to the emergency department that night .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 characterise urgent police contact as an emergency after a patient leaves hospital
Wider context from the report “7. When they obtained this afterwards and then realised that Ms Martin had left the hospital, they contacted the police but did not characterise this as an emergency .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 obtain collateral history from family members before concluding the interview
Wider context from the report “6. Neither doctor nor nurse obtained a collateral history of events from a family member before concluding their interview with Ms Martin.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Confusion about voluntary attendance of patients with mental health needs accompanied by police
Wider context from the report “1. There seemed to be some degree of confusion surrounding the voluntary attendance of a patient with mental health needs accompanied by the police , that suggests a multi agency discussion and agreement would be beneficial.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 critical information disclosed to police call handlers
Wider context from the report “1. The police call handler who spoke to Ms Martin did not record that she said: “I need to jump a balcony” . This was important information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to ask patients about thoughts of harming another person
Wider context from the report “4. He did not ask her about any thoughts of harming another person , regardless of the fact he was not aware that she had threatened this.
” Open source report
13 Oct 2014 Arsema Dawit · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 8 Failure to accurately record and communicate incident information on the CRIS View source Failure to make a linked crime report View source Failure to use interpreting services to enable interview of a non-English-speaking witness View source Gap in investigation pathways for offences outside domestic violence and child abuse team remits View source Inadequate supervision of investigative action plans View source Failure to document investigative decisions sufficiently to inform others View source Failure to record the most serious reported crime as the principal offence View source Failure to correctly classify and reclassify the principal offence View source See 5 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. 6
Action
Operate the broadened Public Access Officer role with mandatory specialist training in front-counter reporting, initial investigation, risk recognition, victim care and safeguarding.
Stated completedThe respondent said that this action was complete when they made their response on 13 October 2014. View source
Action
Provide continuously available policing toolkits and a Reception Services Manual with checklists and flowcharts for recording, escalating and investigating threats to life and other relevant risks.
Stated completedThe respondent said that this action was complete when they made their response on 13 October 2014. View source
Action
Provide accessible translation through 24/7 telephone, remote video, bilingual-staff and central interpreter-booking arrangements for public contact, statements, interviews and court appearances.
Stated completedThe respondent said that this action was complete when they made their response on 13 October 2014. View source
Action
Operate the Crime Assessment Unit as an independent central quality-assurance layer that reviews, confirms and corrects initial crime classifications within defined timescales.
Stated completedThe respondent said that this action was complete when they made their response on 13 October 2014. View source
Action
Operate a backstop procedure assigning responsibility for investigating child-related domestic-abuse cases that fall outside specialist-unit remits.
Stated completedThe respondent said that this action was complete when they made their response on 13 October 2014. View source
Action
Strengthen sergeant and detective-supervisor capability through mandatory training, probationary evidence workbooks, investigative skills courses and documented supervision requirements.
Stated completedThe respondent said that this action was complete when they made their response on 13 October 2014. View source See 3 more actions
×
AI-generated summary
Arsema Dawit · 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
Arsema Dawit, aged 15, died on 2 June 2008 after being stabbed by a former friend who had been stalking her; the inquest jury concluded that the death was unlawful killing. Concerns included the recording and classification of the initial police report, inadequate and untimely investigation, insufficient supervision and communication with the family, gaps in investigative procedures, and reluctance to use interpreting services.
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 accurately record and communicate incident information on the CRIS
Wider context from the report “(1) The senior reception officer prematurely classified the offence, failed to reclassify it when the full details were known at the end of her interviews and entered a misleading entry on the CRIS that the Inspector whom she had briefly asked a question, had been informed of the incident, which he had not, but others assumed he had been . He was clear that had he known the full account of the incident, he would have required further steps to be taken at the outset. Is the SRO appropriate to complete the CRIS in such a case and is the system of recording and reviewing the entered principal offence now understood by reception officers?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to make a linked crime report
Wider context from the report “(2) The court was told that most serious crime reported should be the principal offence, but the threat to kill was not entered as the principle offence, when at some stage it was reviewed by senior supervising officers, nor was a linked crime report made . The entry of the second Inspector was insufficient to properly inform others of his decisions. Two inspectors were involved and that gave false reassurance to more junior officers, who did not question the appropriateness of the principal offence, despite contrary evidence. It was not clear whether this was a series of misunderstandings or a systemic or cultural failure to properly document and ensure flexibility in investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to use interpreting services to enable interview of a non-English-speaking witness
Wider context from the report “(5) There appeared to be some reluctance to use the interpreting service , so that the mother was never interviewed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Gap in investigation pathways for offences outside domestic violence and child abuse team remits
Wider context from the report “(4) According to the MPS Standard Operating Procedures at the time, the offence could not have been reported as domestic violence as those involved were not adult and was outside the remit of the child abuse investigation team. There appeared to be a gap, which might mean inappropriate or insufficient investigation could be carried out .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of investigative action plans
Wider context from the report “(3) The action plans that were adopted appeared to have been supervised sub-optimally by Detective Sergeants . It is not clear whether these were individual weaknesses or reflect a wider weakness in the role of supervisors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 document investigative decisions sufficiently to inform others
Wider context from the report “(2) The court was told that most serious crime reported should be the principal offence, but the threat to kill was not entered as the principle offence, when at some stage it was reviewed by senior supervising officers, nor was a linked crime report made. The entry of the second Inspector was insufficient to properly inform others of his decisions . Two inspectors were involved and that gave false reassurance to more junior officers, who did not question the appropriateness of the principal offence, despite contrary evidence. It was not clear whether this was a series of misunderstandings or a systemic or cultural failure to properly document and ensure flexibility in investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 most serious reported crime as the principal offence
Wider context from the report “(2) The court was told that most serious crime reported should be the principal offence, but the threat to kill was not entered as the principle offence , when at some stage it was reviewed by senior supervising officers, nor was a linked crime report made. The entry of the second Inspector was insufficient to properly inform others of his decisions. Two inspectors were involved and that gave false reassurance to more junior officers, who did not question the appropriateness of the principal offence, despite contrary evidence. It was not clear whether this was a series of misunderstandings or a systemic or cultural failure to properly document and ensure flexibility in investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 correctly classify and reclassify the principal offence
Wider context from the report “(1) The senior reception officer prematurely classified the offence, failed to reclassify it when the full details were known at the end of her interviews and entered a misleading entry on the CRIS that the Inspector whom she had briefly asked a question, had been informed of the incident, which he had not, but others assumed he had been. He was clear that had he known the full account of the incident, he would have required further steps to be taken at the outset. Is the SRO appropriate to complete the CRIS in such a case and is the system of recording and reviewing the entered principal offence now understood by reception officers?
” 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 Operate the broadened Public Access Officer role with mandatory specialist training in front-counter reporting, initial investigation, risk recognition, victim care and safeguarding.
Verbatim wording from the response “Response:
A decision was taken by Management Board in 2007 that the Station Reception Officer (SRO) role would cease to exist with effect from 31 July 2008. Initially, those staff recruited to the revised position after this date were called ‘Station Police Community Support Officers’ (‘SPCSOs’), who were part of the Police Community Support Officer family. Patrolling had not formerly been part of the remit of the SRO, and so” Source location 2014-0442-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 Provide continuously available policing toolkits and a Reception Services Manual with checklists and flowcharts for recording, escalating and investigating threats to life and other relevant risks.
Verbatim wording from the response “In support of such better decision making, a further innovation since 2008 has been the refashioning of our sometimes unwieldy policies and procedures into a series of user-friendly ‘toolkits’, available 24 hours a day, seven days a week, from any MPS computer workstation. These are designed to be clear, concise guides, ‘Frequently Asked Questions’ and checklists which can support any frontline officer or staff member before, during, or after dealing with any situation which they may be unfamiliar with. For example, links to an easy to follow flow chart of necessary actions setting out how a ‘Threat To Life’ should be recorded, reported, and progressed is now included in a bespoke online reference guide, the Reception Services Manual, for use by Public Access staff. This manual contains, inter alia, specific guidance on how to deal with:” Source location 2014-0442-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 Provide accessible translation through 24/7 telephone, remote video, bilingual-staff and central interpreter-booking arrangements for public contact, statements, interviews and court appearances.
Verbatim wording from the response “Response
Since 2008, routes to access immediate translation services for initial communication with victims and witnesses, together with arrangements to access security-checked and court-qualified interpreters for more considered encounters such as victim and witness statement taking, suspect interviewing, or court appearances, have been streamlined and improved. The MPS is consciously recruiting from a wider pool of diverse language speakers, and acknowledging the spontaneous availability of the many bilingual officers and staff we already employ. Work is in hand to use a database of these skills to improve our ability to engage with a diverse public.” Source location 2014-0442-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 Operate the Crime Assessment Unit as an independent central quality-assurance layer that reviews, confirms and corrects initial crime classifications within defined timescales.
Verbatim wording from the response “significant improvement in our business processes since 2008 has been the introduction in 2012 of a centralised, independent quality assurance layer which assumes responsibility for the confirmation of initial classification for all reported crimes MPS wide. This centralised independence provides an opportunity to correct local errors of the type which occurred in the initial recording of Miss Dawit’s allegation. The supervision is provided by the Crime Assessment Unit (CAU), comprising three teams of experienced detective and uniformed officers and staff, each headed up by an inspector. The CAU run a series of automated searches to ensure that any reports lacking the necessary classification confirmation are undertaken by them are reviewed and progressed appropriately.” Source location 2014-0442-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 Operate a backstop procedure assigning responsibility for investigating child-related domestic-abuse cases that fall outside specialist-unit remits.
Verbatim wording from the response “Whilst this definitional ‘gap’ still exists, therefore, and is not directly within the power of the MPS to alter, we have acknowledged this, and have since 2008 developed safeguards to deal with it.” Source location 2014-0442-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 Strengthen sergeant and detective-supervisor capability through mandatory training, probationary evidence workbooks, investigative skills courses and documented supervision requirements.
Verbatim wording from the response “Since 2008, considerable work has been undertaken nationally and within the MPS on these fronts, beginning with a number of significant changes nationally and within the MPS in the training and support of all newly promoted and serving uniformed and detective officers.” Source location 2014-0442-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 police cannot directly alter national crime definitions governing specialist unit remits.
Verbatim wording from the response “In the Dawit case, the matter was referred to a Detective officer to deal, albeit within the ‘generalist’ main office of CID, and with an (incorrect) assumption that the substantive offence involved was Actual Bodily Harm. Despite decisions made by some individuals in the case therefore, at the level of process, the remit issue highlighted in Dawit did not impinge on the skills level of investigator allocated to deal. Clearly, though, specialist units do ‘add value’ through their greater knowledge and experience of certain crime types, and it is here the remit issue was relevant. Resolution of this, however, lies ultimately beyond the reach of the MPS to address directly, as I will now explain.” Source location 2014-0442-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 PAO training and business processes are considered sufficient for accurate crime recording and useful initial investigation.
Verbatim wording from the response “The current PAO training course was designed centrally in conjunction with MPS training command, known as ‘Met Training’ and is delivered by dedicated trainers from Met Training. It takes place over 13 days and is a mandatory requirement before a new staff member can take up a post within the MPS. Attendance and successful completion of the course is monitored by line managers on the trainee's home Borough Operational Command Unit (‘BOCU’). The curriculum of the course covers all aspects of the role of staffing a front office or other public access point. Topics covered most relevant to the Dawit case include:” Source location 2014-0442-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 Borough Crime Manager is responsible for adjudicating disputes over which unit owns an investigation.
Verbatim wording from the response “Responsibility for adjudicating in any dispute falls ultimately to the Crime Manager (Detective Chief Inspector) responsible for the Borough which ‘owns’ the crime, under National Crime Reporting Guidelines. In conclusion on this point, therefore, I am confident that our layered quality assurance procedures and ‘backstop’ process are now sufficient to capture and resolve any ‘remit’ difficulties which might arise from current national crime definitions.” Source location 2014-0442-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 Centralised quality assurance and the remit backstop are considered sufficient to identify and resolve difficulties assigning investigations.
Verbatim wording from the response “Whilst this definitional ‘gap’ still exists, therefore, and is not directly within the power of the MPS to alter, we have acknowledged this, and have since 2008 developed safeguards to deal with it.” Source location 2014-0442-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 Existing translation services and interpreter booking arrangements are considered comprehensive and readily accessible to staff.
Verbatim wording from the response “Response
Since 2008, routes to access immediate translation services for initial communication with victims and witnesses, together with arrangements to access security-checked and court-qualified interpreters for more considered encounters such as victim and witness statement taking, suspect interviewing, or court appearances, have been streamlined and improved. The MPS is consciously recruiting from a wider pool of diverse language speakers, and acknowledging the spontaneous availability of the many bilingual officers and staff we already employ. Work is in hand to use a database of these skills to improve our ability to engage with a diverse public.” Source location 2014-0442-Response-by-Metropolitan-Police
Open published response
28 Aug 2014 Lauren Barfoot · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to classify a missing person as high risk when warranted View source Failure to relay full and detailed high-risk information to the missing persons unit View source Failure to hold a timely strategy meeting to pool information and resources for an effective search View source Failure to carry out an effective search for a missing person View source Failure to record and make accessible comprehensive contact information for people who could assist in a search 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
Lauren Barfoot · 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
Lauren Barfoot was a 14-year-old looked-after child who went missing from Micawber House on 22 June 2012 and was later discovered in the porch of her putative father’s home. The report identified concerns about failures to share information, classify the level of risk, conduct an effective search, and hold a timely strategy meeting. The inquest concluded that her accidental death was contributed to by failures in sharing information and pooling and using resources.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to classify a missing person as high risk when warranted
Wider context from the report “(3) There was a failure by the MPS Missing Person's Unit (Greenwich) to carry out an effective search for Lauren as a consequence of the lack of information not shared with the Unit by those responsible for looking after and searching for Lauren, and therefore a missed opportunity for the Missing Person's Unit to classify Lauren as a “high risk missing person” .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 relay full and detailed high-risk information to the missing persons unit
Wider context from the report “(2) There was a failure by Ethelbert’s Children’s Services to relay full and detailed information to the Missing Person’s Unit (Greenwich) as to the level of risk classified as “high” in relation to Lauren’s misuse of solvent abuse and vulnerability of sexual exploitation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 a timely strategy meeting to pool information and resources for an effective search
Wider context from the report “(4) There was a failure by the London Borough of Bexley to hold a timely “strategy meeting” by those concerned in the care for Lauren after she had been missing for several days in order to pool information and resources in order to carry out an effective search for Lauren .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 an effective search for a missing person
Wider context from the report “(3) There was a failure by the MPS Missing Person's Unit (Greenwich) to carry out an effective search for Lauren as a consequence of the lack of information not shared with the Unit by those responsible for looking after and searching for Lauren, and therefore a missed opportunity for the Missing Person's Unit to classify Lauren as a “high risk missing person”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 and make accessible comprehensive contact information for people who could assist in a search
Wider context from the report “(1) There was a failure by the London Borough of Bexley Social Services to record and make accessible, a comprehensive list of Lauren’s friends, family and acquaintances and their addresses and contact numbers , with whom contact could be made in order to assist professionals in an effective search for Lauren.
” 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 the response and existing measures against the inquest findings to ensure they address the identified issues and are embedded in current practice.
Verbatim wording from the response “I enclose a report detailing our actions, addressing the specific issues of information sharing and risk assessment, but also our broader response to the serious case review that followed Lauren's death. I have caused our response to be reviewed in light of the inquest to ensure that those measures introduced following the serious case review account for the issues raised in your report and are fully embedded in current practice.” Source location 2014-0385-Response-by-Metropolitan-Police
Open published response
29 May 2014 Mark Duggan · Prevention of Future Deaths report London (North)
View report summary
Concerns raised 10 Lack of fully independent control over fatal shooting scenes during investigation View source Failure to video record fatal police shooting scenes View source Failure to consider pursuing a planned weapons-seizure operation after a fatal shooting View source Failure to record armed police operations after State Red View source Lack of access to all relevant intelligence for fatal-operation investigations View source Failure to review operational strategy in response to developing events View source Failure to devise a coordinated strategy capable of seizing guns before collection View source Failure to develop and share operational intelligence between the MPS and SOCA View source Failure to obtain prompt comprehensive statements from all police witnesses to fatal shootings View source Lack of an agreed protocol between the IPCC, coronial and prosecution bodies View source See 7 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
Mark Duggan · 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 4 August 2011, Mark Duggan was shot by an armed police officer during an enforced vehicle stop in London and was pronounced dead at the scene. The report raises concerns about intelligence sharing and operational decisions before the shooting, the investigation and preservation of evidence at the scene, the recording of the operation, and the coordination and access to intelligence during the investigation and inquest.
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 fully independent control over fatal shooting scenes during investigation
Wider context from the report “Concern 3: The IPCC had primacy at the scene but did not have the resources to conduct all relevant activities there
I am concerned that no scene of a fatal shooting should be the subject of any confusion about the purpose of the investigation, or about what should be done to further that investigation. There is a tension, in a case such as this, between the duty of the MPS to obtain and secure evidence at the scene, its position as being under investigation, and the IPCC’s obligation to investigate independently. The pragmatic approach adopted of the MPS consulting the IPCC about what should happen may not always resolve that tension. My primary concern is whether that position should persist. If it does then I am concerned that the police service has the practical control of many aspects of the scene and what happens there despite being under investigation , without the public realising that the investigation does not have full independence which the IPCC’s role appears to safeguard . This concern is addressed to the IPCC, the Home Secretary and the MPS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 video record fatal police shooting scenes
Wider context from the report “Concern 4: The scene of the fatal police shooting was not video recorded
I believe that it is important to minimise distrust in the police in connection with fatal shootings, as that distrust can then permeate the entire investigation which follows and may mean that civilian witnesses will not come forward. That plainly has the capacity to prevent lessons being learned which could prevent deaths in the future. This concern is addressed to the MPS, the IPCC and ACPO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to consider pursuing a planned weapons-seizure operation after a fatal shooting
Wider context from the report “Concern 5: The planned operation to seize weapons was not pursued after the fatal shot was fired
My concern is that no consideration appears to have been given to the prospect . A starting point should have been that one of the Trident officers saw the minicab turn into Burchell Road for the handover, and that was a short cul-de-sac. This concern is addressed to the MPS, the IPCC and ACPO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 armed police operations after State Red
Wider context from the report “Concern 6: The armed police operation was not recorded after State Red was called
I am therefore concerned that the cars involved in stopping the minicab containing Mr Duggan had data available to be downloaded or that the technology was not as effective in 2011 as it was in 2005. I expect to be told the actual position. In the circumstances I address these concerns to the MPS and ACPO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 access to all relevant intelligence for fatal-operation investigations
Wider context from the report “Concern 8: The IPCC and Counsel to an inquest do not have access to all intelligence
These limitations not only give rise to understandable suspicions in the minds of those not party to the intelligence but also plainly create a risk that an intelligence-led operation which results in death will not be fully investigated so that lessons may be learned. This concern is addressed to the Home Secretary.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 review operational strategy in response to developing events
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA, and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so, in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him . The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan. This concern is directed to the MPS and NCA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 devise a coordinated strategy capable of seizing guns before collection
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA, and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so, in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him. The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan . This concern is directed to the MPS and NCA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 develop and share operational intelligence between the MPS and SOCA
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA , and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so , in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him. The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan. This concern is directed to the MPS and NCA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 obtain prompt comprehensive statements from all police witnesses to fatal shootings
Wider context from the report “Concern 2: Comprehensive accounts were not taken from police witnesses at the first possible opportunity
I am concerned that fatal police shootings are not as rigorously examined as they could be and that doubts about the accuracy of police accounts are not minimised. Lessons learned after a death should be as complete as possible. My concern is that not all witnesses to a fatal shooting are asked to give full statements as soon as possible after the event, giving a detailed account of what they saw . I am also concerned about whether there is any purpose in seeking to distinguish between “principal officers” and other police officers save that, where there is any reason to caution an officer, then of course that must be done. I am concerned that witnesses who perceived a threat from the person who was shot did not set that out in their statements . I therefore invite ACPO and the MPS to deal with what I have said when they respond to the IPCC consultation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 agreed protocol between the IPCC, coronial and prosecution bodies
Wider context from the report “Concern 7: The IPCC does not have a protocol agreed with the Chief Coroner, ACP and the CPS
With a view to coroners holding effective inquests as soon as practicable I address this concern to the IPCC and ask it to consider approaching the Crown Prosecution Service, the Association of Chief Police Officers, the Chief Coroner and the Coroner’s Society with a view to integrating its memorandum with theirs.
” 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 Work with the IPCC to formally record a protocol requiring strategic scene-coordination meetings for parallel investigations.
Verbatim wording from the response “Scene control and the manner in which the MPS assists the IPCC must and are being addressed by the MPS and IPCC working together to achieve clarity of responsibility and effective communication at the scene of a police shooting. You will be aware that paragraphs 7-12 of the IPCC’s draft statutory guidance relate to the identification and preservation of all potentially relevant evidence and scenes. The MPS generally supports these paragraphs. It is an area in which very considerable progress has been made in this area since 2011 in response to events of 4th August 2011 and subsequent incidents, for example, the shootings in Woolwich following the murder of Lee Rigby. On 25th September 2013, a Tabletop Workshop was held by the MPS.” Source location 2014-0182-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 Adopt a procedure requiring DPS to call a Garage Sergeant or Collision Investigator to download vehicle Incident Data Recorder data at every future police shooting scene.
Verbatim wording from the response “In light of the Coroner’s concerns, the MPS will adopt a procedure for all future police shootings whereby a Garage Sergeant / Collision Investigator is called by the DPS to download the IDR at the scene, which then will be available to police, the IPCC and any subsequent legal proceedings.” Source location 2014-0182-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 Conduct a feasibility study on assigning an operations team officer to record pre-planned shooting scenes until specialist investigators or support services arrive.
Verbatim wording from the response “Another option that is currently being explored by the MPS in the case of pre-planned operations is to assign this role to an operations team officer. This officer’s primary responsibility would be to record the scene in the event of a police shooting until such time that either a police helicopter (if available or able to deploy), independent investigators (DPS/IPCC) or any specialist support services deployed by them (for example, Crime Scene Managers or the Computer Aided Modelling Bureau - see below) arrive on scene. A feasibility study is currently being conducted to ensure that any issues associated with this option can be considered.” Source location 2014-0182-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 Require a senior officer to attend the Post Incident Management suite while officers produce statements, ensuring accounts contain sufficient detail.
Verbatim wording from the response “The MPS understands the need to prevent any perception that the systems employed lack integrity. The MPS can and does in striving to achieve best practice adopt and implement procedures which go beyond but are consistent with national practice and guidance. Thus, for example, a senior officer must now be present in the Post Incident Management [‘PIM’] suite whilst officers produce witness statements, with a view to ensuring the openness and transparency of the process. The MPS agrees that the current Post Incident Procedure (PIP) does not attract public confidence and needs to be made more transparent.” Source location 2014-0182-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 Continue providing training and refresher training to senior officers on consistent high-standard decision-making during planned firearm-seizure operations.
Verbatim wording from the response “The MPS will continue to provide training and refresher training to these senior officers to ensure the high standards of decision making expected by the MPS are consistently applied.” Source location 2014-0182-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 Work with law firms representing firearms officers to clarify expectations for detailed post-incident accounts.
Verbatim wording from the response “a. The MPS agrees that ‘bland and uninformative’ accounts, if and whenever provided, are not acceptable. The MPS now requires a senior officer to be present in the PIM suite, whose functions include ensuring the inclusion of sufficient detail in initial and subsequent accounts. Sufficient detail includes the presence or absence of any perceived threat and the officer’s response thereto. The MPS is working with law firms who represent firearms officers to ensure that its expectations are clearly understood. The success of these measures was demonstrated by the post incident processes adopted following the events of May 2013 in Woolwich and the quality of the witness statements produced through those processes.” Source location 2014-0182-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 Assign Covert Intelligence Managers responsibility for oversight of covert intelligence processes and Senior Investigating Officer awareness.
Verbatim wording from the response “The MPS is adopting processes and developing training specifically designed to ensure the relevant Senior Investigating Officer [‘SIO’] is fully sighted on all available intelligence. Covert Intelligence Managers will have a specific responsibility to maintain oversight of covert intelligence processes in order to ensure that the SIO is aware of intelligence relevant to achieving his or her strategy. Emphasis will be laid on ensuring that the oversight must include dynamic responses to changes in the SIO’s strategy in light of all available intelligence. Training for MPS Intelligence Officers will be reviewed to guarantee that there is sufficient emphasis on their role in ensuring the Senior Investigating Officer is aware of intelligence relevant to achieving his or her strategy in each case.” Source location 2014-0182-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 Intelligence Officer training to strengthen their role in ensuring Senior Investigating Officers receive relevant intelligence.
Verbatim wording from the response “The MPS is adopting processes and developing training specifically designed to ensure the relevant Senior Investigating Officer [‘SIO’] is fully sighted on all available intelligence. Covert Intelligence Managers will have a specific responsibility to maintain oversight of covert intelligence processes in order to ensure that the SIO is aware of intelligence relevant to achieving his or her strategy. Emphasis will be laid on ensuring that the oversight must include dynamic responses to changes in the SIO’s strategy in light of all available intelligence. Training for MPS Intelligence Officers will be reviewed to guarantee that there is sufficient emphasis on their role in ensuring the Senior Investigating Officer is aware of intelligence relevant to achieving his or her strategy in each case.” Source location 2014-0182-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 Begin operational use of body-worn cameras by uniformed officers in armed policing.
Verbatim wording from the response “The MPS believes that the audio and visual recording of the actions of firearms officers and those with whom they engage is an essential element of that transparency. The MPS has long been committed to the testing (in training) and piloting (in firearms operations) of Body Worn Cameras (BWC) with a view to their introduction in London. The processes, which began in November 2013 under the auspices of DCC Simon Chesterman (ACPO lead, Armed Policing), have established that, for overt policing, the kit is effective and functional. The trials for the use of BWC by uniformed ARV officers concluded in June 2014. On 21st July 2014, the College of Policing produced” Source location 2014-0182-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 Adopt intelligence processes and develop training ensuring Senior Investigating Officers receive all relevant intelligence and dynamic strategy changes.
Verbatim wording from the response “The MPS is adopting processes and developing training specifically designed to ensure the relevant Senior Investigating Officer [‘SIO’] is fully sighted on all available intelligence. Covert Intelligence Managers will have a specific responsibility to maintain oversight of covert intelligence processes in order to ensure that the SIO is aware of intelligence relevant to achieving his or her strategy. Emphasis will be laid on ensuring that the oversight must include dynamic responses to changes in the SIO’s strategy in light of all available intelligence. Training for MPS Intelligence Officers will be reviewed to guarantee that there is sufficient emphasis on their role in ensuring the Senior Investigating Officer is aware of intelligence relevant to achieving his or her strategy in each case.” Source location 2014-0182-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 command and control at critical-incident scenes through a Directorate of Professional Standards-led working group with IPCC input.
Verbatim wording from the response “found on the grass. The scene of the shooting was, clearly, a key evidential area for both investigations. The control of the scene immediately after the shooting remained with the Tactical Firearms Commander pursuant to the 2011 Manual of Guidance pending the involvement of the IPCC. Such parallel investigations are common to most cases involving the discharge of a firearm by police officers and are likely to share some, though not all, investigative objectives. The issue of command and control at the scene of a critical incident is presently under review within the MPS. A working group led by the Directorate of Professional Standards has been formed to review and examine the issue from the Operational Firearms Commander through to Management Board and DSI incidents. The IPCC has been invited to provide input to this process.” Source location 2014-0182-Response-by-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 Further armed deployment to pursue an additional firearm was not justified because its location was unknown and sufficient certainty and knowledge were absent.
Verbatim wording from the response “The firearm that was handed to Mark Duggan by Kevin Hutchinson-Foster on 4th August 2011 was recovered in Ferry Lane. The intended outcome of the planned operation – that is, the interception of Mark Duggan and the recovery of the firearm from him - was achieved. Officers were not deployed to Burchell Road to seek to arrest Kevin Hutchinson-Foster after Mark Duggan was shot. As a matter of fact, the Burchell Road address at which one of Kevin Hutchinson-Foster girlfriends lived remained unknown to the MPS until the arrest of Kevin Hutchinson-Foster on 24th October 2011. Whilst intelligence provided to the MPS by SOCA had indicated that Kevin Hutchinson-Foster was storing a gun or guns for Mark Duggan, the critical piece of information for the recovery of any further firearm under Hutchinson-Foster’s control - that is, its location - remained wholly unknown.” Source location 2014-0182-Response-by-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 Firearms officers should not be responsible for recording post-incident scene preservation; responsibility should fall to investigators or an assigned operations team officer.
Verbatim wording from the response “It is the view of the MPS that firearms officers should not be responsible for recording post incident scene preservation. MPS firearms officers are due to commence the piloting of Body Worn Cameras (see Concern 6, below). This may provide some level of recording of the actions taken to preserve the scene in the immediate aftermath but they have limitations in that they will only capture a certain camera angle. In a spontaneous incident, it is likely that this will be the only method of immediately recording the scene.” Source location 2014-0182-Response-by-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 Taking full statements immediately from officers affected by shock, distress or extreme fatigue was considered counterproductive and of limited forensic value.
Verbatim wording from the response “d. Officers involved in a fatal shooting are under intense scrutiny. A decision about criminal or disciplinary proceedings may not be made for months or years after such a shooting. Such officers are required to carry out difficult and/or dangerous tasks, at not infrequently, great personal risk. Any witness may speak to a solicitor prior to giving information to police. The same is true of any suspect. A witness is entitled to provide their account in the manner of their choosing. Officers involved in a fatal shooting should be entitled to no lesser protections and support than any other member of the public who is a witness. This is codified in the Ministry of Justice 2011 guidance for Achieving Best Evidence [‘ABE’] regarding the timing of any interview and the provision of a full and detailed account.” Source location 2014-0182-Response-by-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 Firearms officers’ priorities of saving life, protecting the public and securing the scene were treated as limiting the feasibility of comprehensively recording every aspect.
Verbatim wording from the response “In the immediate aftermath of a police shooting, it is inevitable that only the officers on scene will be available to carry out an immediate video or photographic capture. The convoy of cars on 4th August 2011 was equipped with both video and still cameras. The primary purpose for which that equipment is provided is to capture images of locations and environments to assist in tactical planning. Armed officers are not currently trained or equipped to record scenes to an evidential standard. On 4th August 2011, officers were able to and did, as an incidence of individual decision making and availability in the circumstances of the particular case of resources, use both cameras to record some parts of the scene, in particular, the provision of first aid.” Source location 2014-0182-Response-by-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 Continuous surveillance to locate the suspected gun holder was not a justifiable use of significant MPS resources given the available intelligence.
Verbatim wording from the response “Intelligence provided to the MPS by SOCA indicated Kevin Hutchinson-Foster was storing a gun or guns for Mark Duggan. The MPS did not telephone Mr Hutchinson-Foster’s probation officer, which might have confirmed his bail hostel address and telephone number. Possession of that address by the MPS might, theoretically, on application and diversion of very significant and valuable resources, have led eventually to the location of Mr Hutchinson-Foster at the bail hostel. He was not at the hostel on the night of the 3rd August 2011. The protracted and continuous” Source location 2014-0182-Response-by-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 The IPCC, through its senior investigating officer, holds ultimate responsibility for recording the scene of a fatal police shooting.
Verbatim wording from the response “The MPS acknowledges that the recording of the scene of a fatal police shooting is a desirable aspect of crime scene management and recognises the importance of securing best evidence in the immediate aftermath and ongoing investigation of a police shooting. This is the ultimate responsibility of the senior investigating officer (SIO); in the case of a fatal police shooting; that” Source location 2014-0182-Response-by-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 The operational head or senior investigating officer must decide whether to continue an armed response, based on the particular circumstances and available information.
Verbatim wording from the response “The MPS is committed to the removal of guns from the streets of London. It recognises the importance of continuing and concluding planned operations in the furtherance of that commitment. Where an operation in the context of which a police shooting occurs remains a crime in action, for example an ongoing kidnap or a planned armed robbery, the onus is on the operational head of that investigation to decide to continue the police response to prevent harm/serious injury, to arrest offenders and retrieve evidence.” Source location 2014-0182-Response-by-Metropolitan-Police-Service
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing joint MPS and NCA intelligence processes were considered robust, risk managed and accountable, with clear governance for developing intelligence opportunities.
Verbatim wording from the response “Following a comprehensive review of intelligence procedures and liaison conducted in response to your PFD report, the MPS has concluded that there were, and continue to be, robust, risk managed and accountable joint MPS/NCA (and previously SOCA) processes to request, refuse and allow intelligence opportunities to be developed with clear lines of governance. The MPS have collaborated with the NCA on all aspects of review and learning undertaken as a result of the tragic death of Mark Duggan. These include (a) professional development training courses for staff and managers in specialist skills and (b) reviews into safe-guarding and critical incident procedures.” Source location 2014-0182-Response-by-Metropolitan-Police-Service
Open published response
3 Mar 2014 Lee Sean MACPHERSON · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Failure to complete escort handover details on the PER View source Failure to ensure that police documentation recorded as accompanying the PER is available to escort staff View source Lack of shared understanding about police documentation accompanying persons in custody View source Failure to complete and provide the police risk assessment before custody escort View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lee Sean MACPHERSON · 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
Lee Sean MACPHERSON was found dead in a safer custody cell at HMP Wormwood Scrubs on 17 October 2012, after being remanded into custody the previous afternoon. Concerns related to incomplete and inconsistently transferred police risk-assessment and escort handover documentation between the police, SERCO and prison 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 complete escort handover details on the PER
Wider context from the report “(3) The escort handover details on the PER were not completed by the prison staff (or SERCO staff which is a matter SERCO have already addressed).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 police documentation recorded as accompanying the PER is available to escort staff
Wider context from the report “(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER. Boxes on the PER had been ticked indicating that, among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 shared understanding about police documentation accompanying persons in custody
Wider context from the report “(2) There was a lack of common understanding between SERCO staff and prison staff about what police documentation, including the police risk assessment, accompanied a person in custody, in addition to the PER. Boxes on the PER had been ticked indicating that, among other things, it was accompanied by a police risk assessment but SERCO staff said they had not seen that or the other documents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 and provide the police risk assessment before custody escort
Wider context from the report “(1) The police risk assessment was not completed until the deceased had already been collected by SERCO and it was a police risk assessment completed in the early hours of the morning that found its way to the prison .
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations