21 Oct 2013 Daniel Maurice McMahon · Prevention of Future Deaths report North London
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Concerns raised 4 Failure to identify difficulties experienced by patients on Section 17 leave View source Failure to stop trains and set signals to danger when an unwell person is trespassing on the line View source Lack of clear guidance on whether lung decompression needles should be used with a valve View source Failure to gather and pass accurate trespasser and track-section location information 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
Daniel Maurice McMahon · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Maurice McMahon suffered severe head injuries after being hit by a train at Willesden Junction Station on 11 January 2012, following reports that he had fallen from a bridge and moved onto the railway track. The report raised concerns about the accuracy and completeness of information recorded by police about the location of a person trespassing on the railway, procedures for stopping trains when an unwell person is on the line, support during mental-health leave, and the use of lung-decompression needles without a valve.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Failure to identify difficulties experienced by patients on Section 17 leave
Wider context from the report “(2) Department of Health:-
Consideration to be given to using a feedback form, where a patient is on S17 of the MHA 1983 leave, to be completed by those caring for the patient in the community and the professional staff at the hospital to ensure that any difficulties that a patient has while on leave are picked 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 Failure to stop trains and set signals to danger when an unwell person is trespassing on the line
Wider context from the report “(3) RSSB:-
The Rule book be amended to require that trains stop, (signals are set to danger), when a person who is identified as being unwell or there is reason to believe might be unwell is trespassing on the line . (The current position would be to set the signals to caution ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 guidance on whether lung decompression needles should be used with a valve
Wider context from the report “(4) London Ambulance Service:-
The LAS consider the guidance on the use of lung decompression needles and whether these should be used with a valve .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, 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 gather and pass accurate trespasser and track-section location information
Wider context from the report “(1) Metropolitan Police :-
That steps should be taken to ensure that when report is passed to the police concerning a person who is seen to be trespassing on the railway line that correct information is gathered to locate that person and the section of the track that person is on so that this information can be passed to those responsible for contacting the network covering that section of the track . This is in addition to the attendance location and the incident location normally recorded when a 999 call is made.
” Open source report
23 Sep 2013 Michael James SWEENEY · Prevention of Future Deaths report London North (Inner)
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Concerns raised 2 Reliance on “excited delirium” as an apparent diagnosis risking missed organic causes View source Lack of shared recognition of the term “excited delirium” across emergency services 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
Michael James SWEENEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael James Sweeney died after taking cocaine and becoming extremely agitated; he was transported to hospital by police after an ambulance was not sent within the target time. He was restrained prone until sedation was effective, then arrested and died less than two hours later. The principal concerns were the inconsistent use and understanding of the term “excited delirium”, the risk of missing other medical causes of extreme agitation, and ambulance-service prioritisation of such emergencies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Reliance on “excited delirium” as an apparent diagnosis risking missed organic causes
Wider context from the report “Police officers had clearly been trained in the condition described to them as excited delirium. The training was effective in facilitating their understanding of Mr Sweeney’s condition as a medical emergency. However, this term is not widely used in this country, and neither ambulance, nursing nor even some of the medical staff had heard of it in April 2011.
It would be possible to give ambulance and hospital personnel an understanding of the term excited delirium. However, given that this describes a medical condition, it seems more logical for the police to follow health services in this, rather than the other way round.
Moreover, although it did not happen in Mr Sweeney’s case, there could be situations where a person exhibits extreme agitation that is not related to an acute drug psychosis. There is the potential for an organic cause to be missed because of reliance on that term as an apparent diagnosis . Extreme agitation can be caused by conditions such as a bleed on the brain, sepsis from infection (e.g. meningitis), or a diabetic coma.
From the evidence I heard, the safest and most effective way to deal with a person exhibiting such an acute behavioural disturbance seems to be simply to use the term “extreme agitation”. This describes the constellation of symptoms without purporting to diagnose the cause.
1. Such an approach would require the Metropolitan Police Service simply to amend the training it currently delivers, to describe the condition as “extreme agitation” rather than “excited delirium”.
2. The take home message that the condition is a medical emergency should still be part and parcel of the training, in just the way it is now.
3. This training would also need to be delivered in some form to police control staff, so that they recognise the importance of the term when an officer uses it, and pass this on to the ambulance service.
4. Finally, it would require London Ambulance Service to amend its protocols and training to recognise extreme agitation as a medical emergency and prioritise appropriately.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Metropolitan Police Service; that does not assign responsibility.
PFD Monitor interpretation Lack of shared recognition of the term “excited delirium” across emergency services
Wider context from the report “Police officers had clearly been trained in the condition described to them as excited delirium. The training was effective in facilitating their understanding of Mr Sweeney’s condition as a medical emergency. However, this term is not widely used in this country , and neither ambulance, nursing nor even some of the medical staff had heard of it in April 2011 .
It would be possible to give ambulance and hospital personnel an understanding of the term excited delirium. However, given that this describes a medical condition, it seems more logical for the police to follow health services in this, rather than the other way round.
Moreover, although it did not happen in Mr Sweeney’s case, there could be situations where a person exhibits extreme agitation that is not related to an acute drug psychosis. There is the potential for an organic cause to be missed because of reliance on that term as an apparent diagnosis. Extreme agitation can be caused by conditions such as a bleed on the brain, sepsis from infection (e.g. meningitis), or a diabetic coma.
From the evidence I heard, the safest and most effective way to deal with a person exhibiting such an acute behavioural disturbance seems to be simply to use the term “extreme agitation”. This describes the constellation of symptoms without purporting to diagnose the cause.
1. Such an approach would require the Metropolitan Police Service simply to amend the training it currently delivers, to describe the condition as “extreme agitation” rather than “excited delirium”.
2. The take home message that the condition is a medical emergency should still be part and parcel of the training, in just the way it is now.
3. This training would also need to be delivered in some form to police control staff, so that they recognise the importance of the term when an officer uses it, and pass this on to the ambulance service.
4. Finally, it would require London Ambulance Service to amend its protocols and training to recognise extreme agitation as a medical emergency and prioritise appropriately.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the joint MPS–LAS Memorandum of Understanding containing documented call-handling guidance and communication arrangements for suspected Acute Behavioural Disorder.
Verbatim wording from the response “Point 4 above is of course a matter for the London Ambulance Service. I understand they will be replying to you separately on this. I would anticipate however that they will in that response make reference to the adoption of a new Memorandum of Understanding between our respective services, on providing ‘...guidance on joint working including use of CAD Link and Joint Response Units’, which we are now in the final stages of completing.” Source location 2013-0236-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt Acute Behavioural Disorder as the common terminology for the relevant medical emergency.
Verbatim wording from the response “Secondly, both national and Metropolitan Police training on the correct terminology to use have in fact already moved on since the date of this incident. Though the ‘constellation of behaviours’ has at various points in the developing knowledge about it’s causes and effects been known (inter alia) as ‘cocaine psychosis’, and ‘excited delirium’, since 2010 the generally recognised phrase within UK police texts has been ‘Acute Behavioural Disorder’ (‘ABD’). This phrase was chosen to provide exactly the “ ‘precision without ‘diagnosis’ “ you indicated would be a necessary element of any common terminology adopted. Inspector ████████ provides the practitioner’s context:” Source location 2013-0236-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 Encourage NHS partners to adopt Acute Behavioural Disorder terminology and increase supporting awareness of the condition.
Verbatim wording from the response “The potential information gap for MPS civil staff working at Central Communications Command who do not receive this training routinely has been addressed by the issuing of direct practice notes, and supported by a programme of in-house training on awareness of the issues and correct procedures to adopt. Meanwhile, the development of a detailed and documented joint agency call-handling protocol with our partners at London Ambulance Service, contained within the new Memorandum of Understanding, gives both ‘First Responder’ agencies a common wellspring of guidance to draw upon, a robust channel of communication where ABD is suspected, and clarity regarding the expectations each agency can have of the other’s response in these circumstances. It is now important that staff in emergency departments are also made aware of this condition and its management.” Source location 2013-0236-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 Direct Central Communications Command staff to identify relevant calls in messages to the ambulance service and provide supporting training on awareness and procedures.
Verbatim wording from the response “These moves to enhance staff awareness of the condition and the terminology of ABD to describe it, undertaken by our partners in the LAS, have been mirrored in steps undertaken within our own call-handling centre, the Central Communications Command (CCC). On the 20th September 2013, Chief Inspector Horwood issued the following practice direction to all Central Communications Command Staff:” Source location 2013-0236-Response-by-Metropolitan-Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain Acute Behavioural Disorder content in officers’ regular Officer Safety and Emergency Life Support training, including refresher training.
Verbatim wording from the response “The generic term Acute Behaviour Disorder was selected as the most appropriate term and ABD was subsequently fast-tracked into the National Personal Safety Manual. The Faculty of Forensic and Legal Medicine also adopted the terminology of ABD, and have produced guidance on the management of this condition. The medical implications of the manual's techniques and guidance (including ABD) were reviewed by Professor ████████ in 2010. Furthermore, additional improvements were most recently made to the ABD advice by Professor ████████ in 2012, following Rule 43 advice in another case.” Source location 2013-0236-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 “Extreme agitation” is rejected because its broad meaning could obscure the specific constellation of behaviours indicating a medical emergency.
Verbatim wording from the response “However, the use of the particular phrase ‘extreme agitation’ in place of ‘extreme delirium’ was universally rejected, by both the local partner agencies approached by ████████ through the Clinical Panel, and by the setters of national police policy through the Association of Chief Police Officers, as reported by Inspector ████████ The reasons for this were as follows:” Source location 2013-0236-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 Existing Acute Behavioural Disorder training makes additional police training changes on terminology and recognising the medical emergency unnecessary.
Verbatim wording from the response “Your recommendation regarding a common terminology has been accepted by all partners. It is respectfully submitted however that the adoption by the London Ambulance Service of the term ‘Acute Behavioural Disorder’ as the term of choice effectively negates the additional training changes recommended in points 1 and 2 of your report, as active training on ABD and responses to it remain an ongoing element in all regular refresher training sessions for police officers, and this, we are given to understand, is now being paralleled within the LAS via their own training and practice direction regimes.” Source location 2013-0236-Response-by-Metropolitan-Police
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations