20 Oct 2025 Ms. Amy Jo Cross · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of a system for passing important healthcare information between criminal justice healthcare providers during conveyance View source Lack of a standard medical records system accessible to each healthcare organisation 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
Ms. Amy Jo Cross · 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. Amy Jo Cross was arrested on 9 June 2023, experienced reported drug and alcohol withdrawal symptoms, and died in a prison cell on 10 June 2023 after being found unresponsive before prescribed medication was administered. The report identified concerns about the transfer of healthcare information, including recent medication administration and physical observations, between police, court and prison healthcare providers, and the absence of a shared medical records system.
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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for passing important healthcare information between criminal justice healthcare providers during conveyance
Wider context from the report “(1) There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare in the criminal justice system at the time a person is conveyed between the police, the court and the 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard medical records system accessible to each healthcare organisation
Wider context from the report “(2) There is no standard medical records system which can be accessed by each healthcare organisation to ensure the efficient and effective transfer of medical information.
” Open source report
25 Oct 2024 Frank Steve Rios OSPINA · Prevention of Future Deaths report West London
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Concerns raised 4 Failure to provide accessible multilingual communications for arranging visits View source Restriction of Rule 35(2) report generation to general practitioners View source Failure to make Rule 35(2) reports when detainees are suspected of suicidal intentions View source Failure to control and document access to closed visits 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.
×
AI-generated summary
Frank Steve Rios OSPINA · 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
Frank Steve Rios OSPINA died by suicide in detention, with the cause of death recorded as ligature compression of the neck and coronary heart disease. The report raised concerns about the failure to make a Rule 35(2) report after apparent suicide attempts, inconsistent understanding of the reporting process, the conduct and oversight of a closed family visit, and difficulties faced by his non-English-speaking mother in arranging visits and telephone calls.
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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accessible multilingual communications for arranging visits
Wider context from the report “(3) Frank's mother does not speak English and found it very difficult to arrange a visit . In fact rather than successfully navigate the system, she just turned up and was permitted to see her son as set out above. Telephone calls were not facilitated with an interpreter. The web site where visits should be booked is entirely and only in English. This is a facility that by definition detains foreign nationals and predictably some of the family members do not speak English. A quick check of the local authority website (Hammersmith and Fulham) revealed a full immediate translation facility into over 100 languages, and so this is readily available technology. The Home Office and MITIE should consider the communications currently available to relatives trying to visit their loved ones and whether these can be improved by reasonable adjustments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Restriction of Rule 35(2) report generation to general practitioners
Wider context from the report “(1) During the inquest evidence was heard about the use of Detention services order 09/2016 Detention centre rule 35 (2)
The purpose of rule 35 of the Detention Centre Rules 2001, as set out in Detention - general guidance (chapter 55), is “to ensure that particularly vulnerable detainees are brought to the attention of those with direct responsibility for authorising, maintaining and reviewing detention.
Rule 35 (2) states
2. ‘The medical practitioner shall report to the manager on the case of any detained person he suspects of having suicidal intentions, and the detained person shall be placed under special observation for so long as those suspicions remain, and a record of his treatment and condition shall be kept throughout that time in a manner to be determined by the Secretary of State.
‘The manager shall send a copy of any report under paragraphs (1), (2) or (3) to the Secretary of State without delay.
Despite Frank Ospina being witnessed as having made an attempt to take his life, and self-reporting a further attempt during his detention, no R35 report was made.
The GP evidence was that there was a long waiting list of 4 weeks of over 100 individuals who were dealt with in separate dedicated surgeries, that he had only made "a small number" of R35 (2) reports and that he would usually await and rely on additional evidence such as that from a Consultant Psychiatrist before submitting a R35 (2) report. In contrast, the Home Office evidence was that they were "surprised" that a R35 report had not been submitted. If it had been it would have been considered by a responsible officer within 2 working days.
There was a clear mismatch between the healthcare and Home Office expectations and practical application of the R35 provisions. HMC was advised that this is under review currently by the Home Office and NHS England and so this report is written to inform and assist that review process by raising the concerns from this inquiry. HMC would also question the restriction of the report having to be generated by a general practitioner, although detainees were seen by a multi-disciplinary team of healthcare professionals, many of whom could potentially carry out this task.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to make Rule 35(2) reports when detainees are suspected of suicidal intentions
Wider context from the report “(1) During the inquest evidence was heard about the use of Detention services order 09/2016 Detention centre rule 35 (2)
The purpose of rule 35 of the Detention Centre Rules 2001, as set out in Detention - general guidance (chapter 55), is “to ensure that particularly vulnerable detainees are brought to the attention of those with direct responsibility for authorising, maintaining and reviewing detention.
Rule 35 (2) states
2. ‘The medical practitioner shall report to the manager on the case of any detained person he suspects of having suicidal intentions, and the detained person shall be placed under special observation for so long as those suspicions remain, and a record of his treatment and condition shall be kept throughout that time in a manner to be determined by the Secretary of State.
‘The manager shall send a copy of any report under paragraphs (1), (2) or (3) to the Secretary of State without delay.
Despite Frank Ospina being witnessed as having made an attempt to take his life, and self-reporting a further attempt during his detention, no R35 report was made.
The GP evidence was that there was a long waiting list of 4 weeks of over 100 individuals who were dealt with in separate dedicated surgeries, that he had only made "a small number" of R35 (2) reports and that he would usually await and rely on additional evidence such as that from a Consultant Psychiatrist before submitting a R35 (2) report. In contrast, the Home Office evidence was that they were "surprised" that a R35 report had not been submitted. If it had been it would have been considered by a responsible officer within 2 working days.
There was a clear mismatch between the healthcare and Home Office expectations and practical application of the R35 provisions. HMC was advised that this is under review currently by the Home Office and NHS England and so this report is written to inform and assist that review process by raising the concerns from this inquiry. HMC would also question the restriction of the report having to be generated by a general practitioner, although detainees were seen by a multi-disciplinary team of healthcare professionals, many of whom could potentially carry out this task.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to control and document access to closed visits
Wider context from the report “(2) Visits. The inquest was advised that Frank Ospina's mother visited him in the Heathrow Immigration Removal Centre on one occasion, and that was conducted as a "closed" visit.
Her son was accompanied by 2 Officers and their meeting held behind a glass screen where no physical contact was possible. The Officers were overhearing the family conversation and making notes.
MITIE who are responsible for the day to day running of the IRC were unaware that a "closed" visit had occurred and apologised for this, confirming it was inappropriate and Frank Ospina and his mother should have been allowed to meet in the usual communal area where they could have embraced and had a private conversation. This was the last time Frank Ospina was seen alive by his mother and the visit greatly distressed her.
HMC is concerned that any "closed" visits could take place seemingly without the knowledge and consent of the Duty Manager , that no documentation had to be presented and the "closed visit" room was accessible even though rarely required (the inquest was advised it had not been used at all during the past few months).
” Open source report
Concerns raised 12 Failure to provide formal written LDS mental health assessments to police View source Lack of a documented LDS mental health plan for custody View source Unavailability of appropriate LDS-police liaison templates View source Lack of local or national procedures for obtaining mental health assessments during intoxication View source Difficulty obtaining collateral mental health information from other services View source Failure of LDS and police information sharing about custody mental health presentation View source Unavailability of a 24-hour LDS service in custody View source Lack of formal police documentation of family concerns about mental health deterioration View source Lack of formal written handovers of mental health presentation between police officers View source Lack of guidelines for undertaking formal mental health assessments in intoxicated individuals View source Lack of formal documentation procedures for LDS and police custody care View source Lack of police decision-making guidelines for further mental health assessment or Appropriate Adult support 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
Miles Ethan Hurley · 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
Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formal written LDS mental health assessments to police
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented LDS mental health plan for custody
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody .
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriate LDS-police liaison templates
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of local or national procedures for obtaining mental health assessments during intoxication
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated , a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Difficulty obtaining collateral mental health information from other services
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure of LDS and police information sharing about custody mental health presentation
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest , was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed ). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a 24-hour LDS service in custody
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of formal police documentation of family concerns about mental health deterioration
Wider context from the report “2. Lack of relevant Documentation by the Police
Throughout Mr Hurley’s time in custody on the 9th July 2022, his parents spoke to multiple police officers and allied staff on the phone and on attending the custody suite to inform them of their concerns over their son’s sudden deterioration in his mental health on a background of longstanding extreme social anxiety. Whilst this was generally known by the officers within the custody suite, there was no formal documentation, either individually or collectively of these concerns to inform and assist police officers in their decision making .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of formal written handovers of mental health presentation between police officers
Wider context from the report “1. Lack of effective Communication between police officers
The absence of a formal written handover between police officers regarding how an individual is presenting to be able to more accurately assess and appropriately direct assessment and care, particularly for first time offenders such as Miles who was not known to the police. Prior to and at the time of his arrest he was recognised by members of the public and the arresting police officers as showing significant signs of disturbance in his mental health with incongruent speech, inappropriate behavioural affect, and delusional beliefs such as thinking he was playing ‘Grand Theft Auto’ whilst driving recklessly, on a background of intoxication. The extent and the severity of his mental health difficulties was not adequately conveyed through standard ‘word of mouth’ communication between police officers , complicated by Mr Hurley appearing to be more contained and less obviously mentally unwell in custody.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines for undertaking formal mental health assessments in intoxicated individuals
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of formal documentation procedures for LDS and police custody care
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures , or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of police decision-making guidelines for further mental health assessment or Appropriate Adult support
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” Open source report
28 Aug 2019 Amir Siman-Tov · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 14 Failure to communicate and establish vomiting during return to the healthcare unit View source Failure to provide detailed written clinical information and directions on discharge View source Failure to use the code blue procedure to summon an immediate emergency ambulance View source Failure to administer naloxone in suspected opiate overdose View source Lack of authority to require healthcare staff participation in the ACDT process View source Failure of the Consultant Forensic Psychiatrist to read ACDT documents View source Failure to apply renal impairment information in codeine overdose assessment View source Failure of healthcare staff to understand and participate in the ACDT process View source Failure to position an unresponsive patient on the floor for effective resuscitation View source Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC View source Unclear healthcare staff roles in the ACDT process View source Failure to provide explicit clinical direction and handover to night staff View source Inconsistent checks that detainees swallow issued medication View source Failure to wake, assess and take vital signs of a sleeping patient at risk View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Amir Siman-Tov · 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
Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and establish vomiting during return to the healthcare unit
Wider context from the report “9. During the journey back to the Colnbrook IRC Mr Siman-Tov vomited several times. He vomited on his return to the healthcare unit. The nurse on duty was not told by the escorting custody staff and did not ask about any vomiting in the returning minus. In oral evidence the nurse said that had he known of the vomiting then he would have returned Mr Siman-Tov to the hospital for further assessment. He did not know because he did not ask and was not told .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detailed written clinical information and directions on discharge
Wider context from the report “8. On discharge Mr Siman-Tov in the early evening of the 16ᵗʰ February 2016 was returned to Colnbrook IRC with no accompanying clinical information at all and no advice or directions to the clinical staff at the Colnbrook IRC from the hospital . The only information provided was that one of the hospital doctors had spoken to one of the Colnbrook IRC on the telephone and that Mr Siman-Tov was “good to go”. Failure to provide detailed written information puts patients at 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to use the code blue procedure to summon an immediate emergency ambulance
Wider context from the report “12. At approximately 3.10 on the 17ᵗʰ February 2016 Mr Siman-Tov was found to be unresponsive by custody officers. Medical assistance was called for but the required “code blue” for summoning an immediate emergency ambulance was not used .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to administer naloxone in suspected opiate overdose
Wider context from the report “14. An emergency bag was brought containing adrenaline autoinjector and also naloxone which Dr Harris said was a temporary antidote to opiates . A nurse gave an injection of adrenaline into the thigh “because he thought it might help”. Naloxone was not given , even though ████████ had required emergency admission the day prior because of an opiate overdose. This puts detainees at 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of authority to require healthcare staff participation in the ACDT process
Wider context from the report “4. The Centre Manager gave evidence that he recognised the importance of the ACDT process in keeping detainee’s safe and he actively encouraged as wide participation in the process as possible. He stated that he was only able to direct the custody staff and it was not in his power to direct that healthcare staff participated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure of the Consultant Forensic Psychiatrist to read ACDT documents
Wider context from the report “3. The Consultant Forensic Psychiatrist did not read the ACDT documents . This puts detainees at 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to apply renal impairment information in codeine overdose assessment
Wider context from the report “6. Mr Siman-Tov was taken to the Hillingdon Hospital in the late morning following his overdose on the 16ᵗʰ February 2016. At the Hillingdon Hospital an assessment, examination and blood tests were taken. The blood tests indicated renal impairment. An information system TOXBASE is used in emergency departments to provide assistance to clinicians. Toxbase indicates that in renal impairment greater care must be taken in cases of codeine overdose. This was missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare staff to understand and participate in the ACDT process
Wider context from the report “1. A GP who had seen Mr Siman-Tov during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the documents as a custody officer process. He told the Court that it was not customary for healthcare staff to attend or participate in the ACDT process . This puts detainees at 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to position an unresponsive patient on the floor for effective resuscitation
Wider context from the report “13. Nursing and other staff arrived. A custody officer asked the nurse if Mr Siman-Tov should be moved to the floor for resuscitation. The nurse replied no. Dr Harris, an expert in Emergency Medicine said that he should have been moved to the floor for effective resuscitation . This puts detainees at 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC
Wider context from the report “7. The hospital clinicians gave evidence which suggested that they were not fully aware of the level of medical monitoring and supervision available at Colnbrook IRC . Mr Siman-Tov had taken an overdose whilst supervised within that facility and a decision was made to return him to that environment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Unclear healthcare staff roles in the ACDT process
Wider context from the report “2. The nurses who gave evidence similarly were uncertain of their role with respect to the ACDT process and had variable accounts of their involvement in the ACDT process . This puts detainees at 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to provide explicit clinical direction and handover to night staff
Wider context from the report “10. Mr Siman-Tov’s care was then handed over to night staff. No explicit direction or handover was given . The explanation for this was that the observations should be second signature and did not need elaboration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Inconsistent checks that detainees swallow issued medication
Wider context from the report “5. Mr Siman-Tov expressed that he might save his medication and take as an overdose. There was conflicting evidence as to the rigour of the checks to ensure detainees had swallowed issued medicine at the time of dispensing and the nurses who gave evidence described different practices of observation . Mr Siman-Tov was able to collect sufficient codeine ultimately to be able to end his life. This lack of consistency of checks puts detainee’s at 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to wake, assess and take vital signs of a sleeping patient at risk
Wider context from the report “11. The night nurse on duty at around 2100 noted that Mr Siman-Tov was sleeping and snoring. He made no attempt to wake him, check him or take his vital signs . This put Mr Siman-Tov at risk .
” Open source report
21 Feb 2019 Terrence Arthur Albert Smith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 17 Lack of call-handling provision for identifying unrecognised ED/ABD presentations View source Inconsistency between police conveyance policy and officer training View source Conveyance policy restricting timely transport of medical emergencies View source Unavailability of national guidance for out-of-hospital rapid tranquilisation View source Lack of timely escalation of serious ED/ABD safety matters to senior management View source Insufficient coverage of ED/ABD training for front-line response staff View source Contradictory ambulance call-handling instructions View source Training that conflates ED/ABD death risk with positional asphyxia View source Conveyance policy restricting timely transport of medical emergencies View source Failure of the police Mental Health Guide to separately address ED/ABD View source Police training that mischaracterises ED/ABD as controversial View source Omission of patient containment guidance from ED/ABD training View source Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD View source Inaccurate monitoring and capture of ED/ABD incidents View source Confusing clinical-staff ED/ABD training content View source Police training that conflates ED/ABD with positional asphyxia View source Failure of call-handling guidance to capture patient restraint status View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Terrence Arthur Albert Smith · 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
Terrence Smith died in hospital on 13 November 2013 after developing amphetamine-induced Excited Delirium/Acute Behavioural Disturbance, being subjected to prolonged restraint, and stopping breathing while being transported to hospital. The principal concerns included failures to recognise the condition as a medical emergency, inadequate assessment and training, excessive restraint, delayed conveyance to hospital, and deficiencies in relevant emergency response, clinical, police and custody policies and 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of call-handling provision for identifying unrecognised ED/ABD presentations
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Inconsistency between police conveyance policy and officer training
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I have two concerns :
(a) I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary, and could result in a fatal delay in the provision of life-saving treatment.
(b) I am concerned that the content of this policy is inconsistent with the training I was told is given to police officers , namely that they may convey a patient to hospital by police vehicle if the use of an ambulance is not an available or practical option , and as long as the conveyance is approved by a senior officer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Conveyance policy restricting timely transport of medical emergencies
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary , and could result in a fatal delay in the provision of life-saving 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Unavailability of national guidance for out-of-hospital rapid tranquilisation
Wider context from the report “I was told that although the London Ambulance Service has provided out of hospital rapid tranquilisation of patients (such as may well be needed by a patient suffering ED/ABD) for some years, SECAMB will not do so until a national protocol or guidance has been issued by JRCALC . In those circumstances, whilst I understand that work on the production of such guidance is being undertaken, I am nevertheless concerned that none is yet in place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of timely escalation of serious ED/ABD safety matters to senior management
Wider context from the report “I was told by the Chief Executive Officer of SECAMB that he was not aware of Terry’s death and SECAMB’s involvement in it, nor of the issues arising at the Inquest, until very shortly before being required to give oral evidence at the Regulation 28 hearing. Given the length of the Inquest and the seriousness of the issues arising in relation to SECAMB (including their failure to recognise that Terry was suffering ED/ABD and to ensure he was treated as a medical emergency and taken to an Accident and Emergency Department), I am concerned that there is no system in place to ensure that such matters are drawn to the attention of the most senior management in a timely manner so as to ensure there is strategic planning for the prevention of other 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Insufficient coverage of ED/ABD training for front-line response staff
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be). Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Contradictory ambulance call-handling instructions
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Training that conflates ED/ABD death risk with positional asphyxia
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all .
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Conveyance policy restricting timely transport of medical emergencies
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I have two concerns :
(a) I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary , and could result in a fatal delay in the provision of life-saving treatment .
(b) I am concerned that the content of this policy is inconsistent with the training I was told is given to police officers, namely that they may convey a patient to hospital by police vehicle if the use of an ambulance is not an available or practical option, and as long as the conveyance is approved by a senior officer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure of the police Mental Health Guide to separately address ED/ABD
Wider context from the report “Surrey Police’s Mental Health Guide addresses ED/ABD only in bullet point form alongside reference to Positional Asphyxia . The conditions are separate and different and the absence of a separate sheet addressing ED/ABD alone could mislead those reading the Guide in to thinking that the conditions are necessarily connected .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Police training that mischaracterises ED/ABD as controversial
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD .
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia. The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Omission of patient containment guidance from ED/ABD training
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all.
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD
Wider context from the report “The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly . I was told that it is intended that version 17 will do so but this is not yet in use. My concern is that, unless and until it is in use, there will continue to be a failure by call handlers to recognise ED/ABD and respond 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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Inaccurate monitoring and capture of ED/ABD incidents
Wider context from the report “I am concerned that SECAMB is not currently monitoring accurately the incidence of cases of ED/ABD in the regions it covers. A witness told me that she believed there were very few incidents (under ten a year) and that they were all apparent from the data gathered. On the basis of the evidence heard at the Inquest it seems unlikely that there are very few incidents given that SECAMB cover three large counties with a total population of over 4 million people and given the much higher incidence in other areas. Further, there were at least two incidents of ED/ABD (from 2018 and 2019) referred to in evidence which had not been captured at all by SECAMB’s data gathering.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Confusing clinical-staff ED/ABD training content
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be) . Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Police training that conflates ED/ABD with positional asphyxia
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD.
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia . The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure of call-handling guidance to capture patient restraint status
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint . If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call .
” Open source report
Concerns raised 2 Failure to ensure experienced mental health professional assessment of older people who self-harm View source Lack of healthcare professional access to detainees’ medical and mental health records 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
David Nigel Phillips · 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
David Nigel Phillips, who had a history of mental illness, previous suicide attempts, alcohol-related issues and type 2 diabetes, was found drowned in a rock pool near Mumbles Pier on 4 January 2015. He had been arrested the previous day after being found intoxicated in his parked car and had told police he had been attempting to take his own life. The principal concerns were that an experienced mental health professional should have assessed him and that the healthcare professional lacked access to his medical records, including mental health records, to review his medication and risks accurately.
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 Mitie; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure experienced mental health professional assessment of older people who self-harm
Wider context from the report “My concerns are that:-
(1) An experienced mental health doctor or nurse should have been called to carry out the assessment rather than a nurse . The quality of the assessment is critical rather than a box ticking exercise .
(2) The Health Care Professional did not have access to detainee’s medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred.
An ability to review medication and if necessary prescribe medication would be helpful and access to medical records is critical. Access to electronic Individual Health Records to include mental health records
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mitie; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare professional access to detainees’ medical and mental health records
Wider context from the report “My concerns are that:-
(1) An experienced mental health doctor or nurse should have been called to carry out the assessment rather than a nurse. The quality of the assessment is critical rather than a box ticking exercise.
(2) The Health Care Professional did not have access to detainee’s medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred .
An ability to review medication and if necessary prescribe medication would be helpful and access to medical records is critical . Access to electronic Individual Health Records to include mental health records
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations