Concerns raised 11 Lack of police training for mental health-related incidents involving illicit substance use View source Lack of cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance View source Delays and non-attendance in EMAS ambulance response to s.136 conveyance requests View source Unavailability of mental health management, monitoring and treatment for people with co-occurring substance misuse who cannot abstain View source Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy View source Failure of police training on ambulance conveyance for s.136 detainees View source Lack of police training on communicating s.136 detention decisions and reasons View source Lack of an out-of-hours local protocol for police access to mental health advice View source Lack of joined-up agency policy for s.136 detention and conveyance View source Reliance on unrealistic self-referral for people requiring mental health and substance misuse support View source Failure to align Street Triage Team capacity with current demand View source See 8 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
Kaine Regan FLETCHER · 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
Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.
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 Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police training for mental health-related incidents involving illicit substance use
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee. Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances . I am concerned that training in the area of mental health generally is lacking , which is impacting upon the approach of the police officers dealing with mental health related incidents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-sector working and joint agency policy for Acute Behavioural Disorder/Disturbance
Wider context from the report “1. Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance
In September 2022, the Royal College of Psychiatrists issued a position statement on Acute Behavioural Disturbance and Excited Delirium. The RCP recommend that:
• A cross-sector working group should be convened to develop an interim consensus on ‘ABD’, with active involvement of patients and carers, to agree terminology, key principles for professional guidance, and priorities for further research.
• This group should include representatives from police, custodial, ambulance, emergency medicine, mental health, and the judicial and coronial system. Support from relevant government departments would help ensure consistency across services.
• Further research should be urgently commissioned, including detailed investigation into how racial bias plays into the application of terminology such as ‘ABD’.
• Members of the cross-sector working group should collaborate on the development and delivery of training materials for staff working across public services
• All services should seek to improve standardised collection of disaggregated data on presentations and outcomes, and to conduct regular multi-disciplinary reviews to support high-quality research on this topic.
I have heard evidence that in Nottingham and Nottinghamshire, no such cross-sector working is in place or joint agency policy is in place . I have also heard evidence that there is no knowledge of such cross-sector working or joint agency policy in place within the East Midlands generally, or nationally. The consequence of this is that there is no joined up thinking, procedure or policy, between front-line services who are regularly dealing with cases of ABD . That lack of collaborative working between services gives rise to a risk of future death for persons who develop ABD both in the community or in custody. People at risk of developing ABD often also fall into categories of vulnerability, such as suffering with a mental health disorder or using illicit substances. To my mind, this increases the risk of future death in the absence of any collaboration. I am concerned that this appears to be a national issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Delays and non-attendance in EMAS ambulance response to s.136 conveyance requests
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee.
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all .
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance. Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS . This may, in part, be explained by the policy/service level agreement confusion within EMAS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health management, monitoring and treatment for people with co-occurring substance misuse who cannot abstain
Wider context from the report “6. Mental Health Services – ‘the gap’
I am concerned that there is a ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis . Clinically, I understand that substance misuse can provide a barrier to effective treatment of any mental health condition. However, I have heard evidence that there is no service available to patients for management, monitoring and treatment in circumstances where they are unable to abstain from substances but require care for the residual mental health condition . In circumstances where it is clinically recognised that substance misuse can exacerbate the symptoms of many mental health conditions, this gives risk to a clear risk of future death. The evidence that I have heard is that once treatment or referral options for these patients have been exhausted, they are discharged from the Local Mental Health Team with signposting to other services e.g. substance misuse services/charities or CRISIS. These services often required self-referral, which is not realistic for many people in these circumstances. Kaine fell into this gap, and I am concerned that there is a risk of future death for other patients if this gap is not filled. Again, it seems to me that this is an issue of national concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure within EMAS to ratify, disseminate and implement the relevant s.136 joint agency policy
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation . They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy , rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance. For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of police training on ambulance conveyance for s.136 detainees
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee .
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all.
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance . Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS. This may, in part, be explained by the policy/service level agreement confusion within EMAS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police training on communicating s.136 detention decisions and reasons
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee . Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances. I am concerned that training in the area of mental health generally is lacking, which is impacting upon the approach of the police officers dealing with mental health related incidents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of an out-of-hours local protocol for police access to mental health advice
Wider context from the report “5. The availability of the Street Triage Team
I heard evidence that Nottinghamshire is pioneering in its provision of a Street Triage Team, a service that has been available since 2014. This team is comprised of one police officer and one community psychiatric nurse who can travel to mental health incidents to provide assessment and advice to the response officers, particularly in relation to exercising s.136 powers.
I heard that this service is available between 8am and 1am, and that the resourcing of the service (both in terms of the shift patterns and the available cars) was determined by analysis of a data set in 2017.
At the time that the incident arose with Kaine on 3 July 2022, no STT was available as it was out of hours.
I am concerned that there is a need to review the data to ensure that the demand for the service in 2025 is still reflected in the shift patterns. I am concerned, based on the evidence that I heard from EMAS in relation to an increase of ~60% in mental health related calls, that the demand for service may have changed since 2017.
I note that the Mental Health Code of Practice includes the following guidance at [16.23] in relation to triage and s.136: “When deciding that detention may be necessary, the police may also benefit from seeking advice before using section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours”. I am concerned that I have not seen any local protocol as to who the police should contact out of hours , and I note that EMAS do have available mental health nurses between the hours of 1am and 8am. This again appears to be a local policy and communication issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of joined-up agency policy for s.136 detention and conveyance
Wider context from the report “2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions
I issued a PFD on 17 July 2025, part way through the final inquest hearing, to raise my concern over apparent confusion with both the police and EMAS as to the applicable joint agency policy dealing with s.136 MHA 1983 detention and conveyance.
Since that PFD was issued, the evidence has developed and the position at the end of the inquest was as follows:
• The police confirmed that the document titled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency sections 135 and 136 Mental Health Act 1983 Procedures” has been ratified within their organisation and continues to remain the relevant joint-agency policy for s.136 detention and conveyance. This policy has been implemented for the police since its inception.
• EMAS cannot confirm whether the above policy has been ratified in its current version within the organisation. They have confirmed that an employee at EMAS signed off on the 2021 version, but that this information was never disseminated within the organisation because the finalised version of the policy remained within that employee’s email inbox. The consequence appears to be that EMAS has never implemented this policy, rather they have been working to an internal policy for Mental Health Conveyance that contains different working standards.
Acknowledging that there is no confusion for the police as to the relevant policy, and that they do consider that it has been implemented, I remain concerned. My concerns can now properly be formulated as follows:
• There is no joined up thinking between agencies on the local policy for s.136 MHA 1983 detention and conveyance . For a policy to be effective, all purported parties to that policy need to know it applies to them.
• Internal disorganisation within EMAS has culminated in a situation where, even after a period of investigation between 17 July – 25 July, they are unable to tell the Court which, if any, joint agency policy applies to them. They are unable to tell the Court whether they are still part of the relevant working group. EMAS have allowed a situation to perpetuate in which they appear, on the face of the policy documents, to be party to an agreement (which includes service level agreements for conveyance) when they simply do not know if this is correct. The upshot of this is that other agencies may be placing reliance on the conveyance terms within the policy when they are dealing with s.136 detention.
My concerns are supported by the guidance available at ss. 16.30 – 16.35 of the Mental Health Code of Practice, which highlights the importance of local policy for s.136 detention. It does not appear that there is compliance with this guidance, published by the Department of Health.
The lack of joined up thinking between agencies locally gives rise to a risk of future death for persons detained under s.136 MHA 1983.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Reliance on unrealistic self-referral for people requiring mental health and substance misuse support
Wider context from the report “6. Mental Health Services – ‘the gap’
I am concerned that there is a ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis. Clinically, I understand that substance misuse can provide a barrier to effective treatment of any mental health condition. However, I have heard evidence that there is no service available to patients for management, monitoring and treatment in circumstances where they are unable to abstain from substances but require care for the residual mental health condition. In circumstances where it is clinically recognised that substance misuse can exacerbate the symptoms of many mental health conditions, this gives risk to a clear risk of future death. The evidence that I have heard is that once treatment or referral options for these patients have been exhausted, they are discharged from the Local Mental Health Team with signposting to other services e.g. substance misuse services/charities or CRISIS. These services often required self-referral, which is not realistic for many people in these circumstances . Kaine fell into this gap, and I am concerned that there is a risk of future death for other patients if this gap is not filled. Again, it seems to me that this is an issue of national concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to align Street Triage Team capacity with current demand
Wider context from the report “5. The availability of the Street Triage Team
I heard evidence that Nottinghamshire is pioneering in its provision of a Street Triage Team, a service that has been available since 2014. This team is comprised of one police officer and one community psychiatric nurse who can travel to mental health incidents to provide assessment and advice to the response officers, particularly in relation to exercising s.136 powers.
I heard that this service is available between 8am and 1am, and that the resourcing of the service (both in terms of the shift patterns and the available cars) was determined by analysis of a data set in 2017 .
At the time that the incident arose with Kaine on 3 July 2022, no STT was available as it was out of hours.
I am concerned that there is a need to review the data to ensure that the demand for the service in 2025 is still reflected in the shift patterns . I am concerned, based on the evidence that I heard from EMAS in relation to an increase of ~60% in mental health related calls, that the demand for service may have changed since 2017 .
I note that the Mental Health Code of Practice includes the following guidance at [16.23] in relation to triage and s.136: “When deciding that detention may be necessary, the police may also benefit from seeking advice before using section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours”. I am concerned that I have not seen any local protocol as to who the police should contact out of hours, and I note that EMAS do have available mental health nurses between the hours of 1am and 8am. This again appears to be a local policy and communication issue.
” Open source report
Concerns raised 1 Lack of shared understanding of applicable local policy and working standards for s.136 detention View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kaine Regan FLETCHER · 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
Kaine Regan FLETCHER died on 3 July 2022 after deteriorating during a period of restraint following detention under section 136 of the Mental Health Act, with cocaine and other substances also identified in the stated cause of death. The report raises concern that the police and ambulance service did not share an understanding of the applicable local policy and working standards for managing section 136 incidents, creating a potential risk of preventable future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding of applicable local policy and working standards for s.136 detention
Wider context from the report “Confusion over applicable local policy and working standards for dealing with s.136 detention
I am concerned that there is a lack of understanding by the police and EMAS on local policy and working standards for dealing with s.136 detention.
At the outset of this investigation, a direction was given for disclosure of “Local memoranda or policies concerning how EMAS and Notts police jointly manage health incidents”. In response to that direction, a number of policies were disclosed, including a document entitled “Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency, sections 135 and 136 Mental Health Act 1983 Procedures”. Various versions of this policy were disclosed to the coroner, including a 2018, 2021 and 2024 version.
During the course of the inquest so far, I heard evidence from both the police and the ambulance service in relation to the local policy for managing s.136 incidents. The police and the ambulance service do not share an understanding of which policy they are expected to adhere to and whether there is a joint local policy. The police consider that the document above (as amended) is the applicable framework, whilst EMAS are currently unable to tell me if this policy has agreed to by them, notwithstanding that they appear as one of the agencies that formed part of the working group for each version of the MOU. The witness who gave policy evidence on behalf of EMAS told me that they only work to their own internal local standard, which is different to that in the MOU.
Persons detained under s.136 of the Mental Health Act 1983 are some of the most vulnerable in society. Their liberty has been removed, and they are reliant upon state agencies to protect their right to life. I am extremely concerned that there is no joined up thinking, or understanding, between the police and the ambulance service as to which policy and which working standards apply when furthering the protection of that right. I am concerned that this lack of basic understanding of policy and working standards by emergency services, if it persists, poses a risk of preventable future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support EMAS and partners in developing and implementing a new regional mental-health conveyance policy.
Verbatim wording from the response “EMAS have advised that instead they intend to lead on the creation of a new regional Mental Health (MH) conveyance policy with system partners, and in the interim continue to utilise their current regional policy. We understand this is due to complexities across county boundaries where localised agreements may cause confusion resulting in less optimal patient experience. We remain in regular contact with EMAS and will fully support the development of this new regional policy being implemented in the most expedient way possible.” Source location 2025-0363 - Response from Nottingham and Nottinghamshire Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation EMAS will lead development of a new regional mental health conveyance policy instead of implementing or refining the existing local multi-agency policy.
Verbatim wording from the response “We have consulted with colleagues from EMAS to address this issue and suggested several potential remedies. We have been advised by the EMAS Head of Mental Health, that after careful consideration their Chief Executive has directed that they will not be seeking to implement or refine the existing multi-agency policy and procedure for Nottingham and Nottinghamshire.” Source location 2025-0363 - Response from Nottingham and Nottinghamshire Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The current regional policy and interim internal governance arrangements are considered sufficient to minimise risks until the new regional policy is implemented.
Verbatim wording from the response “EMAS have advised that instead they intend to lead on the creation of a new regional Mental Health (MH) conveyance policy with system partners, and in the interim continue to utilise their current regional policy. We understand this is due to complexities across county boundaries where localised agreements may cause confusion resulting in less optimal patient experience. We remain in regular contact with EMAS and will fully support the development of this new regional policy being implemented in the most expedient way possible.” Source location 2025-0363 - Response from Nottingham and Nottinghamshire Police
Open published response
1 Jul 2025 Barry Christopher Spooner · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1 Failure to provide previous PPNs to Adult Social Care when a current PPN is referred immediately View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Barry Christopher Spooner · 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
Barry Christopher Spooner engaged with police after concerns that a woman was financially exploiting him to buy drugs. He was financially exploited until his death and was found at home having been murdered by the woman. The principal concern was insufficient information sharing from Nottinghamshire Police to the Local Authority, including that one Public Protection Notice was not referred to Adult Social Care.
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 Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide previous PPNs to Adult Social Care when a current PPN is referred immediately
Wider context from the report “1. Insufficient information sharing from Nottinghamshire Police to the Local Authority in the event of a public protection concern.
I heard evidence about the new Vulnerability Policy followed by the police in order to try to improve information sharing between organisations. I was told that when a PPN is completed and sent to the MASH it is considered by an experienced officer who decides whether or not to refer it on to Adult Social Care for their consideration. If they decide not to refer onwards then the officer will consider all PPNs from the previous 12 months. If this review causes them to change their opinion then the current PPN and the previous PPNs will be referred onwards. This ensures Adult Social Care has all relevant information to help them decide upon the best course of action.
In accordance with the Vulnerability Policy, it was explained to me that when a PPN is considered suitable for referral to Adult Social Care straight away then previous PPNs are not reviewed and sent on to Adult Social Care if they have not already had them . This means that in a scenario where there have been previous PPNs that have not been provided to Adult Social Care, then that team will not be aware of all of the relevant information when considering the referral from the MASH and the most appropriate course of action .
This may impact upon Adult Social Care’s ability to make a proper decision in such cases and may put vulnerable people at more of a risk depending upon whether previous PPNs have been provided to Adult Social Care, or not.
” Open source report
24 Dec 2024 Paul Taylor · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1 Failure to automatically refer suspects interviewed voluntarily for relevant offences to mental health services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Taylor was under police investigation and, within a fortnight of learning that criminal charges had been authorised, intentionally took a large quantity of prescription medication and was found deceased at home on 3 January 2024. The report raises a concern that suspects interviewed voluntarily are not automatically referred to mental health services, with only welfare assessments by the investigating officer and no healthcare involvement.
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 Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to automatically refer suspects interviewed voluntarily for relevant offences to mental health services
Wider context from the report “When a suspect is arrested for offences requiring a referral to a mental health nurse, commonly referred to in Nottinghamshire as “Liaison and Diversion” the custody sergeant makes that referral automatically, which allows the opportunity for a suspect to obtain assistance from a healthcare professional, if they desire. In addition, there are welfare assessments conducted by the officer in charge of the investigation. In cases where a suspect is interviewed on a voluntary basis for relevant offences, the suspect is not dealt with at a custody suite and a referral to a mental health nurse is not automatic. In this latter scenario, only welfare assessments are completed by the officer in charge of the investigation without any involvement from healthcare services.
” 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 Communicate the amended safeguarding policy across the organisation by 1 March 2025.
Verbatim wording from the response “A policy revision is being undertaken to ensure that the procedures for supporting and safeguarding suspects of relevant offences are consistent, irrespective of whether the individual has been arrested or invited for voluntary attendance. In both scenarios, suspects receive an officer welfare assessment together with an automatic referral to Liaison and Diversion (healthcare services). The amendment to the policy and communication to the organisation will be implemented by 1st March 2025.” Source location Response from Nottinghamshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise procedures so voluntary and arrested suspects receive consistent welfare assessments and automatic Liaison and Diversion referrals.
Verbatim wording from the response “A policy revision is being undertaken to ensure that the procedures for supporting and safeguarding suspects of relevant offences are consistent, irrespective of whether the individual has been arrested or invited for voluntary attendance. In both scenarios, suspects receive an officer welfare assessment together with an automatic referral to Liaison and Diversion (healthcare services). The amendment to the policy and communication to the organisation will be implemented by 1st March 2025.” Source location Response from Nottinghamshire Police
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maxine Betty Davison and 4 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to condition firearms licensing delegation on adequate training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training .
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training .
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Absence of a mandatory requirement for role-specific firearms licensing training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training . I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular .
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff ;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
14 Oct 2021 Paul Ashley Barton · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Failure to account for fluctuating and contradictory suicidal intentions when assessing patient risk View source Failure of investigations to challenge false assumptions View source Failure of investigation processes to identify themes of concern View source Failure of investigations to maintain accurate evidence-based findings View source Failure of crisis resolution home treatment to prioritise protection of life beyond preventing hospital admission View source See 2 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
Paul Ashley Barton · 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
Paul Ashley Barton experienced significant distress, personality changes, dysfunctional behaviour, possible paranoid or delusional thoughts, and repeated suicidal thoughts and acts. He died by hanging on 28 November 2020. Concerns included the Crisis Resolution Home Treatment Team’s focus on avoiding inpatient admission, reliance on patients’ expressed intentions or denials despite fluctuating suicidal intentions, and shortcomings in the Trust’s investigation of his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to account for fluctuating and contradictory suicidal intentions when assessing patient risk
Wider context from the report “(2) This inquest was one of a number of inquests I have conducted where staff members from Nottinghamshire Healthcare NHS Foundation Trust have placed great reliance upon their interpretation of a patient’s intention and / or a patient’s denial of ongoing suicidal intention . This is so even where, as was the case for Mr Barton, there is a clear and established pattern of fluctuating and contradictory intentions and desires towards suicide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to challenge false assumptions
Wider context from the report “(3) The quality of the Trust’s own investigation into the circumstances of Mr Barton’s death. It failed to identify themes of concern. It included many false and inaccurate statements, failed to challenge false assumptions made at the time and introduced new false information which was not taken from any available records. It caused distress to the family and did not reassure me that the Trust had taken an appropriate response to the concerning facts of this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of investigation processes to identify themes of concern
Wider context from the report “(3) The quality of the Trust’s own investigation into the circumstances of Mr Barton’s death. It failed to identify themes of concern. It included many false and inaccurate statements, failed to challenge false assumptions made at the time and introduced new false information which was not taken from any available records. It caused distress to the family and did not reassure me that the Trust had taken an appropriate response to the concerning facts of this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to maintain accurate evidence-based findings
Wider context from the report “(3) The quality of the Trust’s own investigation into the circumstances of Mr Barton’s death. It failed to identify themes of concern. It included many false and inaccurate statements , failed to challenge false assumptions made at the time and introduced new false information which was not taken from any available records . It caused distress to the family and did not reassure me that the Trust had taken an appropriate response to the concerning facts of this case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of crisis resolution home treatment to prioritise protection of life beyond preventing hospital admission
Wider context from the report “(1) The approach of the Crisis Resolution Home Treatment Team of considering their role to be limited to avoiding the need for patients to receive inpatient treatment . The primary role of any medical professional ought to be the protection of life, but within the written and oral evidence from the CRHTT the focus was on prevention of hospital admission alone .
” Open source report
6 Nov 2017 RYAN JAMES VOUT · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant View source Failure to inform family before discharge View source Failure of hospital and community professionals to liaise before discharge View source Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant 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
RYAN JAMES VOUT · 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
Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.
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 Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(2) The inability to pre-arrange attendance of an ambulance when police officers exercise a s.135 (1) MHA Act 1983 warrant;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital and community professionals to liaise before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Nottinghamshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(3) The lack of a formality to the ‘briefing’ or risk assessment exercise before officers enter premises with a view to exercising a s.135 (1) MHA Act 1983 warrant.
” 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