Summary
Trends
Evidence
Reports, concerns and published responses Receiving a report does not make the recipient responsible for every concern in it. PFD Monitor does not verify whether stated actions happened.
Reports over time Reports naming this recipient by issue year.
* 2026 is projected from reports observed to 7 Sep 2026.
Reports 1 Naming this recipient
Published responses 0% Found for named reports
Concerns addressed 0 Across all linked responses
Stated actions 0 Described in responses
16 Nov 2021 Joseph MARTIN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to search all relevant records before returning safety-critical information View source Failure to communicate safety-critical mental-health and medical information to relevant agencies View source Failure to record safety-critical contacts in missing-person and occurrence records View source
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
Joseph MARTIN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joseph Martin approached Metropolitan Police Service officers near Westminster Bridge on 3 June 2021, after concerns had been raised about his mental health and safety. The inquest found that he was suffering a psychotic relapse at the time of his death, but the exact circumstances were unclear. The report raised concerns that important information about his mental health and vulnerability was not shared between police forces and that individual errors and wider system weaknesses failed to provide a safety net.
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 Police Service of Northern Ireland; that does not assign responsibility.
PFD Monitor interpretation Failure to search all relevant records before returning safety-critical information
Wider context from the report “Joseph Martin was reported as a person of concern to the PSNI on 28 May 2021 by staff at the hostel where he lived.
His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others.
The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further.
However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed. I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer. Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts .
Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back. I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given.
There were individual errors, and more significantly a system that does not seem to have provided a safety net.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Police Service of Northern Ireland; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate safety-critical mental-health and medical information to relevant agencies
Wider context from the report “Joseph Martin was reported as a person of concern to the PSNI on 28 May 2021 by staff at the hostel where he lived.
His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others.
The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further.
However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed . I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer. Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts.
Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back . I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given .
There were individual errors, and more significantly a system that does not seem to have provided a safety net.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Police Service of Northern Ireland; that does not assign responsibility.
PFD Monitor interpretation Failure to record safety-critical contacts in missing-person and occurrence records
Wider context from the report “Joseph Martin was reported as a person of concern to the PSNI on 28 May 2021 by staff at the hostel where he lived.
His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others.
The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further.
However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed. I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer . Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts.
Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back. I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given.
There were individual errors, and more significantly a system that does not seem to have provided a safety net.
” Open source report
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· Data reviewed 7 Sep 2026 · About data quality and limitations
Data last updated 7 September 2026
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations