Concerns raised 3 Failure to communicate dynamic risk assessments to the control centre during pursuits View source Single-manning of pursuit crews requiring one officer to undertake all pursuit tasks View source Failure to identify vital risk information during pursuits because of competing driving tasks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alexander Rhys Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alexander Rhys Lewis, a motorcyclist, died from chest injuries following a road traffic collision while being pursued by police. The report raises concerns that a pursuing officer had to undertake multiple tasks alone, limiting communication of dynamic risk assessments and causing vital information about risks, including a red-light contravention, to be missed. Evidence also indicated that double-manning the pursuit crew would be safer, although this would reduce the number of available trained units.
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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate dynamic risk assessments to the control centre during pursuits
Wider context from the report “During the course of the inquest evidence was heard regarding the circumstances that the pursuit occurred and the events that unfolded. One such instance was that the pursuing police officer did not observe Alex contravening a red light due to having to control his vehicle as well as negotiating the other traffic and he would have had to be looking around to do this, whereas the dashcam fitted to the car that picked up the contravention of the red light continued to point straight ahead. The impact of this was that had he seen it, it may have raised the dynamic risk assessment to high and may have caused him to stand the pursuit down. The pursuing driver also stated that given the driving responsibilities there was no opportunity to communicate a dynamic risk assessment to the control centre , although he would have been undertaking a dynamic risk assessment throughout.
The evidence of the officer in charge of driver training confirmed the evidence of the pursuing officer in that the pursuing officer would have to do a number of things including declaring a pursuit and negotiating the traffic. In his words “...there would be a lot going on in the car...”. He stated that the pursuing officer would be on their own in the car and as such have to undertake all the tasks involved in a pursuit themselves, and acknowledged that it would be safer for the crew to be double manned so the tasks can be shared, although you are then halving the number of TPAC trained units available to assist.
I am concerned that in pursuit situations, pursuit officers are required to undertake a significant number of tasks on their own, and the decisions they take as a result of undertaking those tasks can have an impact on their safety, the subject vehicle’s safety as well as the safety of other road users and the general public.
1. There was no opportunity for the pursuing driver to communicate a dynamic risk assessment to the control centre, to assist the control centre in making a decision to authorise or stand down the pursuit . the control centre indicated that such information would go towards authorising the pursuit as opposed to standing it down in the present case
2. The number of tasks having to be undertaken by the pursuing driver meant that vital information as to the risks involved in continuing the pursuit were missed, in the present case that being a contravention of a red light
3. The officer in charge of driver training confirmed that from a safety perspective, it would be safer to have the crew in a pursuit situation “double manned”.
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Single-manning of pursuit crews requiring one officer to undertake all pursuit tasks
Wider context from the report “During the course of the inquest evidence was heard regarding the circumstances that the pursuit occurred and the events that unfolded. One such instance was that the pursuing police officer did not observe Alex contravening a red light due to having to control his vehicle as well as negotiating the other traffic and he would have had to be looking around to do this, whereas the dashcam fitted to the car that picked up the contravention of the red light continued to point straight ahead. The impact of this was that had he seen it, it may have raised the dynamic risk assessment to high and may have caused him to stand the pursuit down. The pursuing driver also stated that given the driving responsibilities there was no opportunity to communicate a dynamic risk assessment to the control centre, although he would have been undertaking a dynamic risk assessment throughout.
The evidence of the officer in charge of driver training confirmed the evidence of the pursuing officer in that the pursuing officer would have to do a number of things including declaring a pursuit and negotiating the traffic. In his words “...there would be a lot going on in the car...”. He stated that the pursuing officer would be on their own in the car and as such have to undertake all the tasks involved in a pursuit themselves , and acknowledged that it would be safer for the crew to be double manned so the tasks can be shared, although you are then halving the number of TPAC trained units available to assist.
I am concerned that in pursuit situations, pursuit officers are required to undertake a significant number of tasks on their own, and the decisions they take as a result of undertaking those tasks can have an impact on their safety, the subject vehicle’s safety as well as the safety of other road users and the general public.
1. There was no opportunity for the pursuing driver to communicate a dynamic risk assessment to the control centre, to assist the control centre in making a decision to authorise or stand down the pursuit. the control centre indicated that such information would go towards authorising the pursuit as opposed to standing it down in the present case
2. The number of tasks having to be undertaken by the pursuing driver meant that vital information as to the risks involved in continuing the pursuit were missed, in the present case that being a contravention of a red light
3. The officer in charge of driver training confirmed that from a safety perspective, it would be safer to have the crew in a pursuit situation “double manned” .
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to identify vital risk information during pursuits because of competing driving tasks
Wider context from the report “During the course of the inquest evidence was heard regarding the circumstances that the pursuit occurred and the events that unfolded. One such instance was that the pursuing police officer did not observe Alex contravening a red light due to having to control his vehicle as well as negotiating the other traffic and he would have had to be looking around to do this, whereas the dashcam fitted to the car that picked up the contravention of the red light continued to point straight ahead. The impact of this was that had he seen it, it may have raised the dynamic risk assessment to high and may have caused him to stand the pursuit down. The pursuing driver also stated that given the driving responsibilities there was no opportunity to communicate a dynamic risk assessment to the control centre, although he would have been undertaking a dynamic risk assessment throughout.
The evidence of the officer in charge of driver training confirmed the evidence of the pursuing officer in that the pursuing officer would have to do a number of things including declaring a pursuit and negotiating the traffic. In his words “...there would be a lot going on in the car...”. He stated that the pursuing officer would be on their own in the car and as such have to undertake all the tasks involved in a pursuit themselves, and acknowledged that it would be safer for the crew to be double manned so the tasks can be shared, although you are then halving the number of TPAC trained units available to assist.
I am concerned that in pursuit situations, pursuit officers are required to undertake a significant number of tasks on their own, and the decisions they take as a result of undertaking those tasks can have an impact on their safety, the subject vehicle’s safety as well as the safety of other road users and the general public.
1. There was no opportunity for the pursuing driver to communicate a dynamic risk assessment to the control centre, to assist the control centre in making a decision to authorise or stand down the pursuit. the control centre indicated that such information would go towards authorising the pursuit as opposed to standing it down in the present case
2. The number of tasks having to be undertaken by the pursuing driver meant that vital information as to the risks involved in continuing the pursuit were missed , in the present case that being a contravention of a red light
3. The officer in charge of driver training confirmed that from a safety perspective, it would be safer to have the crew in a pursuit situation “double manned”.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Single-crewed pursuit training and national standards are considered sufficient to prepare officers for live operations and dynamic risk decisions.
Verbatim wording from the response “Training and Operational Practice
Police pursuit training, as delivered under the College of Policing’s Police Driving National Policing Curriculum (PDNCP) to all national forces, reflects real-world operational conditions. During both Initial Phase Pursuit (IPP) and Tactical Phase Pursuit (TPP) training, officers operate single-crewed, even when accompanied by an instructor, so that they replicate day-to-day working practices. This approach ensures officers are fully prepared for the responsibilities they will assume in live operations.
While single-crewed, officers are trained to:” Source location Response from South Wales Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Default double-crewing for pursuits cannot be adopted because available resources would reduce specialist roads-policing coverage across the wider network.
Verbatim wording from the response “Resourcing and Operational Realities
Adopting a default position of double-crewing vehicles for pursuits would significantly reduce South Wales Police’s ability to maintain specialist roads policing coverage across the wider network. Our challenge is to fully address the concerns raised in the Reg 28 notice while safeguarding our statutory duty to serve the broader South Wales community and manage wider risk.
When setting crewing models, we must strike a balance between operational effectiveness and resource availability. To sustain a strong capability for pursuits and TPAC tactics across the road network, single crewing remains the most practical option given the number of vehicles and trained officers required. This approach enables us to respond effectively to both planned and spontaneous incidents while maintaining public safety and operational resilience.” Source location Response from South Wales Police
Open published response
Concerns raised 3 Absence of a Police-HSE memorandum of understanding or protocol for domestic explosion evidence requirements View source Failure to give orders securing evidence for domestic explosion investigations View source Lack of understanding of evidence requiring preservation during domestic explosion investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian Lyn Davies · 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
Brian Lyn Davies was pronounced dead at his home on 13 March 2023 after sustaining chest and neck injuries in an explosion. The cause of the explosion could not be determined because material evidence was not preserved during the search and rescue and clean-up operations, and concerns were raised about the lack of guidance or a protocol between the Police and the HSE on preserving evidence from domestic explosions.
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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Absence of a Police-HSE memorandum of understanding or protocol for domestic explosion evidence requirements
Wider context from the report “During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion may not be secured and as such was disposed of without an exercise to determine its significance to the investigation.
The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation.
It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events.
I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence.
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion;
2. There was no order given to secure such evidence;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to give orders securing evidence for domestic explosion investigations
Wider context from the report “During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion may not be secured and as such was disposed of without an exercise to determine its significance to the investigation.
The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation.
It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events.
I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence.
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion;
2. There was no order given to secure such evidence ;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of evidence requiring preservation during domestic explosion investigations
Wider context from the report “During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion may not be secured and as such was disposed of without an exercise to determine its significance to the investigation.
The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation.
It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events.
I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence.
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion ;
2. There was no order given to secure such evidence;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the identified investigation concerns with the National Liaison Committee for consideration in the Protocol review.
Verbatim wording from the response “In this respect, South Wales Police will take steps to raise your concerns with the National Liaison Committee in order that due regard may be had to such a possibility in the future, so that any amendments which are considered appropriate, may be made to the Protocol.” Source location Response from South Wales Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The National Liaison Committee is responsible for deciding and implementing any appropriate amendments to the Protocols.
Verbatim wording from the response “As would be expected, the Protocols contains provisions and guidance which provide full or partial answers to the issues you have raised. However, it remains important that the Protocols are reviewed and refreshed as appropriate. In this regard, it is significant that Detective Superintendent ████████
████████ from South Wales Police attended the National Work Related Death Liaison Committee on 17 November 2025 which is the national multi agency meeting that oversees the Protocol and linked matters. At that meeting the Protocols, were discussed as it was universally agreed that these documents need to be updated. The motion to give effect to the same was carried, and the National Liaison Committee has committed to undertaking a review and update as appropriate.” Source location Response from South Wales Police
Open published response
29 Sep 2023 Leighton Alan Dickens · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 5 Limited availability and capacity of mental health crisis teams View source Failure to provide clinically qualified mental health tactical adviser support View source Lack of multiple medically qualified sources of urgent mental health support for police officers View source Lack of access to the PARIS mental health records system for tactical adviser support View source Failure to implement the intended “111 press 2” mental health triage service View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leighton Alan Dickens · 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
Leighton Alan Dickens died by incomplete atypical hanging alone at his home address on 14 October 2020. The inquest heard that police did not detain him at hospital for mental health assessment, and identified limited access to qualified, clinically informed mental health advice and records for officers responding to community mental health crises.
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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Limited availability and capacity of mental health crisis teams
Wider context from the report “(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams.
(2) The crisis teams may not be readily available and deal with their own case load .
(3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system.
(4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place.
(5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clinically qualified mental health tactical adviser support
Wider context from the report “(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams.
(2) The crisis teams may not be readily available and deal with their own case load.
(3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system.
(4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place.
(5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Lack of multiple medically qualified sources of urgent mental health support for police officers
Wider context from the report “(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams .
(2) The crisis teams may not be readily available and deal with their own case load.
(3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system.
(4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place.
(5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Lack of access to the PARIS mental health records system for tactical adviser support
Wider context from the report “(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams.
(2) The crisis teams may not be readily available and deal with their own case load.
(3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system .
(4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place.
(5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the intended “111 press 2” mental health triage service
Wider context from the report “(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams.
(2) The crisis teams may not be readily available and deal with their own case load.
(3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system.
(4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place .
(5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a dedicated 24-hour pathway for officers to obtain medically qualified advice about section 136 decisions.
Verbatim wording from the response “Policy section 1.2 (Mental Health – Section 136) defines the specific requirement for police to seek advice from a health professional who are maintained on an agreed list, before detaining a person under s136 of the Mental Health Act. The policy outlines both the legislative and practical considerations in obtaining advice for use in decision making on s136. Within this section of the policy, it contains the contact details for each crisis team in the respective health board area should urgent advice be required.” Source location Response from South Wales 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 Continue working with NHS Wales and health boards to ensure officers can obtain medically qualified advice at any time.
Verbatim wording from the response “Medically qualified advice for officers can be invaluable to a police officer when faced with a person in crisis and the sharing of information and opinion can be relevant to the formation of the officer’s final judgement on the need for detention for a person’s own protection. As such the force will continue to ensure that we work in partnership with NHS Wales and each of the health boards to ensure that processes are effective for officers to obtain advice at any time.” Source location Response from South Wales Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and operate a police contact protocol with NHS Wales clarifying access to urgent mental health advice and signposting to crisis teams.
Verbatim wording from the response “Since the concerns raised in this inquest, we have worked with NHS Wales to develop an ‘NHS 111 Press 2 - Police Contact Protocol’. This provides clarity on how a range of professionals, including the police can access advice relating to urgent mental health concerns.” Source location Response from South Wales 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 Monitor crisis-line accessibility daily and scrutinise section 136 use through internal strategic boards and partnership forums.
Verbatim wording from the response “As a result of the Regulation 28 Notice, the accessibility of these crisis lines is monitored daily by the force Public Protection Department to identify adverse incidents and accessibility. Information pertaining to the use of s136 powers is also scrutinised in internal strategic boards and partnership forums, such as the Mental Health Act Monitoring Group.” Source location Response from South Wales 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 existing 24-hour crisis-team pathway provides medically qualified advice and satisfies requirements for advice before using section 136 powers.
Verbatim wording from the response “Policy section 1.2 (Mental Health – Section 136) defines the specific requirement for police to seek advice from a health professional who are maintained on an agreed list, before detaining a person under s136 of the Mental Health Act. The policy outlines both the legislative and practical considerations in obtaining advice for use in decision making on s136. Within this section of the policy, it contains the contact details for each crisis team in the respective health board area should urgent advice be required.” Source location Response from South Wales 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 Responsibility for commenting on crisis-team capacity rests with the Health Board, whose director has been directly informed of the concern.
Verbatim wording from the response “(2) The crisis teams may not be readily available and deal with their own case load.
Whilst I cannot provide specific comment on behalf of the Health Board on the capacity of their Crisis Teams, I can provide assurance that the concerns within the regulation 28 notice have been raised directly with ████████ Director of Operations, Mental Health Clinical Board.” Source location Response from South Wales Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police should continue using established crisis contact points for section 136 advice; NHS 111 Press 2 is not the replacement route.
Verbatim wording from the response “Since the concerns raised in this inquest, we have worked with NHS Wales to develop an ‘NHS 111 Press 2 - Police Contact Protocol’. This provides clarity on how a range of professionals, including the police can access advice relating to urgent mental health concerns.” Source location Response from South Wales Police
Open published response
29 Sep 2023 Leighton Alan Dickens · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Limited access to qualified mental health advice with relevant clinical records View source Lack of access to the PARIS mental health records system for mental health tactical advice View source Limited availability of medically qualified urgent mental health support for police officers View source Failure to provide the intended “111 press 2” replacement mental health triage service View source Provision of mental health tactical advice by staff without clinical qualification View source Unavailability and capacity constraints of mental health crisis teams View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Leighton Alan Dickens · 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
Leighton Alan Dickens died by incomplete atypical hanging alone at his home on 14 October 2020, after police encountered him undressed by the roadside while his partner was trying to take him to hospital. The report raised concerns that police did not detain him under section 136 of the Mental Health Act for assessment and that officers had limited access to qualified, clinically informed mental health advice and records when responding to community mental health crises.
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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Limited access to qualified mental health advice with relevant clinical records
Wider context from the report “This leaves officers with limited sources of qualified mental health advice , with access to relevant clinical records , when responding to the risks posed by those suffering from mental health crisis within the community
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Lack of access to the PARIS mental health records system for mental health tactical advice
Wider context from the report “The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system .
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Limited availability of medically qualified urgent mental health support for police officers
Wider context from the report “Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams .
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the intended “111 press 2” replacement mental health triage service
Wider context from the report “The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Provision of mental health tactical advice by staff without clinical qualification
Wider context from the report “The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system.
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability and capacity constraints of mental health crisis teams
Wider context from the report “The crisis teams may not be readily available and deal with their own case load .
” Open source report
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 South Wales 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 South Wales 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 South Wales 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
25 Oct 2022 John Henry WHITE · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 2 Failure to provide bespoke training to frontline officers for handling similar situations View source Incomplete distribution of ligature cutters to frontline officers 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
John Henry WHITE · 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
John Henry White suspended himself on 20 October 2019 and was transferred to Royal Glamorgan Hospital, where he died on 23 October 2019. The inquest jury concluded that the failure to release the ligature sooner possibly contributed to his chances of survival. The principal concerns were the incomplete distribution of ligature cutters to frontline officers and the availability of bespoke training for officers responding to similar incidents.
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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide bespoke training to frontline officers for handling similar situations
Wider context from the report “2. A collateral concern, not directly causative of Mr White’s death, arose during the inquest and which I also wish to bring to your attention.
This concerns the availability of bespoke training to response officers in relation to handling similar situations faced by the officers on the 20th of October 2019.
The three attending officers on 20.10.19 indicated that they had not received specific training (notwithstanding the evidence I received from retired Detective Chief inspector ████████ that he had prepared a video for officers covering this type of scenario as part of mental health awareness training in 2017) to assist them in managing the scenario they faced.
Retired Detective Chief Inspector ████████ indicated that he had delivered training that year to officers within the force for the purposes of cascading the same widely.
Given both the statistical and anecdotally evidenced increase in mental health crisis incidents (on occasions resulting in death) that your officers are required to attend, I believe that it would be of benefit to those officers who have not received this bespoke training , (as well, perhaps those who may benefit from refreshing their knowledge) for consideration to be given to retaining the same and expediting its delivery widely – i.e. to all frontline staff.
I would stress that the two immediate response officers cannot be, nor indeed were, criticised in their individual interactions with Mr White on the 20th October 2019. Indeed, and without the apparent benefit of the training, they interacted with Mr White in accordance with the approach advocated by retired Detective Chief Inspector ████████.
” 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Incomplete distribution of ligature cutters to frontline officers
Wider context from the report “1. In June 2020 the Independent Office for Police Complaints recommended that all response vehicles be equipped with a ligature cutter or similar.
That recommendation was accepted by Chief Superintendent Clare Evans on behalf of South Wales Police in July 2020.
I received evidence from Chief Inspector ████████ that in 2020 South Wales Police had determined to widen the scope of the recommendation to all frontline officers. She informed me that ligature cutters were delivered to the force in July 2022.
As at the 4th of October 2022, approximately 25% of those had been distributed to frontline officers.
She was unable to assist the court with the timeline for the remaining distribution other than in relation to her own force division - a target date of the 22nd of October 2022.
She candidly accepted in her evidence that the incomplete distribution to all frontline officers at this time meant that the scenario faced by the response officers attending upon Mr White on the 20th of October 2019 was still patent & the opportunity to release a suspended individual currently dependent upon whether there had been distribution to the tasked response officers.
That is the concern that I have and wish you to consider and address.
” Open source report
Concerns raised 1 Failure to arrange an independent assessment of driving ability after a collision View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brian Griffiths · 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
Brian Griffiths died in hospital on 2 October 2019 after being struck and pinned by a vehicle that unexpectedly accelerated at a Tesco Express store and petrol station on 30 September 2019. The principal concern was that an opportunity may have been missed after an earlier collision in April 2019 to obtain an independent assessment of the driver's fitness to drive, including through an elderly-driver referral scheme.
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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange an independent assessment of driving ability after a collision
Wider context from the report “On 29th April 2019 (5 months prior to the fatal collision) the driver had been involved in another collision at the same location of the Tesco Petrol station in the Gower. The collision was damage only and the road traffic officer dealt with the collision by way of SI70 (exchange of details). The other driver involved was later treated for whiplash but this was not disclosed at the scene.
No D751 medical referral was considered by the road traffic officer but no medical factors were disclosed or identified that would support the submission. There is no obligation to submit the form based only on the fact that the driver was elderly.
An opportunity was missed at the time of the collision in April 2019 for an independent assessment of the driving ability of the driver.
I was informed at the Inquest that there are a number of police forces which have elderly person driver referral schemes / fitness to drive which can be used as an alternative to a prosecution for minor driving offences or collisions.
Dyfed Powys have a scheme that has been running for 4 years after an initial pilot and it has been used as a successful tool to take unsafe elderly drivers off the road
The schemes involves a cognitive test and also a driving test to assess the standard of an individual’s driving.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage Criminal Justice Services, the Motoring Unit and Wales Mobility Driver Assessment Service to discuss implementing the scheme in South Wales.
Verbatim wording from the response “South Wales Police is committed to ensuring and improving the safety of road users within the force area and identifying opportunities for early interventions for those whose driving is found to fall below the required standard. Therefore, prior to receiving your letter, the South Wales Police Serious Collision Investigation Unit (SCIU) had already engaged with colleagues in Dyfed Powys Police to fully understand the elderly person referral scheme that they have in place, to inform a review as to how South Wales Police could establish a scheme of a similar nature. In addition, Inspector ████████ Head of SCIU, has also engaged colleagues in Criminal Justice Services, the Motoring Unit and the Wales Mobility Driver Assessment Service, who facilitate the running of the courses, to discuss the implementation of the scheme in South Wales.” Source location 2020-0203-Response-from-South-Wales-Police_Redacted.pdf
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 Engage Dyfed Powys Police to understand its elderly person referral scheme and inform consideration of a similar South Wales Police scheme.
Verbatim wording from the response “South Wales Police is committed to ensuring and improving the safety of road users within the force area and identifying opportunities for early interventions for those whose driving is found to fall below the required standard. Therefore, prior to receiving your letter, the South Wales Police Serious Collision Investigation Unit (SCIU) had already engaged with colleagues in Dyfed Powys Police to fully understand the elderly person referral scheme that they have in place, to inform a review as to how South Wales Police could establish a scheme of a similar nature. In addition, Inspector ████████ Head of SCIU, has also engaged colleagues in Criminal Justice Services, the Motoring Unit and the Wales Mobility Driver Assessment Service, who facilitate the running of the courses, to discuss the implementation of the scheme in South Wales.” Source location 2020-0203-Response-from-South-Wales-Police_Redacted.pdf
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 Implement an elderly person referral scheme in South Wales Police by May 2021, with delivery brought forward if possible.
Verbatim wording from the response “South Wales Police is committed to ensuring and improving the safety of road users within the force area and identifying opportunities for early interventions for those whose driving is found to fall below the required standard. Therefore, prior to receiving your letter, the South Wales Police Serious Collision Investigation Unit (SCIU) had already engaged with colleagues in Dyfed Powys Police to fully understand the elderly person referral scheme that they have in place, to inform a review as to how South Wales Police could establish a scheme of a similar nature. In addition, Inspector ████████ Head of SCIU, has also engaged colleagues in Criminal Justice Services, the Motoring Unit and the Wales Mobility Driver Assessment Service, who facilitate the running of the courses, to discuss the implementation of the scheme in South Wales.” Source location 2020-0203-Response-from-South-Wales-Police_Redacted.pdf
Open published response
20 Jan 2020 Deborah Margaret LAMONT · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Lack of specific guidance on classification of hotel rooms under the s136(1A) exception View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Deborah Margaret LAMONT · 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
Deborah Margaret Lamont travelled to a hotel on 28 March 2019, where she suspended herself by a ligature and was found deceased by police officers shortly after 11pm. The principal concern was that police officers might incorrectly conclude that the power under section 136 of the Mental Health Act did not apply in a hotel room, potentially placing an individual at risk of 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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance on classification of hotel rooms under the s136(1A) exception
Wider context from the report “Regard was had during the Inquest as to the Department of Health Guidance to the changes to the MHA 1983, published in October 2017. No specific guidance as to the classification of a hotel room for the purposes of whether that falls within the exception in s136 (1A) is provided.
Whilst it is accepted, both by myself, & in the Guidance, as above, that there will always be some degree of discretion for a police officer to exercise in relation to the interpretation of whether a person is living in a hotel room, the evidence here was that DL had booked into the room for one night & had no more than a bare licence to occupy it (which would contrast with, for example, an individual or family temporarily housed in a hotel room by a local authority, or a care home resident occupying indefinitely a room in a care home).
Hence, based upon the evidence I received, and my interpretation (in these particular circumstances) of whether a hotel room came within s136 (1A) MHA, I found it likely that ████████ did have the power to remove DL to a place of safety
My concern is that faced with a similar situation (albeit in circumstances were the officer did consider a person was suffering from mental disorder and requiring of immediate care, or control), an officer may reach the same conclusion as ████████ determine the power to remove did not exist, and this may lead to a risk of death to that individual.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fully consider the use of hotel rooms and section 136 under the Mental Health Act as an interim force safety issue.
Verbatim wording from the response “The Chief Constable has also asked that this issue is fully considered by the Force Mental health lead in the intervening period and the use of hotel rooms and s.136 is subject of a specific note upon force guidance and within training. This will be the interim position until such time as the Home Office and/or College of Policing offer the additional guidance and/or legislative amendment etc.” Source location 2020-0008-Response-from-the-Chief-Constable-of-South-Wales_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include a specific note on hotel rooms and section 136 within force training.
Verbatim wording from the response “The Chief Constable has also asked that this issue is fully considered by the Force Mental health lead in the intervening period and the use of hotel rooms and s.136 is subject of a specific note upon force guidance and within training. This will be the interim position until such time as the Home Office and/or College of Policing offer the additional guidance and/or legislative amendment etc.” Source location 2020-0008-Response-from-the-Chief-Constable-of-South-Wales_Redacted
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 Add a specific note on hotel rooms and section 136 to force guidance.
Verbatim wording from the response “The Chief Constable has also asked that this issue is fully considered by the Force Mental health lead in the intervening period and the use of hotel rooms and s.136 is subject of a specific note upon force guidance and within training. This will be the interim position until such time as the Home Office and/or College of Policing offer the additional guidance and/or legislative amendment etc.” Source location 2020-0008-Response-from-the-Chief-Constable-of-South-Wales_Redacted
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 Further national guidance or legislative amendment on section 136 and hotel rooms is assigned to the Home Office and College of Policing.
Verbatim wording from the response “The Chief Constable notes that the College will circulate a summary of this issue to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. It is noted that in addition, the College has raised the issue with the Home Office and will work together to assess the need for relevant changes to the current national guidance (APP) in relation to the use of s136 and hotel rooms. The College will ensure that all Forces are kept appraised of developments.” Source location 2020-0008-Response-from-the-Chief-Constable-of-South-Wales_Redacted
Open published response
13 Feb 2019 Matthew William Lewis · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Failure to provide clear and consistent rescue instructions in hanging episodes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Matthew William Lewis · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew William Lewis died following a hanging on 27 February 2018; the inquest conclusion was suicide and the recorded medical cause of death was hanging. Concerns included confusion and inconsistency in call-handler instructions about whether rescuers should approach him, with the report noting that unclear instructions could cause delay in future incidents. Guidance and training for call handlers in such scenarios were identified as desirable or mandated.
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 South Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and consistent rescue instructions in hanging episodes
Wider context from the report “(1) Both ████████ in their evidence expressed confusion as to the instructions that were passed to them by the call handler. In particular, whether they should approach Mr Lewis and attempt to cut him down or refrain from doing so in the interests of scene preservation
(2) The subsequent evidence of the Officer in Charge, ████████ was to the effect that his primary role as a police officer was the preservation of life. The initial instructions of the Call handler here appeared inconsistent with that expressed overriding duty.
(3) In any hanging episode, time is very much of the essence following suspension. Whilst it could be determined on the evidence the exact time that that occurred on 27.2.18, medical evidence received at the Inquest indicated that death/irreversible brain injury would likely occur, no later than 5 minutes post suspension. With such a narrow “rescue window”, the clarity of instructions to willing rescuers appears paramount . Whilst it was found on the evidence that the actions of the call handler were neither directly, nor indirectly causative of Mr Lewis’ death, there is a risk that in the future, a repeat of confusing/inconsistent call handler instructions may lead to delay & potentially contribute to the prospects of an unsuccessful rescue .
(4) Guidance/training for call handlers as to how to deal with such scenarios would seem desirable/mandated
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop force procedures providing hanging-incident guidance for call handlers and incorporate that guidance into their training.
Verbatim wording from the response “In addition, whilst there is no national guidance for this type of circumstance issued by the College of Policing to Call Handlers in Police Forces, South Wales Police has taken steps to develop a procedure for call handlers, which incorporates appropriate guidance into its force procedures. The new procedure is incorporated into training that call handlers receive and in particular, the paragraph below that highlights the presumption that ‘life is not extinct’.” Source location 2019-0048-Response-by-South-Wales-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 Maintain trainer or experienced-operator monitoring and rapid intervention for new and inexperienced call handlers.
Verbatim wording from the response “South Wales Police invest considerably in training call handlers to deal with a multitude of situations; however, a training scenario can never replicate the experience gained from with real incidents. In respect of this, I can confirm that South Wales Police have a procedure in place for new and inexperienced call handlers, where a trainer or more experienced operator monitors and is able to step in very quickly when the new operator is unsure of the advice they should be giving.” Source location 2019-0048-Response-by-South-Wales-Police
Open published response
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.
×
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 South Wales Police; 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 South Wales Police; 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