Concerns raised 4 Failure to audit use of police handover forms View source Failure to update policies supporting handover-form implementation View source Failure to appropriately communicate key information in police handovers for people detained under the Mental Health Act View source Failure to clearly record police handovers View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Roger Gary Leadbeater · 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
Roger Gary Leadbeater died on 9 August 2023 from multiple stab wounds inflicted by a patient detained under the Mental Health Act who had absconded from escorted leave. The report identified concerns about inadequate and poorly recorded handovers between police forces and the mental health trust, which meant significant risk information was not clearly communicated and may have affected decisions to grant leave. It also noted that, as of January 2026, relevant policies and auditing arrangements had not been updated to support the use of new handover forms.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to audit use of police handover forms
Wider context from the report “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died.
The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation.
On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use.
I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to update policies supporting handover-form implementation
Wider context from the report “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died.
The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation.
On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use.
I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately communicate key information in police handovers for people detained under the Mental Health Act
Wider context from the report “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died.
The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation.
On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use.
I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated . This is turn may affect risk assessments and decisions around patients being granted leave.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record police handovers
Wider context from the report “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died.
The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation .
On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use.
I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave.
” Open source report
Concerns raised 4 Failure to include recent s136 detention information in force control communications View source Failure to inform next of kin how to contact the s136 suite and provide further updates View source Failure to record recent s136 detention information on the PNC check View source Failure to pass relevant details, including next-of-kin information, to the s136 suite View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Herrin Dodds · 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
Andrew Herrin Dodds was assessed and detained under section 136 after expressing suicidal thoughts and threatening to harm himself, but was later released and allowed to board a train. He took his own life on the train and was pronounced deceased at Tamworth train station. The principal concerns were failures to pass on next-of-kin and recent section 136 information, and missing information that might have prompted further contact with mental health services.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to include recent s136 detention information in force control communications
Wider context from the report “(2) There was missing information on the PNC check which meant that Andrew was not flagged as recently being held under s136. The further email from force control also did not mention that he was recently detained under s136 . I was told if this had been on the system BTP would have contacted mental health services for more information.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform next of kin how to contact the s136 suite and provide further updates
Wider context from the report “(1) Police did not pass over relevant details including next of kin to the s136 suite meaning next of kin could not be contacted. They also did not inform next of kin to contact the s136 directly and did not provide any further updates . This happened shortly after a shift change over so whether a full handover was provided between officers to allow this information to be given is not clear.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record recent s136 detention information on the PNC check
Wider context from the report “(2) There was missing information on the PNC check which meant that Andrew was not flagged as recently being held under s136 . The further email from force control also did not mention that he was recently detained under s136. I was told if this had been on the system BTP would have contacted mental health services for more information.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to pass relevant details, including next-of-kin information, to the s136 suite
Wider context from the report “(1) Police did not pass over relevant details including next of kin to the s136 suite meaning next of kin could not be contacted. They also did not inform next of kin to contact the s136 directly and did not provide any further updates. This happened shortly after a shift change over so whether a full handover was provided between officers to allow this information to be given is not clear.
” 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 A temporary S136 flag would not comply with the PNC Code of Practice because its necessity ends at handover.
Verbatim wording from the response “The use of a S136 MHA flag would not satisfy the codes of practice for PNC. The use of a flag would only become ‘relevant’ upon a Police Constable making that individual assessment to detain the person in question under S136 MHA and would cease to be ‘relevant’ once the individual was in a place of safety. The ‘necessity’ test would therefore not be met as the individual is already detained by a Police Constable at this point. Further, for most the population with no criminal history, there would be no substantive PNC account to ‘hang’ this flag from.” Source location Response from South Yorkshire 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 Data protection legislation prevents police contacting an adult’s next of kin about detention without expressed consent.
Verbatim wording from the response “Data Protection legislation would preclude us from contacting the next of kin to share information about an adult without their expressed consent, this would include the fact that they have been detained under S136 MHA or taken to a medical establishment. This would be classed as health data and therefore falls within the stronger legal protections of the Data Protection legislation.” Source location Response from South Yorkshire 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 Because the proposed PNC recommendation conflicts with the Code of Practice, no further action is proposed.
Verbatim wording from the response “As a result of this recommendation not being compatible with the Codes of Practice we do not propose any further action on this matter.” Source location Response from South Yorkshire 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 South Yorkshire Police cannot alter the national PNC to implement the proposed S136 flagging change.
Verbatim wording from the response “Whilst we would always seek any opportunity to learn lessons and make changes to systems and processes to mitigate future risks, unfortunately South Yorkshire Police is unable to make changes to the Police National Computer that would satisfy this point. Further, the flagging of S136 MHA would not be in line with the Code of Practice for PNC, it is a temporary policing power that can only be used in the moment based on the officers assessment of the individual at that time, usually at point of crisis to take them to a place of safety where they can be supported and assessed by trained professionals.” Source location Response from South Yorkshire 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 Having complied with data protection legislation, no further action is proposed regarding next-of-kin contact.
Verbatim wording from the response “Having reviewed our actions, we complied with Data Protection legislation and therefore we do not propose any further action in relation to this matter.” Source location Response from South Yorkshire 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 After police handover, the NHS trust assumes responsibility for care and appropriate next-of-kin updates.
Verbatim wording from the response “Once this handover has been completed the police role ceases completely and the NHS trust assume responsibility for the individual, along with any relevant updates to next of kin if assessed as appropriate and in line with Data Protection legislative requirements. This is in line with the protocols in place between South Yorkshire Police and the Integrated Care Boards.” Source location Response from South Yorkshire Police
Open published response
Concerns raised 9 Lack of police officer training in recognising drug intoxication and determining when hospital treatment is required View source Lack of mandatory or refresher police officer training in constant observations View source Lack of police officer training to reduce positional asphyxia risk in intoxicated persons View source Unclear and poorly structured level 4 supervision form design View source Lack of police officer training in recognising mental health conditions and their behavioural effects View source Lack of mandatory or refresher training on information handover during detainee booking View source Inconsistent or omitted custody sergeant briefings for constant observations View source Lack of audit trail for signed constant observation forms and sergeant briefings View source Lack of timely controlled handover of constant observation forms View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Review the booking-in sheet and create holding-area posters reminding officers to report illness, injuries and intoxication to the Custody Sergeant.
Stated plannedThe respondent said that this action was planned when they made their response on 4 April 2024. View source
Action
Deliver scenario-based training on Acute Behavioural Disturbance, positional asphyxia, safer restraint and continuous observation of restrained subjects.
Stated completedThe respondent said that this action was complete when they made their response on 4 April 2024. View source
Action
Deliver mental-health awareness training to frontline officers, including recognition of mental-health problems and crisis indicators.
Stated completedThe respondent said that this action was complete when they made their response on 4 April 2024. View source
Action
Introduce the poisoning module into the MOD 2 initial First Aid course.
Stated plannedThe respondent said that this action was planned when they made their response on 4 April 2024. View source
Action
Design force screen savers and deliver annual local CPD reinforcing information, roles and responsibilities when booking detainees into custody.
Stated plannedThe respondent said that this action was planned when they made their response on 4 April 2024. View source
Action
Refresh positional-asphyxia posters and add clear restraint and observation guidance to the constant-observation document.
Stated plannedThe respondent said that this action was planned when they made their response on 4 April 2024. View source
Action
Conduct compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.
Stated plannedThe respondent said that this action was planned when they made their response on 4 April 2024. View source
Action
Deliver Acute Behavioural Disturbance training through Personal Safety and First Aid courses, including recognition, clinical escalation and treatment principles.
Stated completedThe respondent said that this action was complete when they made their response on 4 April 2024. View source
Action
Consult the Performance and Governance team about activating body-worn video during constant observations.
Stated plannedThe respondent said that this action was planned when they made their response on 4 April 2024. View source
Action
Introduce poisoning, acute alcohol intoxication and intentional overdose content into the year-three First Aid module.
Stated completedThe respondent said that this action was complete when they made their response on 4 April 2024. View source
Action
Provide Custody Sergeants with training and continuing professional development on constant-observation standards and responsibilities following the document review.
Stated plannedThe respondent said that this action was planned when they made their response on 4 April 2024. View source
Action
Review the constant-observation document and consult other forces on improved practices for recording observations and defining officer and Sergeant responsibilities.
Stated plannedThe respondent said that this action was planned when they made their response on 4 April 2024. View source See 9 more actions
×
AI-generated summary
Matthew Terrill · 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 Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer training in recognising drug intoxication and determining when hospital treatment is required
Wider context from the report “1. Lack of training in the First Aid or Personal Safety courses for police officers in relation to recognising the signs and symptoms of drug intoxication. Specifically, how to recognise a drug overdose or the ill-effects of drug intoxication, and when it is appropriate for a detainee to be taken to hospital.
I have been told that officers routinely come across persons who are intoxicated through drugs, and that officers are routinely expected to risk assess these persons and decide whether to transport to hospital or custody. Without proper guidance in place for the officers, I am concerned about the risk of future death to persons who are intoxicated by drugs and requiring hospital treatment.
I note the circulation of the ‘Patient or Prisoner’ cards, but these do not include reference to intoxication by drugs .
I note also that some training is given to trainee officers, but this does not specifically cover intoxication by drugs , and even if it did, I am concerned that training an officer once, at the beginning of their career, leaves the door open to the development of bad practice and the fallibility of human memory.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory or refresher police officer training in constant observations
Wider context from the report “4. Lack of refresher or mandatory annual training for police officers in relation to constant observations.
I am told that there is no specific mandatory training for police officers on constant observations , but that trainee police officers are now given training on constant supervision as part of their introduction to the custody suite. I have been told that there is an optional CPD module available to officers on constant observation training. I am concerned that police officers are being regularly asked to perform constant observations on detainees of the highest risk levels without any mandatory training or refresher training on the subject . Whilst the Custody Sergeant is tasked with providing a briefing to officers who are tasked with constant observations, I am concerned that there is no evidence of consistency in this task being completed to an appropriate standard or at all. There is a risk that in a busy custody suite, this briefing will be overlooked or omitted (and in fact that was the evidence in this case). There is no evidence to reassure me that this was a one-off incident, rather the evidence before me suggested that it was not. This gives rise to a risk of future death for detained persons on level 4 constant observation.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer training to reduce positional asphyxia risk in intoxicated persons
Wider context from the report “3. Lack of training in First Aid or Personal Safety courses for police officers in relation to the heightened risk of positional asphyxia and intoxication.
I have seen guidance from the College of Policing that there is a heightened risk of positional asphyxia in persons who are intoxicated. I am concerned that without some guidance and training, police officers will be unable to take steps to reduce the risk of positional asphyxia in intoxicated persons which may cause a risk of future death.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Unclear and poorly structured level 4 supervision form design
Wider context from the report “7. Jury concern – the design and format of the documentation, specifically the level 4 supervision form, was unclear and poorly structured .
This featured within the jury’s narrative conclusion, and whilst I heard some evidence that certain elements of the form had changed. It is broadly similar in its new format to the copy that the jury were presented with.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer training in recognising mental health conditions and their behavioural effects
Wider context from the report “2. Lack of training in First Aid or Personal Safety courses for police officers in relation to recognising the signs and symptoms of mental health conditions and acute mental health crisis. Specifically, when this may be impacting upon the behaviour of the detained person and whether they require medical assistance from a hospital.
I have been told that officers are trained in methods of communication with persons who are suffering from mental health episodes, but not how to recognise the symptoms . There is training on ABD, and I am not concerned about the officers’ ability to respond to persons with suicidal ideation. Accepting that police officers are not medical professionals, I am concerned that there is no guidance on recognition of symptoms of mental health conditions falling short of crisis (in particular the way in which this may affect behaviour) and appropriate management, then detained persons suffering from a mental health episode, or with pre-existing mental health conditions, may be at risk of future death.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory or refresher training on information handover during detainee booking
Wider context from the report “5. Lack of refresher or mandatory annual training for police officers in relation to information to be passed to the custody officers during the booking in procedure.
I am told that there is no specific mandatory training for police officers on the information expected of them at the custody suite desk during the booking in procedure , but that trainee police officers are now given training on constant supervision as part of their introduction to the custody suite. I am concerned that police officers are regularly handing over to custody officers without any mandatory training or refresher training on the subject , which leaves the information that they decide to pass over open to discretion . Training an officer once, at the beginning of their career, leaves the door open to the development of bad practice and the fallibility of human memory. This gives rise to a risk of future death for detained persons if pertinent information is omitted, for example health or intoxication information.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Inconsistent or omitted custody sergeant briefings for constant observations
Wider context from the report “4. Lack of refresher or mandatory annual training for police officers in relation to constant observations.
I am told that there is no specific mandatory training for police officers on constant observations, but that trainee police officers are now given training on constant supervision as part of their introduction to the custody suite. I have been told that there is an optional CPD module available to officers on constant observation training. I am concerned that police officers are being regularly asked to perform constant observations on detainees of the highest risk levels without any mandatory training or refresher training on the subject. Whilst the Custody Sergeant is tasked with providing a briefing to officers who are tasked with constant observations, I am concerned that there is no evidence of consistency in this task being completed to an appropriate standard or at all . There is a risk that in a busy custody suite, this briefing will be overlooked or omitted (and in fact that was the evidence in this case). There is no evidence to reassure me that this was a one-off incident, rather the evidence before me suggested that it was not. This gives rise to a risk of future death for detained persons on level 4 constant observation.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of audit trail for signed constant observation forms and sergeant briefings
Wider context from the report “6. Lack of safety net for custody suit documentation, specifically the constant supervision forms.
I am told that whilst there has been a welcomed change to the format of the constant observation forms, there is no safety net for ensuring that these forms are handed over in a timely manner or by the custody sergeant. I am also told that there is no audit trail in place for checking that these forms are being signed by police or custody officers to ensure that the envisaged sergeant briefing is being given . I am concerned that there is a risk of future death to detained persons on level 4 constant supervision in circumstances where the sitting officers may not be experienced in the task, have not been trained, and are not consistently being briefed by the custody officers.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of timely controlled handover of constant observation forms
Wider context from the report “6. Lack of safety net for custody suit documentation, specifically the constant supervision forms.
I am told that whilst there has been a welcomed change to the format of the constant observation forms, there is no safety net for ensuring that these forms are handed over in a timely manner or by the custody sergeant . I am also told that there is no audit trail in place for checking that these forms are being signed by police or custody officers to ensure that the envisaged sergeant briefing is being given. I am concerned that there is a risk of future death to detained persons on level 4 constant supervision in circumstances where the sitting officers may not be experienced in the task, have not been trained, and are not consistently being briefed by the custody officers.
” 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 Review the booking-in sheet and create holding-area posters reminding officers to report illness, injuries and intoxication to the Custody Sergeant.
Verbatim wording from the response “Future work” Source location Response from South Yorkshire Police and Humberside 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 Deliver scenario-based training on Acute Behavioural Disturbance, positional asphyxia, safer restraint and continuous observation of restrained subjects.
Verbatim wording from the response “The PST delivery for this year commencing in April 2024 is all scenario-based delivery. There are six different scenarios mandated by the College of Policing. One scenario is based on ‘vulnerable person.’ The Trainers can introduce ABD by slightly adapting the vulnerable person scenario, to having the role player displaying some of the signs and symptoms of ABD, with the trainer also providing input to the role player to display varying signs and symptoms of ABD such as, the person is hot to touch, incredibly strong or sweating heavily etc. From this the student should realise that they are dealing with someone who is having an ABD episode and deal with them accordingly.” Source location Response from South Yorkshire Police and Humberside 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 Deliver mental-health awareness training to frontline officers, including recognition of mental-health problems and crisis indicators.
Verbatim wording from the response “Mental Health training was rolled out to all front line officers via Street Skills in 2018. This was developed and delivered with partners and individuals with lived experience. This gave officers guidance on recognising sign and symptoms of mental health issue including those falling short of a crisis.” Source location Response from South Yorkshire Police and Humberside 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 Introduce the poisoning module into the MOD 2 initial First Aid course.
Verbatim wording from the response “7.7 How to manage a casualty who has been poisoned.
What it is perm/temp
What can Causes alcohol?
Recognise some signs and symptoms.
And treatments going to give.” Source location Response from South Yorkshire Police and Humberside 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 Design force screen savers and deliver annual local CPD reinforcing information, roles and responsibilities when booking detainees into custody.
Verbatim wording from the response “Force screen savers will be designed by the Custody Lead, incorporating key and additional information they must provide to a Custody Sergeant when booking in a detained person into custody, this will be supported by a yearly CPD package and delivered locally by Force Inspectors/Detective Inspectors again reminding officers around their role and responsibilities.” Source location Response from South Yorkshire Police and Humberside 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 Refresh positional-asphyxia posters and add clear restraint and observation guidance to the constant-observation document.
Verbatim wording from the response “Future work” Source location Response from South Yorkshire Police and Humberside 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 Conduct compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.
Verbatim wording from the response “Training/ CPD will be given to all Custody Sergeants following this review setting out clear standards and expectations around their role and responsibilities of this document. Dip samples will be carried out by the Custody Inspectors to ensure compliance, this will include reviewing of CCTV to ensure that this document is briefed, relevant checks by the Sergeant are carried out for anyone under constant observations.” Source location Response from South Yorkshire Police and Humberside 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 Deliver Acute Behavioural Disturbance training through Personal Safety and First Aid courses, including recognition, clinical escalation and treatment principles.
Verbatim wording from the response “However, in both Personal Safety Training (PST) and First Aid training since 2014 officers have received an input on Acute Behavioural Disturbance (ABD) and on how to recognise signs and symptoms in both theory and practice.” Source location Response from South Yorkshire Police and Humberside 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 Consult the Performance and Governance team about activating body-worn video during constant observations.
Verbatim wording from the response “The Custody lead for South Yorkshire Police is to have further consultation with the Performance and Governance team to look at whether BWV should be activated when observing a prisoner, this could then capture the briefing, roles and responsibilities, action of the officers and any behaviour of the detainee.” Source location Response from South Yorkshire Police and Humberside 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 Introduce poisoning, acute alcohol intoxication and intentional overdose content into the year-three First Aid module.
Verbatim wording from the response “A change to the First Aid learning program for next year introduces poison which covers:” Source location Response from South Yorkshire Police and Humberside 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 Provide Custody Sergeants with training and continuing professional development on constant-observation standards and responsibilities following the document review.
Verbatim wording from the response “Training/ CPD will be given to all Custody Sergeants following this review setting out clear standards and expectations around their role and responsibilities of this document. Dip samples will be carried out by the Custody Inspectors to ensure compliance, this will include reviewing of CCTV to ensure that this document is briefed, relevant checks by the Sergeant are carried out for anyone under constant observations.” Source location Response from South Yorkshire Police and Humberside 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 Review the constant-observation document and consult other forces on improved practices for recording observations and defining officer and Sergeant responsibilities.
Verbatim wording from the response “Future Work” Source location Response from South Yorkshire Police and Humberside 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 Existing acute behavioural disturbance and mental-health training means generic mental-health conditions will not be added to first-aid training.
Verbatim wording from the response “However, in both Personal Safety Training (PST) and First Aid training since 2014 officers have received an input on Acute Behavioural Disturbance (ABD) and on how to recognise signs and symptoms in both theory and practice.” Source location Response from South Yorkshire Police and Humberside 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 Force-wide mental-health CPD cannot be delivered before 2025 because current continuing-professional-development capacity is full.
Verbatim wording from the response “South Yorkshire Police CPD is currently booked up until December 2024, a further mental health CPD event will be considered in CPD training from early 2025 where we will look to deliver this force wide.” Source location Response from South Yorkshire Police and Humberside 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 vulnerable-person scenario adequately addresses acute behavioural disturbance and positional-asphyxia risks, so PST delivery need not change.
Verbatim wording from the response “The PST delivery for this year commencing in April 2024 is all scenario-based delivery. There are six different scenarios mandated by the College of Policing. One scenario is based on ‘vulnerable person.’ The Trainers can introduce ABD by slightly adapting the vulnerable person scenario, to having the role player displaying some of the signs and symptoms of ABD, with the trainer also providing input to the role player to display varying signs and symptoms of ABD such as, the person is hot to touch, incredibly strong or sweating heavily etc. From this the student should realise that they are dealing with someone who is having an ABD episode and deal with them accordingly.” Source location Response from South Yorkshire Police and Humberside Police
Open published response
Concerns raised 6 Failure to properly complete the pre-release risk assessment View source Lack of knowledge of Liaison and Diversion information and flagging functionality on the Police Connect system View source Failure to adequately address potentially vulnerable people with mental health needs at discharge View source Failure to understand the importance of the release wellbeing question in the pre-release risk assessment View source Failure to understand processes for involving the Liaison and Diversion team View source Lack of understanding of triggers for Liaison and Diversion contact during custody and at release View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Alfred Kelly · 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
Peter Alfred Kelly was released from police custody on the morning of 26 April 2023 and was found hanged at 07:45 the following day, believed to have been dead for some time. The concerns included failures to complete the pre-release risk assessment properly, understand processes for involving the Liaison and Diversion team, and recognise potential mental health vulnerabilities at release.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to properly complete the pre-release risk assessment
Wider context from the report “3. Failure to properly complete the Pre Release risk assessment and failure to understand the importance of the question asking an individual how they are feeling at the point of release.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of Liaison and Diversion information and flagging functionality on the Police Connect system
Wider context from the report “2. Lack of knowledge regarding the information that is available to the liaison and diversion team on the police connect system and the facility for police officers to enter LND on that system as a flag .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately address potentially vulnerable people with mental health needs at discharge
Wider context from the report “5. It appears that there is a training need for those working within the custody suite to understand how the system works with LND and the importance of adequately addressing those who are potentially vulnerable with regard to their mental health at the point of 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 South Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the importance of the release wellbeing question in the pre-release risk assessment
Wider context from the report “3. Failure to properly complete the Pre Release risk assessment and failure to understand the importance of the question asking an individual how they are feeling at the point of release .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to understand processes for involving the Liaison and Diversion team
Wider context from the report “1. Failure of a custody sergeant to understand the processes for involving Liaison and Diversion team .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of triggers for Liaison and Diversion contact during custody and at release
Wider context from the report “4. A lack of understanding as to the triggers which may lead to contact with LND not just during a person's time whilst held in custody but at the point of release .
” 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 Hold individual discussions with the CPAG Custody Inspector for Custody Sergeants A and B to highlight lessons learned from the investigation.
Verbatim wording from the response “Action:” Source location Response from South Yorkshire 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 Circulate guidance to all Custody Sergeants on entering the Liaison and Diversion flag in CONNECT.
Verbatim wording from the response “Action:” Source location Response from South Yorkshire 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 Review the wording of Pre-Release Risk Assessment questions, including whether terms such as “appear” appropriately identify non-visible mental health issues.
Verbatim wording from the response “Action:” Source location Response from South Yorkshire 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 Circulate clarification on Liaison and Diversion triggers and priorities and place a reference flowchart at booking-in desks across all three custody suites.
Verbatim wording from the response “There is to be further clarification circulated to all Custody Sergeants and custody staff around the triggers and priorities for involving Liaison and Diversion, a flowchart will be provided by Liaison and Diversion and placed at each booking in desk for every Custody Sergeant to visually refer to when completing RA and PRA all three suites.” Source location Response from South Yorkshire 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 Use the contrasting risk assessments and investigation lessons learned in continuing Custody Sergeant training and CPD on Pre-Release Risk Assessments.
Verbatim wording from the response “Action:” Source location Response from South Yorkshire 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 CONNECT does not prevent custody officers from entering the Liaison and Diversion flag to identify and prioritise detainees.
Verbatim wording from the response “The CONNECT system does not provide any barriers to police officers entering ‘L&D’ as a flag to allow Liaison and Diversion to identify and prioritise those identified by Custody Sergeants at any point of detention, but Custody Sergeants A & B are aware of the L&D flag and how to add this but neither chose to do this (as in 1 above) and therefore preventing Liaison and Diversion in both identifying and prioritising.” Source location Response from South Yorkshire 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 South Yorkshire 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 Yorkshire 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 Yorkshire 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
Concerns raised 6 Lack of clarity in BSARCS referral and actioning View source Mishandling of missing person's reports View source Failure to provide specialist training before officers start work in a specialist sexual offences unit View source Deficiencies in investigation of sexual assault allegations View source Failure to personally and sensitively explain decisions not to pursue allegations View source Lack of a suitable room for taking victim video at Wombwell police station View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emily Greene · 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
Emily Greene was found hanging from a tree in fields at the rear of Doghill, Shafton, Barnsley, on 16 November 2018, and the evidence was that she took her own life. The inquest identified concerns including inadequate specialist training, deficiencies in the sexual-assault investigation, unclear referral handling, failure to sensitively explain the decision not to pursue the allegation, unsuitable facilities for recording victim video, and mishandling of the missing-person report.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in BSARCS referral and actioning
Wider context from the report “3. There was lack of clarity around the BSARCS referral and its actioning
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Mishandling of missing person's reports
Wider context from the report “6. There was mishandling of the missing person's report .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide specialist training before officers start work in a specialist sexual offences unit
Wider context from the report “1. There was employment of an officer into a specialist sexual offences unit without the officer being given specialist training before he started work
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in investigation of sexual assault allegations
Wider context from the report “2. There were deficiencies by the investigating officer and SYP in relation to the investigation into the allegation of sexual assault
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to personally and sensitively explain decisions not to pursue allegations
Wider context from the report “4. That Emily was never personally seen to sensitively explain the fact of and reasons why the police were not going to take the allegation any further .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a suitable room for taking victim video at Wombwell police station
Wider context from the report “5. There was (and I understand still is) lack of a suitable room for taking the victim video at Wombwell police station ( due to a parent not being able to be accommodated )
” 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 Update and distribute the CID40 sexual-offences aide-memoire and amend the Force intranet guidance.
Verbatim wording from the response “The CID 40 Sexual Offences booklet used by officers attending the initial report of sexual offences has been reviewed and updated. This booklet acts as an aide memoire for officers and includes information around victim care, officers' actions and suspect management. The revised booklet is currently being distributed across the Force, and the necessary amendments are also being made to the Force intranet site. A copy of the new booklet has been attached for your reference.” Source location 2020-0288-Response-from-South-Yorkshire-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 Refurbish the remaining Achieving Best Evidence rooms, including Wombwell, after refurbishing four sites.
Verbatim wording from the response “South Yorkshire Police has 10 Achieving Best Evidence rooms within the Force, all of these are fit for purpose but there is currently a programme of refurbishment taking place to enhance them. Four sites have been refurbished in the current financial year and there is a plan to refurbish all remaining ABE rooms, including Wombwell, over the next financial year. There have been delays in this work due to the COVID 19 restrictions.” Source location 2020-0288-Response-from-South-Yorkshire-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 Work with SARC services to introduce referral acknowledgments, a consent-based referral form, and recording and follow-up requirements for officers.
Verbatim wording from the response “The force and the commissioned ISVA services are working together to improve the referral process, ensuring that referrals are acknowledged by the ISVA service along with the development of a form in which the officer will complete with the consent of the victim and then forwarded to the ISVA service. Officers will be directed to electronically record the submission within the investigation along with follow up enquiries with the ISVA service to ensure the victim is being supported.” Source location 2020-0288-Response-from-South-Yorkshire-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 Maintain the Smart Contact incident-management system with trained communications staff and ongoing developmental training.
Verbatim wording from the response “The new incident management system is now fully embedded within the Communications Centre and all staff are fully trained, understand and are familiar with the grading process. Staff receive ongoing developmental training. The force is due to implement a new 'missing from home' IT system called 'Compact' which will improve the forces management and recording of persons reported missing. This new system commences in April 2021.” Source location 2020-0288-Response-from-South-Yorkshire-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 the Compact information-technology system for managing and recording persons reported missing.
Verbatim wording from the response “The new incident management system is now fully embedded within the Communications Centre and all staff are fully trained, understand and are familiar with the grading process. Staff receive ongoing developmental training. The force is due to implement a new 'missing from home' IT system called 'Compact' which will improve the forces management and recording of persons reported missing. This new system commences in April 2021.” Source location 2020-0288-Response-from-South-Yorkshire-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 Reinforce the single-point BSARC referral process with officers through Force intranet guidance.
Verbatim wording from the response “The SARC (Sexual Assault Referral Centres) support service covers all four areas of the Force. Barnsley is covered by the BSARC service. The referral process for victims of sexual offences is in place for officers and staff to make a request for support via the professional's portal central on the BSARC webpage. These referrals are sent and allocated at the central hub for ISVA/CHISVA service, located in Doncaster. It has been identified that the referral officer does not receive any acknowledgment that the submission was successful. It has also been identified that different officers used alternative referral processes such as direct emails to ISVA managers and phone calls.” Source location 2020-0288-Response-from-South-Yorkshire-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 Reinforce investigation-review requirements with crime managers and supervisors through cascading guidance and regular compliance scrutiny.
Verbatim wording from the response “An assessment of the quality and efficacy of the investigation review process has recently taken place. All crime managers have been reminded of the process and have been requested to cascade this process to all supervisors. Compliance with the investigation review process in terms of both timeliness and quality is subject of regular scrutiny and performance reporting.” Source location 2020-0288-Response-from-South-Yorkshire-Police_Redacted.pdf
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 Wombwell ABE room was fit for purpose, and the victim’s mother could not appropriately attend because she was an early-disclosure witness.
Verbatim wording from the response “The Achieving Best Evidence Guidance (ABE) issued by the Crown Prosecution Service (CPS) provides guidance to officers in relation to having other persons present in the interview room. This guidance states that Interview supporters can be present in the interview room if it is necessary and would provide emotional support to the victim. This would only be if appropriate and practical:” Source location 2020-0288-Response-from-South-Yorkshire-Police_Redacted.pdf
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 officer was suitably qualified and experienced to investigate sexual offences, having transferred with PIP2 accreditation and completed relevant specialist training.
Verbatim wording from the response “DC ████████ joined South Yorkshire Police in January 2017 having been previously employed by the Metropolitan Police Service between 2007 and 2014. Having been on a career break for less than 3 years he was accepted as a direct transfer, in accordance with our recruitment policies.” Source location 2020-0288-Response-from-South-Yorkshire-Police_Redacted.pdf
Open published response
Concerns raised 9 Failure to adjust the relevant safety assessment after serious injury information View source Insufficient collation and sharing of potentially important incident information View source Deficient national guidelines for incident information collation and sharing View source Failure to accurately collect, share and categorise incident information View source Failure to inform the relevant road-management function of a serious incident View source Failure of location risk assessment to recognise risk and prioritise major works funding View source Failure to maintain tree trimming sufficient to preserve road lighting View source Failure to require sharing of damage-only incidents View source Failure to properly identify incident locations in shared information View source See 6 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
Mr Sean Craig Salvin · 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
Sean Craig Salvin died on 30 December 2015 from severe injuries sustained when his car left a heavily flooded road at Woolley Wood Bottom, Sheffield. The report identified concerns about failures by authorities to collect, share and collate information about incidents and flooding, as well as concerns about risk assessment and the identification of the location's increasing risk.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to adjust the relevant safety assessment after serious injury information
Wider context from the report “d) ████████ had suffered unpleasant injuries including a fractures to his lower back. Although this became known to the South Yorkshire Police, no adjustment was made . Amey advised the court that they had not been made aware of this incident.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient collation and sharing of potentially important incident information
Wider context from the report “a) The evidence showed that there was insufficient system for the collation and sharing of information to assure that each of the authorities was aware of potentially important incidents . If national guidelines were being followed, as was stated, then the evidence suggests that those guidelines are themselves deficient.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Deficient national guidelines for incident information collation and sharing
Wider context from the report “a) The evidence showed that there was insufficient system for the collation and sharing of information to assure that each of the authorities was aware of potentially important incidents. If national guidelines were being followed, as was stated, then the evidence suggests that those guidelines are themselves deficient .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately collect, share and categorise incident information
Wider context from the report “c) Further, the system did not apparently require ‘damage only’ incidents to be shared. It is appreciated that the sharing of minor incidents could easily become burdensome but the case of ████████ (August 2015) which was recorded as ‘damage only’ was actually a serious matter indicating that greater care is needed in the collection/sharing of information and subsequent categorisation .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the relevant road-management function of a serious incident
Wider context from the report “d) ████████ had suffered unpleasant injuries including a fractures to his lower back. Although this became known to the South Yorkshire Police, no adjustment was made. Amey advised the court that they had not been made aware of this incident .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of location risk assessment to recognise risk and prioritise major works funding
Wider context from the report “e) The risk assessment of this location was also of concern to the inquest, both in respect of prioritisation of funding for major work and in terms of the recognition of the degree of risk . This was a location where traffic might be expected to be travelling comparatively quickly with the low hazard of trees immediately adjoining the carriageway. The emergence of a propensity to flood was a most important addition to the risk calculation .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain tree trimming sufficient to preserve road lighting
Wider context from the report “g) Witnesses reported the street lighting as ‘adequate’ and a site inspection did not suggest otherwise. However, the growth of trees and the development of leaves in Spring and Summer will inevitably reduce the lighting available on the road unless proper (and probably substantial) trimming takes place . The court was told that this is a recognised and regular maintenance issue but a concern would arise if this was reduced for any reason such as future budgetary constraints .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to require sharing of damage-only incidents
Wider context from the report “c) Further, the system did not apparently require ‘damage only’ incidents to be shared . It is appreciated that the sharing of minor incidents could easily become burdensome but the case of ████████ (August 2015) which was recorded as ‘damage only’ was actually a serious matter indicating that greater care is needed in the collection/sharing of information and subsequent categorisation.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to properly identify incident locations in shared information
Wider context from the report “b) In particular, such sharing of information as there was did not always fully or even properly identify the location concerned . The inquest showed that it was not difficult to identify that a number of incidents had occurred in the same place prior to the fatal collision.
” Open source report
Concerns raised 29 Failure to review custody records and risk assessments at shift commencement View source Delayed review and response to known alcohol-related detainee risks View source Failure to review transferred risk-assessment information View source Failure to record later healthcare assessment needs View source Failure to record changes to detainee observation levels View source Unrecorded informal cessation of detainee rousing checks View source Failure to call a health professional for alcohol- or drug-dependent detainees View source Failure to implement and record required detainee observation levels View source Failure to refer detainees for medical review and record acute symptoms View source Failure to record known health risks on Prison Escort Forms View source Insufficient custody-suite staffing for safe detainee response View source Risk of fatal acute alcohol withdrawal syndrome when unmanaged View source Failure to communicate medication information to custody staff View source Failure to establish clear healthcare referral arrangements View source Incomplete handover causing unsafe changes to detainee observations View source Custody-suite training failing to provide adequate preparation View source Lack of training on risks to sobering alcohol-dependent detainees View source Failure to complete Prison Escort Forms for detainee transfers View source Incomplete risk-assessment questions and documentation View source Failure to arrange direct doctor engagement with a non-cooperative detainee View source Lack of training for custody-record reviewing inspectors View source Failure to open custody records and complete risk assessments View source Incomplete handover of detainee health risks and observation requirements View source Failure to ensure legible custody-record entries and clarify illegible writing View source Failure to reconsider risk assessments when detainee cooperation improves View source False recording of detainee cell checks View source Unprofessional introduction of a pet dog into the custody suite View source Failure to consider healthcare referral for medically vulnerable detainees View source Incorrect recording of healthcare referrals in custody records View source See 26 more concerns
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
Neil Budziszewski · 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
Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to review custody records and risk assessments at shift commencement
Wider context from the report “(18) The oncoming (night) custody sergeant failed to review the custody record or risk assessment when he came on duty .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Delayed review and response to known alcohol-related detainee risks
Wider context from the report “(28) The morning custody sergeant only reviewed the risk assessment around three hours after coming on duty , claiming that he only then noticed that Mr Budziszewski was an alcoholic. He told the court that this concerned him because for an alcoholic the checks would have been different and a doctor would have been required. In fact, the CCTV makes clear that the oncoming sergeant was told that Mr Budziszewski was an alcoholic on two occasions but he failed to take the actions that he himself described as necessary .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to review transferred risk-assessment information
Wider context from the report “(5) When Mr Budziszewski was returned to Ecclesfield Police Station, the afternoon custody sergeant failed to complete his own risk assessment query issues arising from the risk assessment undertaken at Bridge Street . It is likely that the escorting officers could have added a great deal of knowledge for the custody sergeant about what had been said by Mr Budziszewski at Bridge Street.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record later healthcare assessment needs
Wider context from the report “(7) The afternoon custody sergeant recognised guidance that a doctor would normally be asked to attend for an alcoholic detainee, but failed to record on the custody record or risk assessment that Mr Budziszewski should be considered for an assessment later on .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record changes to detainee observation levels
Wider context from the report “(22) No note was made in the custody record of the decision to place the prisoner back on 30 minute checks after the retching episode so that later officers would be aware.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Unrecorded informal cessation of detainee rousing checks
Wider context from the report “(8) The afternoon civilian detention officer believed that Mr Budziszewski had been taken off rousing checks by 8pm because he had been in custody some five hours and rousing ‘was no longer necessary’ . This seems to be a commonly made informal decision with no record made .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to call a health professional for alcohol- or drug-dependent detainees
Wider context from the report “(17) PACE requires a health professional to be called if the detainee is dependent on alcohol or drugs. This did not take 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to implement and record required detainee observation levels
Wider context from the report “(6) The afternoon custody sergeant at Ecclesfield failed to place Mr Budziszewski on 30 minute routine checks in breach of PACE Code C (paragraph 9.3). Indeed, there was no annotation on the custody record of the level of checks required
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to refer detainees for medical review and record acute symptoms
Wider context from the report “(20) Shortly after 3am if was noted by the night custody sergeant that the sound of retching could be heard from one of the cells. Investigation by the night detention officer showed this to be Mr Budziszewski. This caused his custody record to be reviewed (for the first time) and earlier notation concerning dependence on alcohol and the use of drugs was apparent. No action was taken to refer Mr Budziszewski for medical review even though the doctor was visiting another prisoner in the custody area at the time . No record of this incident was made in the custody record .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record known health risks on Prison Escort Forms
Wider context from the report “(23) The Prison Escort Form for the forthcoming transfer to the Magistrates Court was completed during the night shift. This makes no reference to the risks which were by now known . Expert evidence indicated that the risk of acute alcohol withdrawal syndrome was increasing as time went by rather than decreasing.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient custody-suite staffing for safe detainee response
Wider context from the report “(25) Towards the end of the night shift the custody sergeant informed the civilian detention officer that he could go, thus leaving the custody sergeant alone . Although only a few minutes were involved, this;
a) could have placed the custody sergeant at severe personal risk.
b) may well have prevented the custody sergeant dealing swiftly and appropriately with an issue such as a prisoner collapsed in the cell (i.e. reluctance to open the cell in case the prisoner was faking an illness, resulting in a delay until other persons could be brought in from other areas of the police station).
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Risk of fatal acute alcohol withdrawal syndrome when unmanaged
Wider context from the report “(29) Expert evidence was given that acute alcohol withdrawal syndrome is associated with a high risk of death if not managed properly . The early symptoms such as shaking or retching (both displayed by Mr Budziszewski) indicate a rather lower risk but that could grow with time .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate medication information to custody staff
Wider context from the report “(11) The inspector was at 9pm indicates that Mr Budziszewski took medication for his alcoholism (which was not strictly correct, he took Temazepam to assist him to sleep) and states that the inspector had informed the custody staff of this. That is incorrect, the inspector’s evidence was that he was to return later on and inform the custody staff who were busy at the time but he never did so .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clear healthcare referral arrangements
Wider context from the report “(14) There was unnecessary confusion between the reviewing inspector and the afternoon civilian detention officer as to whether the deceased would be assessed by a health care professional. No referral took 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Incomplete handover causing unsafe changes to detainee observations
Wider context from the report “(26) The handover from the night custody sergeant to the morning custody sergeant was incomplete . Whilst CCTV makes plain that Mr Budziszewski was described as an alcoholic, there was no reference to the retching episode or the change in observations . In consequence of this latter point Mr Budziszewski was inadvertently changed back from 30 minute checks to 60 minutes without any consideration of needs .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Custody-suite training failing to provide adequate preparation
Wider context from the report “(15) The afternoon custody sergeant told the IPCC investigators that he did not think his custody suite training was fit for purpose . He claimed that this had already been raised by another custody sergeant but was not aware of anything happening about it .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of training on risks to sobering alcohol-dependent detainees
Wider context from the report “(9) This detention officer felt that he had not been trained on the risks for alcoholics when they are sobering but was aware that they were susceptible to fits and sickness etc., because he had been told by one of the MEDACS nurses some time before. He recognises that this is important information that he had not been trained on.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Prison Escort Forms for detainee transfers
Wider context from the report “(2) The afternoon custody sergeant failed to complete a Prison Escort Form for a transfer to Bridge Street (for LiveScan identification) in breach of guidance. Similarly, whilst the receiving custody sergeant at Bridge Street commenced a custody record and completed a risk assessment, he also failed to complete a Prison Escort Form for the transfer back.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Incomplete risk-assessment questions and documentation
Wider context from the report “(3) The risk assessment completion at Bridge Street did not include asking Mr Budziszewski if he wanted to see a doctor, if he was on medication or if he was in contact with a medical service . Nor did it document that Mr Budziszewski should be checked every 30 minutes .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange direct doctor engagement with a non-cooperative detainee
Wider context from the report “(21) It is accepted that Mr Budziszewski was asked at this stage if he wanted to see a doctor and admitted. However, expert evidence was given that this was unwise and the doctor should have been asked to engage with the prisoner as this was likely to have resulted in co-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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of training for custody-record reviewing inspectors
Wider context from the report “(12) The reviewing inspector had no training in his task , he was simply given the job because he was an available shift inspector at the police station.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to open custody records and complete risk assessments
Wider context from the report “(1) When Mr Budziszewski was first presented to the Ecclesfield afternoon shift custody sergeant he accepted custody without opening a custody record or completing a risk assessment . Whilst it is accepted that Mr Budziszewski was in drink at the time and un-cooperative there appears to have been no thought given to a risk assessment.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Incomplete handover of detainee health risks and observation requirements
Wider context from the report “(16) The handover from the afternoon custody sergeant to night custody sergeant did not include information about Mr Budziszewski being prescribed Methadone, that he was an alcoholic, or that he was on 30 minute checks . This was accepted not to be a full and effective handover .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure legible custody-record entries and clarify illegible writing
Wider context from the report “(13) A significant amount of the handwriting on the custody record (notably including that by the reviewing inspector) was illegible. Yet nobody sought clarification of what had been written .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to reconsider risk assessments when detainee cooperation improves
Wider context from the report “(4) The custody sergeant at Bridge Street gave evidence that he was unable to conduct a full risk assessment because of Mr Budziszewski‘s ‘lack of compliance. However, no arrangement was made for the risk assessment to be reconsidered at a time when Mr Budziszewski was more compliant (which happened quite shortly thereafter). This officer recognised that an alcoholic who was approaching sobriety is someone who needs to be seen by a health care professional.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation False recording of detainee cell checks
Wider context from the report “(24) The night shift civilian detention officer made false entries of having carried out cell checks on the deceased at 0335 and 0430. On the first occasion it was written that Mr Budziszewski was asleep and breathing regularly but in fact this entry (written later) was made on the assumption that a visit must have been made at around that time and that is what would have been found.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Unprofessional introduction of a pet dog into the custody suite
Wider context from the report “(19) The night custody sergeant brought a young pet dog into the custody suite with him , which he accepted was wholly unprofessional. Whilst there is no evidence that this proved a distraction detrimental to the prisoner on this occasion, that might differ should this conduct be repeated by others.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to consider healthcare referral for medically vulnerable detainees
Wider context from the report “(10) There was no consideration given at that time to calling a health care professional , notwithstanding the information gained which included that Mr Budziszewski was an alcoholic and was a prescribed methadone user. The view seems to have been taken that the medical provider would simply refuse to see a detainee until they were no longer in drink . This carries considerable dangers if the detained person’s condition was not actually caused by drink but by a head injury or hypoglycaemic state etc.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Incorrect recording of healthcare referrals in custody records
Wider context from the report “(27) Further, the custody record had been incorrectly marked during the night that Mr Budziszewski had been referred to a doctor which would at least be initially misleading to the morning shift although there was obviously no paperwork from a doctor.
” 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 Review Acting Inspector custody-review training and develop a protocol, guidance pack and associated electronic review materials.
Verbatim wording from the response “Following this error a review is being undertaken to review the training provided to Acting Inspectors required to carry out custody reviews. This will include a new protocol whereby the custody sergeant will be expected to confirm the Inspector’s familiarity with the process. The new custody digital log contains the legal requirements of the review with drop down menus and guidance. There is also a piece of work ongoing to collate a pack to be provided to Acting and Temporary Inspectors which will contain information and guidance on completing a custody review. It is hoped that the review and the pack will be completed by 31st May 2015, Appendix B shows a copy of the electronic form the Inspector will need to complete.” Source location 2015-0109-Response-by-South-Yorkshire-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 Document and standardise custody handover requirements, including transfer of risk-assessment information.
Verbatim wording from the response “The process for handovers is now documented and is consistent across the force. The process is that the sergeant handing over will summarise to the incoming sergeant personal information about the detainee, details of the offence and the stage of the investigation and any specific risk factors. The focus of the handover is to be around the risk assessment which has been completed. Appendix C shows a completed copy of the handover Sergeants are expected to complete. As this is a live copy, third party data has been redacted out to ensure compliance with the Data Protection Act.” Source location 2015-0109-Response-by-South-Yorkshire-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 Highlight custody-record and risk-assessment requirements in custody training and remind current staff through briefing and rotational training.
Verbatim wording from the response “It is a basic requirement that anyone entering a custody suite should be assigned a custody record and a risk assessment should be completed. This should be done even where the detainee is un-cooperative. This is something which is covered by PACE Code C which is covered in the training provided to custody officers. Having spoken to a sample of custody sergeants during April 2015 an uncooperative detainee under the influence of alcohol is a regular occurrence in custody and a custody record is still routinely opened and a risk assessment completed on the information available and updated in due course. In the future this point will be highlighted in the training and all current staff will be reminded of this requirement by the end of May 2015 by way of briefing document from the Inspectors and rotational training commencing 21 May 2015.” Source location 2015-0109-Response-by-South-Yorkshire-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 Incorporate alcohol withdrawal risks and acute withdrawal symptoms into custody guidance and first-aid training.
Verbatim wording from the response “The training programme which has been provided, both the initial training and the annual refresher, make specific reference to the risks of alcohol. South Yorkshire Police Training department have now been asked to incorporate the risks of alcohol withdrawal and acute alcohol withdrawal symptoms into the training and specifically the impact that this has on the risk assessment in custody. The training which is provided is based on the Home Office training programme and therefore a limited number of health issues are included within the training. It would be difficult to incorporate all health conditions into this training as time is limited. This will be part of the general guidance which will go out from Inspectors by 31 May 2015 and will be included in the next round of First Aid training provided to custody staff.” Source location 2015-0109-Response-by-South-Yorkshire-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 Address healthcare-provider arrangements concerning medical assessment of alcohol-related detainees.
Verbatim wording from the response “Healthcare provision to South Yorkshire Police is provided by a private company. The practice of that company is that they will not routinely see a detainee where that detainee is under the influence of alcohol and they have been in custody for less than six hours. The only exception is where the factors referred to in paragraph five are present:-” Source location 2015-0109-Response-by-South-Yorkshire-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 Circulate written notification explaining that Prisoner Escort Forms must be completed whenever detainees move from custody.
Verbatim wording from the response “It would appear that this was a commonly misunderstood form across South Yorkshire Police with custody staff believing that the PER form was only required where a detainee was being transferred to the custody of another agency and not internally. Following the outcome of the inquest touching upon the death of Mr Neil Budziszewski the policy has been reviewed and all custody staff have been informed of the requirement for this form to be completed when transferring a prisoner between custody suites or police stations as well as when transferring to an external agency. This will be followed up with a written notification to all custody staff explaining the need for this form to be completed whenever a detainee is moved from custody regardless of the agency transferring the detainee.” Source location 2015-0109-Response-by-South-Yorkshire-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 Include medical-referral responsibilities in the Inspector guidance pack and remind substantive Inspectors of the referral requirement.
Verbatim wording from the response “Although the medical referral would be the responsibility of the custody staff, the Inspector has a role to play in requesting the medical referral where, upon review, he or she believes it is necessary. This will all be included within the pack that will be provided to Acting and Temporary Inspectors. Substantive Inspectors will be reminded of this requirement by 31 May 2015.” Source location 2015-0109-Response-by-South-Yorkshire-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 Regularly train current and new custody staff on the standardised handover process.
Verbatim wording from the response “Unfortunately this was an example of extremely poor recording keeping. That cannot be defended however it is certainly below the expectations of South Yorkshire Police. The custody staff involved have all been spoken to following the inquest and advised of this issue and told of the expectations upon them. It is also anticipated that the new handover process should ensure this does not happen going forward and this process will be regularly trained to custody staff, current and new.” Source location 2015-0109-Response-by-South-Yorkshire-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 Retrain custody Inspectors and reiterate Prisoner Escort Form completion requirements and required transfer details to custody staff.
Verbatim wording from the response “As referred to in paragraph two, there appear to have been a number of misunderstandings around the Prisoner Escort Form. These errors have now been retrained to custody Inspectors and will be reiterated to custody staff and the details to be included by 31 May 2015.” Source location 2015-0109-Response-by-South-Yorkshire-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 Mandate in writing that custody staff must not work alone and must request additional staffing when required.
Verbatim wording from the response “Staff have been made aware that lone working in custody should not happen and should not have happened. Staff are aware that they need to request additional staff if there is a staffing issue in custody and that only in extreme circumstances would there be a lone member of staff in custody. This will be mandated in writing to custody staff by 31 May 2015.” Source location 2015-0109-Response-by-South-Yorkshire-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 Remind custody staff of the obligation to seek medical attention when detainees present possible medical concerns, including when they decline an offer.
Verbatim wording from the response “The custody sergeant would be expected to have requested a medical review for the detainee following this action. PACE Code C is clear and note 9C is clear that if there is any doubt over the condition of a detainee then medical attention should be sought. As discussed at paragraph 17, custody staff will be reminded of this in writing by 31 May 2015 and also in subsequent training. It is also anticipated that the new electronic risk assessment will trigger the requirement for a medical review when it is completed. The electronic custody log will have to be updated regularly and the time the log is updated will be recorded which will provide for greater accountability.” Source location 2015-0109-Response-by-South-Yorkshire-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 Remind custody staff to record all decisions about detainee checks in custody records.
Verbatim wording from the response “This is contrary to training which has been provided. All staff have now been reminded that all decisions regarding checks of detainees must be recorded on the custody record and that if the decision is not recorded then the decision has not been made. This was dealt with custody Inspectors on 15 April 2015 and other staff will be reminded of this requirement in a briefing document by the end of May 2015.” Source location 2015-0109-Response-by-South-Yorkshire-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 Establish large-capacity, multi-staffed custody facilities where lone working is not sanctioned.
Verbatim wording from the response “As of April 2016, South Yorkshire Police will have large capacity custody suites rather than the smaller more local custody suites. These will all be multi staffed facilities and lone working will not be sanctioned in any circumstances.” Source location 2015-0109-Response-by-South-Yorkshire-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 Review the Prisoner Escort Form policy and inform custody staff that forms are required for all detainee transfers.
Verbatim wording from the response “It would appear that this was a commonly misunderstood form across South Yorkshire Police with custody staff believing that the PER form was only required where a detainee was being transferred to the custody of another agency and not internally. Following the outcome of the inquest touching upon the death of Mr Neil Budziszewski the policy has been reviewed and all custody staff have been informed of the requirement for this form to be completed when transferring a prisoner between custody suites or police stations as well as when transferring to an external agency. This will be followed up with a written notification to all custody staff explaining the need for this form to be completed whenever a detainee is moved from custody regardless of the agency transferring the detainee.” Source location 2015-0109-Response-by-South-Yorkshire-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 Implement digital custody records requiring electronic recording of checks, observations, assessments and associated audit times.
Verbatim wording from the response “It is accepted that Mr Budziszewski should have been on 30 minute rousing checks and that this should have been annotated on the custody record when the checks were undertaken. South Yorkshire police have now moved to fully digital custody records and each check will have to be placed onto the electronic custody record. This system has been in place since 17 February 2015 and it is mandated that the checks have to be carried out. The appropriate checks are preselected in a drop down menu on the electronic system and therefore clearly defined according to the appropriate guidance.” Source location 2015-0109-Response-by-South-Yorkshire-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 Inspector did not inform custody staff about the medication information because he intended to return later but failed to do so.
Verbatim wording from the response “11. The Inspectors review at 9pm indicates that Mr Budziszewski took medication for his alcoholism (which was not strictly correct, he took Tamazepam to assist him to sleep) and states that the Inspector had informed the custody staff of this. That is incorrect, the Inspector’s evidence was that he was to return later on and inform the custody staff who were busy at the time but he never did so.” Source location 2015-0109-Response-by-South-Yorkshire-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 Thirty-minute checks were unnecessary at Bridge Street because the detainee was never placed in a cell and remained under constant supervision.
Verbatim wording from the response “It is also the case that the risk assessment, once the detainee arrived at Bridge Street, did not refer to the requirement for 30 minute checks because he was never taken to a cell at Bridge Street and therefore under constant supervision. It is right that if he had been taken to a cell then the record would have been updated with the appropriate check times required.” Source location 2015-0109-Response-by-South-Yorkshire-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 detainee was not displaying symptoms or circumstances requiring healthcare professional consultation while at Bridge Street custody.
Verbatim wording from the response “In relation to the requirement to call a doctor for alcohol related matters in custody, there are five criteria where a healthcare professional must be consulted, three of those relate to alcohol issues:-” Source location 2015-0109-Response-by-South-Yorkshire-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 Existing custody training and practices comply with Home Office standards; the identified failures were attributed to individual officer error rather than deficient arrangements.
Verbatim wording from the response “Whilst Mr Budziszewski was at Bridge Street custody he was not cooperative with the risk assessment process. In any event this should have been reviewed upon his return to Ecclesfield. Custody staff are aware of the importance of the risk assessment and the requirement to regularly review where information is missing and therefore this failure on this occasion is down to officer error and not due to an issue with the training and practices. Appendix A refers to the new risk assessment which has been in force since October 2014.” Source location 2015-0109-Response-by-South-Yorkshire-Police
Open published response
Concerns raised 12 Limited Youth Offending Service staff training for the Social Services records system View source Insufficient capacity of supported accommodation View source Failure of frontline social services practitioners to identify when and where to make mental health referrals View source Lack of awareness among custody medical services of out-of-hours access to Children's Services records View source Failure to use previous psychiatric services information in assessment and Child in Need planning View source Inconsistent use of the Child in Need process for homeless young people View source Failure to routinely provide prisoner escort records to the Youth Offending Service View source Lack of a requirement for thorough mental health assessment of young people in custody View source Failure to obtain health-professional advice about risks following previous suicidal ideation View source Limited Youth Offending Service staff access to the Social Services records system View source Lack of a formal step-down process for young people leaving or disengaging from adult mental health services View source Failure to provide needs-based access to mental health and subsistence support for 16- and 17-year-olds in supported accommodation View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Peter Stanley · 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
Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Limited Youth Offending Service staff training for the Social Services records system
Wider context from the report “(10) It is understood that the number of Youth Offending Service staff who have access to, and training for, the Social Services records system is limited.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity of supported accommodation
Wider context from the report “(7) This case shows the need for a greater number of places in supported accommodation .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of frontline social services practitioners to identify when and where to make mental health referrals
Wider context from the report “(9) It is evident that front line social services practitioners are not always aware of when and where to make mental health referrals .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among custody medical services of out-of-hours access to Children's Services records
Wider context from the report “(3) On the basis of evidence given by ████████ Assistant Director of Fieldwork Services, Sheffield City Council, it is clear that the custody nurse could have accessed the Children's Services records for Peter on 14 July, even during the night, by calling the Social Services 'out of hours' team. Every local authority has an out of hours system (which would cover adults as well). However I am told that this is not generally known amongst those providing custody medical services .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to use previous psychiatric services information in assessment and Child in Need planning
Wider context from the report “(11) There is no system to ensure that where there has been previous psychiatric services involvement by a young person that such information will be used to inform assessment and the 'Child in Need' planning process .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Inconsistent use of the Child in Need process for homeless young people
Wider context from the report “(6) Peter was classed as 'intentionally homeless' after his release from court on 15 July. ████████ gave the court compelling evidence that this was wrong and that Peter should have been treated as a 'Child in Need'. Emphasis on the 'Child in Need' process when a young person is homeless would ensure proper assessment and sharing of information . Failures in sharing Peter's mental health history/needs were significant issues in this case . This emphasis is now standard practice in Sheffield but I understand it is not likely to be the case everywhere .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely provide prisoner escort records to the Youth Offending Service
Wider context from the report “(5) A prisoner escort record (known commonly as a PER) would have been handed over from the police to the privatised court detention officers when Peter was produced before the magistrates. This contains details (inter alia) of risks, self harm issues, medical attention and warning markers. I understand that the Youth Offending Service believe that the PER should be routinely given to them it would inform assessments as to the immediate needs of the young person. This would only arise, of course, in the relatively few cases where the young person has spent a period in police cells.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for thorough mental health assessment of young people in custody
Wider context from the report “(4) There is no specific requirement that health professionals completing assessments of young persons in custody suites include a thorough assessment of mental health .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain health-professional advice about risks following previous suicidal ideation
Wider context from the report “(12) There is no system to ensure that when a young person has presented with previous suicidal ideology that advice is taken from health professionals regarding the potential risks .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Limited Youth Offending Service staff access to the Social Services records system
Wider context from the report “(10) It is understood that the number of Youth Offending Service staff who have access to, and training for, the Social Services records system is limited.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal step-down process for young people leaving or disengaging from adult mental health services
Wider context from the report “(2) When young people are discharged from, or have failed to engage with, Adult Mental Health Services there is no formal 'step-down' policy . The Sheffield Child Death Overview Panel advise me that this should include a referral to a Multi Agency Support Team or Community Youth team who can then establish a key worker and 'team around the child' approach.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide needs-based access to mental health and subsistence support for 16- and 17-year-olds in supported accommodation
Wider context from the report “(13) There is no system to ensure that 16 and 17 year olds placed in supported accommodation have needs based access to support services, including mental health and subsistence , irrespective of whether they fall within s.20 of the Childrens Act.
” 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