PFD report

Leighton Alan Dickens · Prevention of Future Deaths report

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Issued 29 Sep 2023•South Wales Central

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised5

  1. Limited availability and capacity of mental health crisis teams
  2. Failure to provide clinically qualified mental health tactical adviser support
  3. Lack of multiple medically qualified sources of urgent mental health support for police officers
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Maintain a dedicated 24-hour pathway for officers to obtain medically qualified advice about section 136 decisions.

    Stated by South Wales PoliceStated completedThe respondent said that this action was complete when they made their response on 2 October 2024.
  2. Action

    Continue working with NHS Wales and health boards to ensure officers can obtain medically qualified advice at any time.

    Stated by South Wales PoliceStated in progressThe respondent said that this action was in progress when they made their response on 2 October 2024.
  3. Action

    Develop and operate a police contact protocol with NHS Wales clarifying access to urgent mental health advice and signposting to crisis teams.

    Stated by South Wales PoliceStated completedThe respondent said that this action was complete when they made their response on 2 October 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The existing 24-hour crisis-team pathway provides medically qualified advice and satisfies requirements for advice before using section 136 powers.

    Stated by South Wales PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Limited availability and capacity of mental health crisis teams

Wider context from the report

“(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams. (2) The crisis teams may not be readily available and deal with their own case load. (3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system. (4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place. (5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide clinically qualified mental health tactical adviser support

Wider context from the report

“(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams. (2) The crisis teams may not be readily available and deal with their own case load. (3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system. (4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place. (5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of multiple medically qualified sources of urgent mental health support for police officers

Wider context from the report

“(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams. (2) The crisis teams may not be readily available and deal with their own case load. (3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system. (4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place. (5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of access to the PARIS mental health records system for tactical adviser support

Wider context from the report

“(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams. (2) The crisis teams may not be readily available and deal with their own case load. (3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system. (4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place. (5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to implement the intended “111 press 2” mental health triage service

Wider context from the report

“(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams. (2) The crisis teams may not be readily available and deal with their own case load. (3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system. (4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place. (5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community ”

Is this part of a recurring concern?

Yes — Failure to provide the NHS 111 mental health crisis triage service.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain a dedicated 24-hour pathway for officers to obtain medically qualified advice about section 136 decisions.

Verbatim wording from the response

“Policy section 1.2 (Mental Health – Section 136) defines the specific requirement for police to seek advice from a health professional who are maintained on an agreed list, before detaining a person under s136 of the Mental Health Act. The policy outlines both the legislative and practical considerations in obtaining advice for use in decision making on s136. Within this section of the policy, it contains the contact details for each crisis team in the respective health board area should urgent advice be required.”

Source location

Response from South Wales Police
Page 2 · response
Published 2 October 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue working with NHS Wales and health boards to ensure officers can obtain medically qualified advice at any time.

Verbatim wording from the response

“Medically qualified advice for officers can be invaluable to a police officer when faced with a person in crisis and the sharing of information and opinion can be relevant to the formation of the officer’s final judgement on the need for detention for a person’s own protection. As such the force will continue to ensure that we work in partnership with NHS Wales and each of the health boards to ensure that processes are effective for officers to obtain advice at any time.”

Source location

Response from South Wales Police
Page 6 · response
Published 2 October 2024

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

Develop and operate a police contact protocol with NHS Wales clarifying access to urgent mental health advice and signposting to crisis teams.

Verbatim wording from the response

“Since the concerns raised in this inquest, we have worked with NHS Wales to develop an ‘NHS 111 Press 2 - Police Contact Protocol’. This provides clarity on how a range of professionals, including the police can access advice relating to urgent mental health concerns.”

Source location

Response from South Wales Police
Page 5 · response
Published 2 October 2024

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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

Monitor crisis-line accessibility daily and scrutinise section 136 use through internal strategic boards and partnership forums.

Verbatim wording from the response

“As a result of the Regulation 28 Notice, the accessibility of these crisis lines is monitored daily by the force Public Protection Department to identify adverse incidents and accessibility. Information pertaining to the use of s136 powers is also scrutinised in internal strategic boards and partnership forums, such as the Mental Health Act Monitoring Group.”

Source location

Response from South Wales Police
Page 3 · response
Published 2 October 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The existing 24-hour crisis-team pathway provides medically qualified advice and satisfies requirements for advice before using section 136 powers.

Verbatim wording from the response

“Policy section 1.2 (Mental Health – Section 136) defines the specific requirement for police to seek advice from a health professional who are maintained on an agreed list, before detaining a person under s136 of the Mental Health Act. The policy outlines both the legislative and practical considerations in obtaining advice for use in decision making on s136. Within this section of the policy, it contains the contact details for each crisis team in the respective health board area should urgent advice be required.”

Source location

Response from South Wales Police
Page 2 · response
Published 2 October 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Responsibility for commenting on crisis-team capacity rests with the Health Board, whose director has been directly informed of the concern.

Verbatim wording from the response

“(2) The crisis teams may not be readily available and deal with their own case load. Whilst I cannot provide specific comment on behalf of the Health Board on the capacity of their Crisis Teams, I can provide assurance that the concerns within the regulation 28 notice have been raised directly with ████████ Director of Operations, Mental Health Clinical Board.”

Source location

Response from South Wales Police
Page 3 · response
Published 2 October 2024

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

Police should continue using established crisis contact points for section 136 advice; NHS 111 Press 2 is not the replacement route.

Verbatim wording from the response

“Since the concerns raised in this inquest, we have worked with NHS Wales to develop an ‘NHS 111 Press 2 - Police Contact Protocol’. This provides clarity on how a range of professionals, including the police can access advice relating to urgent mental health concerns.”

Source location

Response from South Wales Police
Page 5 · response
Published 2 October 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Publish force communications reinforcing how officers obtain urgent medically qualified advice before using section 136 powers.

    Stated by South Wales PoliceStated completedThe respondent said that this action was complete when they made their response on 2 October 2024.
  2. 2

    Provide dedicated Mental Health Liaison Officers and a Strategic Force Mental Health Advisor to educate officers, identify improvements and escalate concerns.

    Stated by South Wales PoliceStated completedThe respondent said that this action was complete when they made their response on 2 October 2024.
  3. 3

    Introduce a mental health tactical adviser scheme providing additional legislation and policy training and advice to officers and staff in key roles.

    Stated by South Wales PoliceStated plannedThe respondent said that this action was planned when they made their response on 2 October 2024.
  4. 4

    Update the Mental Health—Section 136 policy with advice requirements, legislative guidance and crisis-team contact details.

    Stated by South Wales PoliceStated completedThe respondent said that this action was complete when they made their response on 2 October 2024.
  5. 5

    Deliver a newly developed public protection training day for all police officers to reinforce learning about responding to vulnerable people.

    Stated by South Wales PoliceStated plannedThe respondent said that this action was planned when they made their response on 2 October 2024.

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

Publish force communications reinforcing how officers obtain urgent medically qualified advice before using section 136 powers.

Verbatim wording from the response

“In response to this Regulation 28 report, extensive force communications have been published which reinforces the arrangements for seeking urgent medically qualified advice prior the use of powers under s136. These included formal communications via Weekly Orders, signposting on intranet and follow up by our Mental Health Liaison Officers. This communication also highlights additional points of learning as a result of issues arising in this case.”

Source location

Response from South Wales Police
Page 3 · response
Published 2 October 2024

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 dedicated Mental Health Liaison Officers and a Strategic Force Mental Health Advisor to educate officers, identify improvements and escalate concerns.

Verbatim wording from the response

“South Wales Police employs 3 dedicated Mental Health Liaison Officers (MHLO’s) and a Strategic Force Mental Health Advisor, who as part of their responsibilities engage with responding officers, educate on approved practice, identify areas for improvement and escalate concerns both internally and with partners.”

Source location

Response from South Wales Police
Page 3 · response
Published 2 October 2024

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 a mental health tactical adviser scheme providing additional legislation and policy training and advice to officers and staff in key roles.

Verbatim wording from the response

“Mental Health Tactical advisers are not currently deployed within South Wales Police, and it is fully accepted that Mental Health Tactical Advisers will not be clinically qualified members of staff with access to PARIS. The implementation of the provision would not replace the need to consult with a suitably qualified professional which can include, a Doctor, Nurse, or Approved Mental Health Professional (AMHP), who would have access to PARIS.”

Source location

Response from South Wales Police
Page 4 · response
Published 2 October 2024

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

Update the Mental Health—Section 136 policy with advice requirements, legislative guidance and crisis-team contact details.

Verbatim wording from the response

“Since the withdrawal of the service, the South Wales Police ‘Mental Health – Section 136’ policy has been updated. The Policy defines the treatment of people by South Wales Police officers under the Mental Health Act 1983. The policy also provides guidance to officers, and staff in the management of mental health concerns, and on the partnership arrangements in responding to mental health related incidents.”

Source location

Response from South Wales Police
Page 2 · response
Published 2 October 2024

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 a newly developed public protection training day for all police officers to reinforce learning about responding to vulnerable people.

Verbatim wording from the response

“In 2024 all police officers attend a newly developed public protection training day which will reinforce key learning points to consider when responding to vulnerable people in the community.”

Source location

Response from South Wales Police
Page 6 · response
Published 2 October 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026