PFD report

Sean Perry WILLIAMS · Prevention of Future Deaths report

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Issued 20 Feb 2026•Inner North London

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.

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Concerns
12

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
16

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

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Concerns raised12

  1. Failure of custody nurses to recognise and describe drug withdrawal signs and symptoms
    Part of recurring concern: Failure to reliably recognise and respond to drug and alcohol withdrawal in custody
  2. Inadequate assessment of first aid knowledge and competence
    Part of recurring concern: Inadequate staff competence to provide first aid
  3. Failure to provide the transport vehicle location to emergency services
    Part of recurring concern: Unreliable emergency access arrangements for respondersPart of recurring concern: Unreliable monitoring and emergency response during detainee transportPart of recurring concern: Unreliable multi-agency communication procedures
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.13

  1. Action

    Revise relevant prisoner welfare, vehicle escort, death-in-custody and associated procedures, and align corresponding training materials.

    Stated by Serco Group plcStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.
  2. Action

    Develop and display an OCC emergency flowchart with structured prompt questions at controller desks to standardise alarm-activation responses.

    Stated by Serco Group plcStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.
  3. Action

    Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.

    Stated by Serco Group plcStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.

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 of custody nurses to recognise and describe drug withdrawal signs and symptoms

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to drug and alcohol withdrawal in custody.

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

Inadequate assessment of first aid knowledge and competence

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

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 the transport vehicle location to emergency services

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Unreliable emergency access arrangements for responders; Unreliable monitoring and emergency response during detainee transport; Unreliable multi-agency communication procedures.

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 assess and record the clinical picture before and after prescribing

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unsafe medication prescribing.

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

Delays in custody nurse assessment after detention

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Unreliable medical assessments in police custody.

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

Conflicting guidance on driving a casualty directly to hospital

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

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

Delays in opening a detainee cell and administering emergency first aid

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Failure to provide adequate first aid where emergency assistance may be needed; Unreliable emergency response to patient collapse; Unreliable monitoring and emergency response during detainee transport; Unreliable on-site emergency medical and first-aid response arrangements.

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

Insufficient emphasis on urgent life-preserving first aid measures

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

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 of transport crew to maintain focus on monitoring and assisting a detainee in distress

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Unreliable monitoring and emergency response during detainee transport.

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 operate and provide clear guidance on emergency button procedures

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Unreliable communication and understanding of emergency policies and procedures; Unreliable monitoring and emergency response during detainee transport.

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 of first aid staff to provide complete resuscitation measures

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in resuscitation; Inadequate staff competence to provide first aid; Unreliable monitoring and emergency response during detainee transport; Unreliable resuscitation preparedness and response during cardiac arrest.

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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

Inadequate first aid training for seizures and other emergencies

Wider context from the report

“For the MPS The MPS had already recognised before inquest that, following Mr Williams’ detention, he was not seen by a custody nurse for 23 hours. However, there was another sub optimal element of his care that did not appear to have been identified. The custody nurse who reviewed Mr Williams on two separate occasions in the twelve hours immediately before he attended court, did not on the second occasion take any observations of Mr Williams’ vital signs before (or after) prescribing dihydrocodeine, and did not record any part of Mr Williams’ clinical picture. Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence in court the nurse was unable to describe the signs and symptoms of withdrawal. For Serco By 18.11 hours, the Serco van that was transporting Mr Williams had returned to the court car park entrance and the driver had got out of the cab and into the back of the van. At that point, neither the escort nor the driver opened the door to Mr Williams’ cell to administer first aid - at the very least to relieve his slumped, squashed position to try to deal with any potential airway obstruction. At 18.15 hours when he stopped showing any signs of life, they still did not open his door. They only opened his door at 18.23 hours, removing him from the cell at 18.24 hours, and administering chest compressions at 18.25 hours. The driver did not press the emergency button in the cab to alert the operations control centre of the situation. The Serco crew did call the London Ambulance Service from the van, but were unable to give the postcode of their location. I put it to the Serco driver that the focus of the two Serco crew members seemed to be on talking to the three other prisoners in their cells, on phone calls, in fact on anything except getting Mr Williams out of his cell to see if the crew could help him. The driver agreed. The Serco driver eventually administered chest compressions but could not face giving rescue breaths. He seemed to have forgotten that he had a face guard hanging from his belt. Despite evidence from Serco that they were satisfied with the first aid training that was given to the two officers, the jury found that: - the Serco first aid training was inadequate; - it did not include a video of a seizure; - it did not sufficiently emphasise the urgency of potentially life saving measures such as use of the recovery position; - the Serco assessment of the first aid knowledge and competence of its staff was inadequate; - Serco failed to provide clear guidance on the emergency button procedures; - Serco’s policy appeared to conflict with its training slides about whether staff should or are even permitted to drive a casualty direct to hospital; - Serco gave insufficient emphasis on urgency and the paramount importance of preserving life. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

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

Revise relevant prisoner welfare, vehicle escort, death-in-custody and associated procedures, and align corresponding training materials.

Verbatim wording from the response

“Since the death of Mr Williams we have revised Standard Operating Procedure (SOP) 038 Prisoner Welfare on a Vehicle, SOP 009 Duties of a Vehicle Escort Officer and SOP 047 Death or attempted suicide of a prisoner in custody, to improve the clarity of the steps to be taken where a medical emergency is suspected and I understand copies of the updated SOPs have been provided to you. The changes have also been reflected in other SOPs and training documents to ensure consistency.”

Source location

Response from Serco
Page 1 · response
Published 24 February 2026

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 display an OCC emergency flowchart with structured prompt questions at controller desks to standardise alarm-activation responses.

Verbatim wording from the response

“Serco has also developed a corresponding flowchart for the OCC to reflect that provided to PCOs, together with structured prompt questions to assist OCC controllers in identifying the nature of an emergency and providing appropriate support and direction to PCOs when an incident occurs. A copy of the OCC flowchart has also been provided.”

Source location

Response from Serco
Page 4 · response
Published 24 February 2026

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

Create and require staff to complete a separate online medical-emergency vehicle course covering emergency response, basic life support and related vehicle incidents, with an 80% pass threshold.

Verbatim wording from the response

“In addition, in order to remind staff of the required process and aid their retention of the information provided during the training, in March 2025 we created a new online course on Serco’s LMS. This is a mandatory course for all staff members and includes what to do in an emergency medical incident, basic life support, self-harm incidents, vehicle breakdown, fire and anything deemed a vehicle emergency. The content provides a refresher of the training covered in the ITC course, to reinforce learning and gives additional prominence by being a separate module and links together the concepts that staff have learned during their Highfield First Aid training.”

Source location

Response from Serco
Page 3 · response
Published 24 February 2026

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 display laminated emergency-response flowcharts in escort vehicles to clarify required actions and support consistent responses.

Verbatim wording from the response

“As outlined by Serco’s Head of Professional Standards and Security in his evidence, and to support staff on scene in following the correct process, Serco has developed a flowchart for escort officers following the death of Mr Williams. A copy appears in the Inquest bundle. This has since been incorporated into training, and laminated copies are now displayed within all escort vehicles in a position visible from the escort seat. The intention is that this readily accessible guide will reinforce existing training, clarify the required steps, and support escort officers in responding with confidence and consistency during suspected medical emergencies.”

Source location

Response from Serco
Page 4 · response
Published 24 February 2026

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 recovery-position training adequacy and whether additional or new content should be included in the vehicle-emergencies module.

Verbatim wording from the response

“I note the jury’s findings and that one particular concern related to seizures. As you will note the First Aid slides include a whole section on seizures (slides 118-122). Nevertheless, while seizure recognition and response forms part of existing first-aid training, this finding has prompted Serco to consider whether additional measures are required to strengthen staff confidence and recognition with respect to this issue in practice. Similarly, the findings relating to the use of the recovery position have informed a focused review of how this aspect of training is emphasised and reinforced. That said, once again, you will have noted that there is a whole section on the recovery position within the training slides (slides 49-57). I can also confirm that aspects of both of these sections are included in the assessment of staff when the training is concluded.”

Source location

Response from Serco
Page 2 · response
Published 24 February 2026

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 training with Highfield to explore including a seizure video to improve seizure recognition and response retention.

Verbatim wording from the response

“We are also in the process of reviewing the training provided with the awarding organisation, Highfield, to explore the possibility of including a video of a seizure in the training, to assist staff in identifying a seizure, and in retaining the instruction provided on how to deal with a seizure should they encounter one. A review of the adequacy of the training on the recovery position is also being undertaken to ascertain that any possible improvements are implemented. We are also reviewing whether it would be appropriate to include additional and new training on the recovery position within the training module on vehicle emergencies, to emphasise its importance, and to assist in retention of this very importance aspect of the training.”

Source location

Response from Serco
Page 3 · response
Published 24 February 2026

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 a daily case-finding protocol requiring healthcare practitioners and Grip Sergeants to identify detainees with unmet medical needs.

Verbatim wording from the response

“A new protocol for ‘case finding’ was implemented in November 2025, where the HCP on duty runs through the custody whiteboard with the Grip Sergeant² at around 05:30hrs and checks if there are any detainees who may have unmet medical needs (i.e. they do not have a medical request on CONNECT).”

Source location

Response from Metropolitan Police Service
Page 2 · response
Published 24 February 2026

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 induction and annual refresher training on detainee reassessment, vital signs, and recognition of drug and alcohol withdrawal.

Verbatim wording from the response

“The importance of detainee reassessment (including vital signs) each time there is a clinical review cannot be underestimated, and this is communicated to all HCPs during the induction and annual refresher programme (Immediate Life Support and Professional Development Days).”

Source location

Response from Metropolitan Police Service
Page 2 · response
Published 24 February 2026

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 withdrawal assessment tools and clinical guidelines to display COWS signs and symptoms and support earlier medication for detainees likely to withdraw.

Verbatim wording from the response

“The template for opiate dependency / withdrawal uses the COWS score and the list of signs and symptoms are on the screen. Clinical practice guidelines have been updated to ensure that detainees who are likely to withdraw can be medicated earlier to prevent this.”

Source location

Response from Metropolitan Police Service
Page 3 · response
Published 24 February 2026

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

Audit healthcare practitioners’ clinical documentation and provide feedback, guidance, and additional training where practice or records fall below the required standard.

Verbatim wording from the response

“The Clinical Practice Guidelines followed by HCP in custody highlight this approach to safe care and assessment of detainees. Compliance with guidelines and quality of care delivered is monitored through HCP audits led by the Senior HCPs in each area. Feedback and guidance are provided where the documentation falls below, standards or there are learning needs to provide the standard of care expected from all HCPs working in MPS Custody Suites.”

Source location

Response from Metropolitan Police Service
Page 3 · response
Published 24 February 2026

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

Issue operational reminders requiring custody officers to make timely medical requests for detainees needing assessment.

Verbatim wording from the response

“MPS Custody Teams (Police Sergeant Custody Officer and Designated Detention Officers) complete a risk assessment and identify detainees who require medical assessment. They inform the Healthcare Practitioner (HCP) on duty (Nurse, Doctor or Paramedic). The communication takes the form of a ‘medical request’ on the MPS CONNECT¹ system, in addition, a verbal handover is sometimes included direct to the HCP.”

Source location

Response from Metropolitan Police Service
Page 1 · response
Published 24 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Monitor compliance with case-finding and withdrawal-management protocols and provide feedback to healthcare practitioners who do not follow them.

Verbatim wording from the response

“The MPS are monitoring compliance with protocols regarding ‘case finding’ and withdrawal management. Individual detainee cases are reviewed monthly, and feedback provided to HCPs who are not following clinical practice guidelines and actively completing the discussion with the Grip Sergeant.”

Source location

Response from Metropolitan Police Service
Page 2 · response
Published 24 February 2026

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 SYSTMOne templates requiring vital-sign and other observation recording during initial assessments and clinical reviews.

Verbatim wording from the response

“It is a requirement that the HCP records a full set of vital signs and other observations (e.g. COWS - Clinical Opiate Withdrawal Scale) prior to medication administration. In April 2024, the new SYSTMOne³ templates were created which mandate a set of vital signs (unless the patient refuses) to be recorded at the initial clinical assessment and when reviews take place.”

Source location

Response from Metropolitan Police Service
Page 2 · response
Published 24 February 2026

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.3

  1. 1

    Include cellular-vehicle medical-emergency and first-aid principles in the internal annual refresher through the Learning Management System.

    Stated by Serco Group plcStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.
  2. 2

    Review ITC and annual training provision to identify further opportunities to strengthen first-aid and medical-emergency training.

    Stated by Serco Group plcStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.
  3. 3

    Continue monitoring the effectiveness of implemented custody-care changes and make further improvements where necessary.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2026.

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 cellular-vehicle medical-emergency and first-aid principles in the internal annual refresher through the Learning Management System.

Verbatim wording from the response

“To further improve retention of the instruction provided during training, as confirmed by our Training Partner during his evidence at the Inquest, since March 2026 the training on medical emergencies on a cellular vehicle and first aid principles have been included in the PECS internal annual refresher within Serco’s internal Learning Management System (LMS).”

Source location

Response from Serco
Page 2 · response
Published 24 February 2026

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 ITC and annual training provision to identify further opportunities to strengthen first-aid and medical-emergency training.

Verbatim wording from the response

“In light of the concerns raised, we have undertaken additional steps to review our ITC provision and our annual training programme to ensure that any further opportunities to strengthen our approach are given full and proper consideration.”

Source location

Response from Serco
Page 2 · response
Published 24 February 2026

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 monitoring the effectiveness of implemented custody-care changes and make further improvements where necessary.

Verbatim wording from the response

“Oversight for monitoring clinical standards of care is managed by the Clinical Governance Committee (CGC) which is chaired by the Healthcare Director. Attendance and scrutiny are provided by an external Senior Medical Advisor and Consultant Pharmacist. The CGC review learning from incidents, investigations, and inquests. The Clinical Standards Group informs the CGC of national reviews, changes to guidance and supports local dissemination of learning.”

Source location

Response from Metropolitan Police Service
Page 4 · response
Published 24 February 2026

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

Data last updated 7 September 2026