PFD report

Imane Bouasbia · Prevention of Future Deaths report

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Issued 12 Nov 2020•East 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
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
7

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.

Concerns raised3

  1. Failure to communicate expressed suicidal intent in the handover
    Part of recurring concern: Failure to reliably escalate suicidal intent information
  2. Failure to complete a self-harm or suicide risk assessment
    Part of recurring concern: Unreliable assessment of suicide and self-harm risk
  3. Failure to provide an adequately expedited and direct response to suicidal thoughts communicated by text
    Part of recurring concern: Unreliable response to suicidal communications by text
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

    Trial the THRIVE+ vulnerability assessment framework to assess and document vulnerability, including suicidal thoughts, and support ongoing risk review and information sharing.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2020.
  2. Action

    Introduce a mandatory enhanced SOIT risk assessment covering suicide, cultural complexities and honour-based violence, with police-indices review, CRIS recording and supervisor escalation.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
  3. Action

    Require SOIT and investigating officers to notify supervisors of concerning victim contact, agree and document a response, and make immediate telephone contact.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.

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 communicate expressed suicidal intent in the handover

Wider context from the report

“a. The failure of Officer 1 to effectively communicate to Officer 2 either verbally or in the CRIS handover, that Ms Bouasbia had expressed the view that she wished to end her own life following the attack she sustained on 1st Jan 2020. ”

Is this part of a recurring concern?

Yes — Failure to reliably escalate suicidal intent 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete a self-harm or suicide risk assessment

Wider context from the report

“b. The failure of Officer 2 to complete a risk assessment of Ms Bouasbia regarding thoughts of self-harm or suicide. ”

Is this part of a recurring concern?

Yes — Unreliable assessment of suicide and self-harm risk.

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 an adequately expedited and direct response to suicidal thoughts communicated by text

Wider context from the report

“c. The police reaction to Ms Bouasbia’s text message at of 3rd January 2020 indicating suicidal thoughts was limited to a non-expedited instruction on a CAD action. The only response to Ms Bouasbia was a further text message rather than a telephone call. ”

Is this part of a recurring concern?

Yes — Unreliable response to suicidal communications by text.

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

Trial the THRIVE+ vulnerability assessment framework to assess and document vulnerability, including suicidal thoughts, and support ongoing risk review and information sharing.

Verbatim wording from the response

“The MPS has introduced a THRIVE+ vulnerability assessment, which is currently being trialled and is anticipated to be rolled out across the organisation in April 2021. It is a set of principles and a framework to assess the type of policing response or investigation required for a particular set of circumstances. THRIVE covers: Threat – Harm – Risk – Investigation – Vulnerability – Engagement + Prevention/Intervention. The framework is a tool that aligns to, and enhances, the National Decision Model and includes the assessment and ongoing review of risk during investigations. It also provides a common language around risk to improve information sharing and decision-making.”

Source location

2020-0234-Response-from-MPS-Redacted.pdf
Page 2 · response
Published 23 December 2020

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 mandatory enhanced SOIT risk assessment covering suicide, cultural complexities and honour-based violence, with police-indices review, CRIS recording and supervisor escalation.

Verbatim wording from the response

“The MPS has introduced a newly enhanced SOIT risk assessment that specifically covers suicide, cultural complexities and concerns around honour-based violence. It also mandates that the SOIT officer review all police indices including the CAD. The new risk assessment is mandatory for all SOIT officers to complete before speaking to a complainant and must be recorded on the CRIS report and brought to the attention of a supervisor if there is anything of concern.”

Source location

2020-0234-Response-from-MPS-Redacted.pdf
Page 3 · response
Published 23 December 2020

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

Require SOIT and investigating officers to notify supervisors of concerning victim contact, agree and document a response, and make immediate telephone contact.

Verbatim wording from the response

“Upon reflection, the SOIT officer accepts that she should have contacted Ms Bouasbia by telephone to speak directly with her. On 21st December 2020, the MPS addressed this by e-mailing all SOIT officers and Public Protection Department managers with the instruction that SOIT and investigating officers must inform a supervising officer if they receive any contact from a victim that causes them concern. A course of action must be agreed and documented on the CRIS report or CAD message and immediate contact made with the victim by telephone. In addition, SOIT officers must ensure their work mobile telephone recorded answer message provides alternative contact numbers should the SOIT officer be off duty or uncontactable and the caller needs reassurance.”

Source location

2020-0234-Response-from-MPS-Redacted.pdf
Page 4 · response
Published 23 December 2020

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

Publish an Operational Notice requiring staff to review police indices before victim contact, communicate identified vulnerabilities, and record them on the CRIS report.

Verbatim wording from the response

“To immediately address the lessons learned prior to the full introduction of THRIVE+, on 18th December 2020 an Operational Notice was published on the MPS internal website informing all staff, including SOIT officers, that they must review all police indices, including the CAD, prior to contact with the victim. Any identified vulnerabilities must be communicated to the investigating officer or their supervisor and noted on the CRIS report. This will also be addressed in future Continuous Professional Development days for all officers, commencing in February 2021 for SOIT officers.”

Source location

2020-0234-Response-from-MPS-Redacted.pdf
Page 2 · response
Published 23 December 2020

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 vulnerability-review requirements in future Continuous Professional Development days for officers, commencing with SOIT officers in February 2021.

    Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 December 2020.
  2. 2

    Require SOIT officers’ work-mobile voicemail messages to provide alternative contact numbers when they are unavailable or off duty.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
  3. 3

    Include suicide awareness and mental-health-crisis engagement training in further SOIT Continuous Professional Development events from 2021.

    Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 December 2020.

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 vulnerability-review requirements in future Continuous Professional Development days for officers, commencing with SOIT officers in February 2021.

Verbatim wording from the response

“To immediately address the lessons learned prior to the full introduction of THRIVE+, on 18th December 2020 an Operational Notice was published on the MPS internal website informing all staff, including SOIT officers, that they must review all police indices, including the CAD, prior to contact with the victim. Any identified vulnerabilities must be communicated to the investigating officer or their supervisor and noted on the CRIS report. This will also be addressed in future Continuous Professional Development days for all officers, commencing in February 2021 for SOIT officers.”

Source location

2020-0234-Response-from-MPS-Redacted.pdf
Page 2 · response
Published 23 December 2020

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

Require SOIT officers’ work-mobile voicemail messages to provide alternative contact numbers when they are unavailable or off duty.

Verbatim wording from the response

“Upon reflection, the SOIT officer accepts that she should have contacted Ms Bouasbia by telephone to speak directly with her. On 21st December 2020, the MPS addressed this by e-mailing all SOIT officers and Public Protection Department managers with the instruction that SOIT and investigating officers must inform a supervising officer if they receive any contact from a victim that causes them concern. A course of action must be agreed and documented on the CRIS report or CAD message and immediate contact made with the victim by telephone. In addition, SOIT officers must ensure their work mobile telephone recorded answer message provides alternative contact numbers should the SOIT officer be off duty or uncontactable and the caller needs reassurance.”

Source location

2020-0234-Response-from-MPS-Redacted.pdf
Page 4 · response
Published 23 December 2020

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Include suicide awareness and mental-health-crisis engagement training in further SOIT Continuous Professional Development events from 2021.

Verbatim wording from the response

“From 2021, further Continuous Professional Development events for SOIT officers will include suicide awareness and a contribution from a Hostage and Crisis negotiator regarding how to more effectively engage with a person in a mental health crisis.”

Source location

2020-0234-Response-from-MPS-Redacted.pdf
Page 4 · response
Published 23 December 2020

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