PFD report

Olawale ADELUSI · Prevention of Future Deaths report

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Issued 22 Jul 2016•West 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.

View original report
Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised1

  1. Absence of an effective system for transmitting information relevant to detained persons’ self-harm risk or mental health assessment
    Part of recurring concern: Unreliable custody handovers
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

    Review initial-course training for new custody staff on the Prisoner Escort Record process.

    Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 22 July 2016.
  2. Action

    Review Prisoner Escort Record guidance provided through the Custody Toolkit.

    Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 22 July 2016.
  3. Action

    Develop a quality-assurance monitoring system to assess the quality of Prisoner Escort Record completion.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 22 July 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    NOMS owns the PER design and protocols, while national solutions require multi-agency action driven by NOMS and supported by other stakeholders.

    Stated by Metropolitan Police ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Absence of an effective system for transmitting information relevant to detained persons’ self-harm risk or mental health assessment

Wider context from the report

“The absence of an effective system to ensure appropriate transmission of all information relevant to assessment of the (i) risk of self-harm or (ii) mental health, of detained persons BASIS OF CONCERN : – Whilst in police custody Mr Adelusi had been taken to hospital where he remained under police guard. Police Officers kept a Hospital Guard Supervision Log covering a 6.5 hour period and it recorded that Mr Adelusi had: on several occasions deliberately thrown himself from bed to floor in such a way as to cause concern for his safety; been observed crying on several occasions; been observed banging his head on the floor; spoken of a plot to kill him and of his son having been killed by police; and tried to bite the clinical drip pipe. On return to the police station, Mr Adelusi was kept under constant supervision and a Constant Supervision Log was maintained by officers over a period of 23 hours in which they recorded that he had been observed: "pushing his thumbs down on to his neck" until he had to be told to desist; urinating in the corner of his cell; whispering to the Forensic Medical Examiner "they've killed him"; again crying and saying "you've killed him"; trying to strangle himself with a vest; kneeling with his head against the floor, crying; and accusing officers of killing his children and asking to see their bodies. Neither the logs, nor the information recorded in them, was included in Mr Adelusi's Personal Escort Record; nor was that information otherwise transmitted in writing to those responsible for his detention after removal from the police station. Whilst there was evidence of a verbal handover to Escort Personnel, at which some of this information may have been mentioned, no record was made of that conversation. ”

Is this part of a recurring concern?

Yes — Unreliable custody handovers.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review initial-course training for new custody staff on the Prisoner Escort Record process.

Verbatim wording from the response

“For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:”

Source location

Olawale-ADELUSIR-1
Page 4 · response
Published 22 July 2016

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 Prisoner Escort Record guidance provided through the Custody Toolkit.

Verbatim wording from the response

“For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:”

Source location

Olawale-ADELUSIR-1
Page 4 · response
Published 22 July 2016

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 a quality-assurance monitoring system to assess the quality of Prisoner Escort Record completion.

Verbatim wording from the response

“For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:”

Source location

Olawale-ADELUSIR-1
Page 4 · response
Published 22 July 2016

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 the Prisoner Escort Record process in the next custody staff training cycle.

Verbatim wording from the response

“For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:”

Source location

Olawale-ADELUSIR-1
Page 4 · response
Published 22 July 2016

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

NOMS owns the PER design and protocols, while national solutions require multi-agency action driven by NOMS and supported by other stakeholders.

Verbatim wording from the response

“The design of the form and protocols for its use are the responsibility of NOMS, though the current form and any future versions will be agreed in discussion and agreement with all the stakeholders who use the form. The current PER was first issued in 2009 and its use adopted across all agencies during 2010. The PER is currently used by the police, NOMS, Secure Hospital Estate, the Home Office (for immigration detainees) and the escort contractors. The Metropolitan Police are therefore merely one of a number of users of the system, and whilst we can make suggestions and influence the future development of the system from this position, such changes would need to be made in agreement with all the other participating agencies, and with NOMS.”

Source location

Olawale-ADELUSIR-1
Page 2 · response
Published 22 July 2016

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 MPS cannot unilaterally change the PER system because changes require agreement from NOMS and all participating agencies.

Verbatim wording from the response

“The design of the form and protocols for its use are the responsibility of NOMS, though the current form and any future versions will be agreed in discussion and agreement with all the stakeholders who use the form. The current PER was first issued in 2009 and its use adopted across all agencies during 2010. The PER is currently used by the police, NOMS, Secure Hospital Estate, the Home Office (for immigration detainees) and the escort contractors. The Metropolitan Police are therefore merely one of a number of users of the system, and whilst we can make suggestions and influence the future development of the system from this position, such changes would need to be made in agreement with all the other participating agencies, and with NOMS.”

Source location

Olawale-ADELUSIR-1
Page 2 · response
Published 22 July 2016

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