PFD report

Nicholas LEGER · Prevention of Future Deaths report

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Issued 19 Jun 2023•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.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
5

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Report evidence summary

Concerns raised2

  1. Failure to proactively seek information about the mental health of people being charged by PCR
  2. Lack of a formal mental health and suicide or self-harm risk assessment at PCR delivery
    Part of recurring concern: Inadequate mental health risk assessmentPart of recurring concern: Unreliable assessment of suicide and self-harm risk
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.1

  1. Action

    Develop a policy requiring supervised, documented risk assessments before issuing PCRs to recordable-offence suspects, including risk management and decisions on personal service.

    Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 8 September 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Current pre-charge bail arrangements and guidance provide further opportunities to assess suicide risk, so additional assessment at postal charge requisition is not identified.

    Stated by College of PolicingExisting 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

Failure to proactively seek information about the mental health of people being charged by PCR

Wider context from the report

“• That whether an individual is, exceptionally, considered to be in a high-risk category (such as to cause a PCR to be delivered in person) is reliant on information about their mental health coming to the attention of the OIC. There is no formal requirement for the OIC proactively to seek this information. • That there is no formal process for assessing an individual’s mental health and/or risk of suicide or self-harm at the time of delivery of a PCR. It is important to note the following: • At the point of charge, nothing has been proven against the individual concerned. They face an allegation, and are innocent if and until proven guilty to the criminal standard. • Many people are RUI’d. As such, PCR is now routinely used to bring most criminal charges. • Individuals who have been RUI’d can remain with this status for long periods of time (months or years) before a decision is made whether or not to charge them. • Whilst there are formal procedures to assess an individual’s mental health and risk of self-harm or suicide when they attend a police station for interview, once they have left the police station there are no such formal procedures (as above), notwithstanding the potential for a substantial period to elapse between the time they last attended a police station and the time that they are charged. • Being charged with any criminal offence, especially one which carries the potential for a custodial sentence, can, self-evidently, have a significant deleterious effect on an individual’s mental health. It appears to me that, in the absence of a formal mechanism to assess, at the time of being charged, an individual’s mental health and risk of suicide or self-harm, there is an obvious risk of individuals in the future taking their own lives as a result of being charged by way of a PCR (potentially following a lengthy period of having been RUI’d and potentially months or years since there was last any consideration by the police of their mental health and risk of suicide or self-harm). ”

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 a formal mental health and suicide or self-harm risk assessment at PCR delivery

Wider context from the report

“• That whether an individual is, exceptionally, considered to be in a high-risk category (such as to cause a PCR to be delivered in person) is reliant on information about their mental health coming to the attention of the OIC. There is no formal requirement for the OIC proactively to seek this information. • That there is no formal process for assessing an individual’s mental health and/or risk of suicide or self-harm at the time of delivery of a PCR. It is important to note the following: • At the point of charge, nothing has been proven against the individual concerned. They face an allegation, and are innocent if and until proven guilty to the criminal standard. • Many people are RUI’d. As such, PCR is now routinely used to bring most criminal charges. • Individuals who have been RUI’d can remain with this status for long periods of time (months or years) before a decision is made whether or not to charge them. • Whilst there are formal procedures to assess an individual’s mental health and risk of self-harm or suicide when they attend a police station for interview, once they have left the police station there are no such formal procedures (as above), notwithstanding the potential for a substantial period to elapse between the time they last attended a police station and the time that they are charged. • Being charged with any criminal offence, especially one which carries the potential for a custodial sentence, can, self-evidently, have a significant deleterious effect on an individual’s mental health. It appears to me that, in the absence of a formal mechanism to assess, at the time of being charged, an individual’s mental health and risk of suicide or self-harm, there is an obvious risk of individuals in the future taking their own lives as a result of being charged by way of a PCR (potentially following a lengthy period of having been RUI’d and potentially months or years since there was last any consideration by the police of their mental health and risk of suicide or self-harm). ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment; Unreliable assessment of suicide and self-harm risk.

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

Develop a policy requiring supervised, documented risk assessments before issuing PCRs to recordable-offence suspects, including risk management and decisions on personal service.

Verbatim wording from the response

“Following this Prevention of Future Deaths report, a proposal will be made for the implementation of a new policy requiring a risk assessment to be completed by the OIC, no earlier than fourteen days prior to issuing the PCR. This would build on the intelligence already gathered through the relationship between the OIC and the suspect, including any risk assessments completed at the time of their arrest/detention/voluntary interview under caution and by the Custody Sergeant upon release from custody. This would then form the basis of a decision as to whether to post or serve the PCR in person.”

Source location

Response from Metropolitan Police
Page 3 · response
Published 8 September 2023

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

Current pre-charge bail arrangements and guidance provide further opportunities to assess suicide risk, so additional assessment at postal charge requisition is not identified.

Verbatim wording from the response

“Conclusion It is unlikely that someone released on bail for sexual offences would now revert to RUI. This means that they would be recalled to custody for charge, where a pre-release risk assessment can be completed, for which there is full guidance. There is specific custody training aimed at reducing the risks of post detention suicides.”

Source location

Response from College of Policing
Page 4 · response
Published 8 September 2023

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.4

  1. 1

    Provide guidance and a dedicated module for assessing risks associated with people released from custody, including those under investigation for child sexual abuse material.

    Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 8 September 2023.
  2. 2

    Incorporate learning from the incident into College training and guidance.

    Stated by College of PolicingStated plannedThe respondent said that this action was planned when they made their response on 8 September 2023.
  3. 3

    Provide specific custody training aimed at reducing post-detention suicide risks.

    Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 8 September 2023.
  4. 4

    Produce and disseminate statutory pre-charge bail guidance with supporting e-learning, communications and implementation knowledge products.

    Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 8 September 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Investigators are responsible for onward suspect management and welfare assessment, with supervisory oversight.

    Stated by College of PolicingRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    The proposed PCR risk-assessment policy will be restricted to recordable offences because of the volume of work required.

    Stated by Metropolitan Police ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 guidance and a dedicated module for assessing risks associated with people released from custody, including those under investigation for child sexual abuse material.

Verbatim wording from the response

“There is specific College guidance on risk assessments for those released from custody, including a specific module on the higher risks associated with those under investigation for possession of child sexual abuse material – the risks for this cohort of detainees are higher with them comprising around half of all post release suicides.”

Source location

Response from College of Policing
Page 4 · response
Published 8 September 2023

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

Incorporate learning from the incident into College training and guidance.

Verbatim wording from the response

“Thank you for your letter dated 8th June 2023 regarding the death of Mr Nicholas Leger which occurred on the 20th February 2023. We were saddened to hear of the circumstances and the loss felt by Mr Leger’s family and friends. These cases are always tragic and it is incumbent on all of us to ensure that lessons are learned. We would like to assure you that we take the recommendations in your report extremely seriously and will ensure that the learning from this incident will be incorporated into our training and guidance. Thank you for your work and for identifying matters of concern.”

Source location

Response from College of Policing
Page 1 · response
Published 8 September 2023

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 specific custody training aimed at reducing post-detention suicide risks.

Verbatim wording from the response

“Conclusion It is unlikely that someone released on bail for sexual offences would now revert to RUI. This means that they would be recalled to custody for charge, where a pre-release risk assessment can be completed, for which there is full guidance. There is specific custody training aimed at reducing the risks of post detention suicides.”

Source location

Response from College of Policing
Page 4 · response
Published 8 September 2023

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

Produce and disseminate statutory pre-charge bail guidance with supporting e-learning, communications and implementation knowledge products.

Verbatim wording from the response

“The College of Policing produced Statutory Guidance which supports the legislative amendments. The Statutory Guidance can be found here. The following guidance is particularly relevant based on the information provided.”

Source location

Response from College of Policing
Page 3 · response
Published 8 September 2023

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

Investigators are responsible for onward suspect management and welfare assessment, with supervisory oversight.

Verbatim wording from the response

“Onward suspect management and welfare assessment will be the responsibility of the investigator, with oversight from their supervisor. There should be a clear plan in place, linked with the likely progress of the investigation.”

Source location

Response from College of Policing
Page 3 · response
Published 8 September 2023

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 proposed PCR risk-assessment policy will be restricted to recordable offences because of the volume of work required.

Verbatim wording from the response

“Following this Prevention of Future Deaths report, a proposal will be made for the implementation of a new policy requiring a risk assessment to be completed by the OIC, no earlier than fourteen days prior to issuing the PCR. This would build on the intelligence already gathered through the relationship between the OIC and the suspect, including any risk assessments completed at the time of their arrest/detention/voluntary interview under caution and by the Custody Sergeant upon release from custody. This would then form the basis of a decision as to whether to post or serve the PCR in person.”

Source location

Response from Metropolitan Police
Page 3 · response
Published 8 September 2023

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
2/2

Data last updated 7 September 2026