PFD report

Faiza Hassan AHMED · Prevention of Future Deaths report

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Issued 20 Jan 2016•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
0

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 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

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

No concerns are currently included for this report.

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.16

  1. 1

    Implement sector operational management structures with Stakeholder Engagement Managers liaising with relevant stakeholders on wider concerns.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2020.
  2. 2

    Publish a clinical update reinforcing capacity assessment.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2020.
  3. 3

    Expand control-room mental-health nurse capacity to provide patient assessments, crew advice and referrals to appropriate mental-health pathways.

    Stated by London Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2020.
  4. 4

    Complete reflective learning for the crew involved in the incident.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2020.
  5. 5

    Implement sector Quality Assurance and Governance Manager roles to process and develop alternative care plans for Category 4 patients.

    Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2020.
  6. 6

    Invest in training so first responders and investigators have the tools required to perform their roles to the highest standard.

    Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2020.
  7. 7

    Improve fast-time deployment intelligence by reviewing procedures, briefing call-handling staff and providing actionable intelligence to responding officers before arrival.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 15 July 2020.
  8. 8

    Review the management and sharing of information from call handlers to response officers and between police and partner agencies.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2020.
  9. 9

    Review protocols governing deployment of Sexual Offence Investigation Trained specialists.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2020.
  10. 10

    Implement the Vulnerability Assessment Framework across frontline policing and provide workforce training on recognising and responding to vulnerability.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 15 July 2020.
  11. 11

    Increase Sapphire teams’ investigative capacity and capability through a future structure and resourcing model designed for increased reporting levels.

    Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2020.
  12. 12

    Use internal communication channels to keep staff informed of changes to relevant guidance and processes.

    Stated by Department for Work and PensionsStated completedThe respondent said that this action was complete when they made their response on 15 July 2020.
  13. 13

    Implement Six Point Plan arrangements for responding to customer declarations of suicidal intent or self-harm across DWP customer interactions.

    Stated by Department for Work and PensionsStated completedThe respondent said that this action was complete when they made their response on 15 July 2020.
  14. 14

    Provide staff guidance, formal training and regular knowledge refreshers on responding safely to suicidal intent, self-harm and vulnerability.

    Stated by Department for Work and PensionsStated completedThe respondent said that this action was complete when they made their response on 15 July 2020.
  15. 15

    Review local, national and departmental policies, procedures and guidance regularly to identify improvements and ensure they meet their objectives.

    Stated by Department for Work and PensionsStated completedThe respondent said that this action was complete when they made their response on 15 July 2020.
  16. 16

    Issue all DWP staff a reminder about guidance concerning suicidal ideation.

    Stated by Department for Work and PensionsStated plannedThe respondent said that this action was planned when they made their response on 15 July 2020.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.6

  1. 1

    The crew received adequate information about the patient’s suicidal intent despite one uncommunicated call-log detail.

    Stated by London Ambulance Service NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Emergency response times and search limitations prevent provision of complete intelligence to first responders before arrival.

    Stated by Metropolitan Police ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. 3

    It is unclear whether sharing the previous sexual-assault report would have changed the police or ambulance response.

    Stated by Metropolitan Police ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  4. 4

    Police could not lawfully force a person with sufficient capacity to engage or intervene absent an immediate need for care and control.

    Stated by Metropolitan Police ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  5. 5

    Training and technology can maximise rapport-building, but rapport cannot be guaranteed with every victim in all circumstances.

    Stated by Metropolitan Police ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  6. 6

    No opportunity to engage other organisations was missed because staff followed the agreed suicide and self-harm procedures based on available evidence.

    Stated by Department for Work and PensionsDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 sector operational management structures with Stakeholder Engagement Managers liaising with relevant stakeholders on wider concerns.

Verbatim wording from the response

“On 7 September 2015 a new Operational Management Structure was implemented which introduced a Stakeholder Engagement Manager role for each sector of London. This role consists of liaising closely with other stakeholders, including the Metropolitan Police to discuss issues of wider concern for that particular Borough. Issues of concern can include frequent callers, community events, and resident issues.”

Source location

2016-0600-Response-from-the-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 15 July 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 a clinical update reinforcing capacity assessment.

Verbatim wording from the response

“Since the incident the crew involved undertook Reflective Learning and a Clinical Update was published in April 2015 reinforcing the assessment of Capacity. This was disclosed at the Inquest in the evidence about the Serious Incident Report and the actions arising from the incident.”

Source location

2016-0600-Response-from-the-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 15 July 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

Expand control-room mental-health nurse capacity to provide patient assessments, crew advice and referrals to appropriate mental-health pathways.

Verbatim wording from the response

“Furthermore, the LAS have allocated funding for Mental Health Nurses to work in the control room. Currently the Trust has filled 4.5 posts and has an on-going recruitment to fill a further 1.5 posts within the next 6 months. Their role is to provide a telephone assessment from speaking with the patients and advice directly to crews on scene. In addition the Mental Health nurses are skilled at referring patients directly to crisis teams or appropriate pathways for patients with mental health needs.”

Source location

2016-0600-Response-from-the-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 15 July 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

Complete reflective learning for the crew involved in the incident.

Verbatim wording from the response

“Since the incident the crew involved undertook Reflective Learning and a Clinical Update was published in April 2015 reinforcing the assessment of Capacity. This was disclosed at the Inquest in the evidence about the Serious Incident Report and the actions arising from the incident.”

Source location

2016-0600-Response-from-the-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 15 July 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

Implement sector Quality Assurance and Governance Manager roles to process and develop alternative care plans for Category 4 patients.

Verbatim wording from the response

“In addition, a new role of Quality Assurance & Governance Manager has been implemented in every sector. Part of this role is to process and develop specific Care Plans for Category 4 patients. These patients are those with an underlying medical condition and in need of a different/alternative care plan than the wider public.”

Source location

2016-0600-Response-from-the-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 15 July 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

Invest in training so first responders and investigators have the tools required to perform their roles to the highest standard.

Verbatim wording from the response

“Commissioner Sir Bernard Hogan-Howe acknowledges that these pressures have required a reconsideration of the police response, including within the ‘Sapphire’ units, and he has committed to providing the resources to make this possible:”

Source location

2016-0600-Response-from-the-Metropolitan-Police_Redacted.pdf
Page 13 · response
Published 15 July 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

Improve fast-time deployment intelligence by reviewing procedures, briefing call-handling staff and providing actionable intelligence to responding officers before arrival.

Verbatim wording from the response

“In 2015 this process was reviewed as part of the ‘New Way of Working’ and was cemented within that document. Between August and October 2015 1300 Met CC staff were briefed on the provision of ‘deployment intelligence’, and as a result, in excess of 40,000 more deployments have since been made where officers have received actionable intelligence before Time Of Arrival on scene. This is an improvement in the timeliness of our provision of deployment intelligence, but it is important to understand the constraints under which this ‘fast time’ intelligence research must take place.”

Source location

2016-0600-Response-from-the-Metropolitan-Police_Redacted.pdf
Page 11 · response
Published 15 July 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

Review the management and sharing of information from call handlers to response officers and between police and partner agencies.

Verbatim wording from the response

“• Reviewing the management and sharing of information from our call handlers to our response officers; as in the ‘New Way of Working’ discussed above; and between the MPS and our partner agencies, via such initiatives as the MPS/LAS Memorandum of Understanding, and other multi-agency fora.”

Source location

2016-0600-Response-from-the-Metropolitan-Police_Redacted.pdf
Page 13 · response
Published 15 July 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

Review protocols governing deployment of Sexual Offence Investigation Trained specialists.

Verbatim wording from the response

“• Reviewing our protocols for the deployment of Sexual Offence trained specialists”

Source location

2016-0600-Response-from-the-Metropolitan-Police_Redacted.pdf
Page 13 · response
Published 15 July 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

Implement the Vulnerability Assessment Framework across frontline policing and provide workforce training on recognising and responding to vulnerability.

Verbatim wording from the response

“Firstly, it is important to recognise that the totality of information available to police in dealing with vulnerable persons is greater now than it was in 2014. A key part of this is the Vulnerability Assessment Framework (VAF), introduced to the MPS in January 2014, and rolled out across the following year to the whole frontline officer workforce through regular training days.”

Source location

2016-0600-Response-from-the-Metropolitan-Police_Redacted.pdf
Page 9 · response
Published 15 July 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

Increase Sapphire teams’ investigative capacity and capability through a future structure and resourcing model designed for increased reporting levels.

Verbatim wording from the response

“Commissioner Sir Bernard Hogan-Howe acknowledges that these pressures have required a reconsideration of the police response, including within the ‘Sapphire’ units, and he has committed to providing the resources to make this possible:”

Source location

2016-0600-Response-from-the-Metropolitan-Police_Redacted.pdf
Page 13 · response
Published 15 July 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

Use internal communication channels to keep staff informed of changes to relevant guidance and processes.

Verbatim wording from the response

“At a national level, the policy and guidance are reviewed regularly to ensure they continue to meet their objectives and for continuous improvement purposes. DWP uses a variety of internal communication channels to ensure staff remain aware of all changes to its guidance and processes as they occur.”

Source location

2016-0600-Response-from-the-Department-of-work-and-Pensions_Redacted.pdf
Page 4 · response
Published 15 July 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

Implement Six Point Plan arrangements for responding to customer declarations of suicidal intent or self-harm across DWP customer interactions.

Verbatim wording from the response

“The Department takes seriously any declarations of intention to attempt suicide or self harm that are made by its customers and has put in place a well-designed process that seeks to ensure appropriate action is taken. There is a clear, detailed six point action plan that staff must follow if a customer declares an intention to kill or harm themselves. In addition, DWP provides both guidance and training to help staff deal with these incidents. The policy, procedures and guidance are reviewed regularly to ensure that they continue to meet their objectives and to identify areas for improvement.”

Source location

2016-0600-Response-from-the-Department-of-work-and-Pensions_Redacted.pdf
Page 1 · response
Published 15 July 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

Provide staff guidance, formal training and regular knowledge refreshers on responding safely to suicidal intent, self-harm and vulnerability.

Verbatim wording from the response

“The Department takes seriously any declarations of intention to attempt suicide or self harm that are made by its customers and has put in place a well-designed process that seeks to ensure appropriate action is taken. There is a clear, detailed six point action plan that staff must follow if a customer declares an intention to kill or harm themselves. In addition, DWP provides both guidance and training to help staff deal with these incidents. The policy, procedures and guidance are reviewed regularly to ensure that they continue to meet their objectives and to identify areas for improvement.”

Source location

2016-0600-Response-from-the-Department-of-work-and-Pensions_Redacted.pdf
Page 1 · response
Published 15 July 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

Review local, national and departmental policies, procedures and guidance regularly to identify improvements and ensure they meet their objectives.

Verbatim wording from the response

“The Department takes seriously any declarations of intention to attempt suicide or self harm that are made by its customers and has put in place a well-designed process that seeks to ensure appropriate action is taken. There is a clear, detailed six point action plan that staff must follow if a customer declares an intention to kill or harm themselves. In addition, DWP provides both guidance and training to help staff deal with these incidents. The policy, procedures and guidance are reviewed regularly to ensure that they continue to meet their objectives and to identify areas for improvement.”

Source location

2016-0600-Response-from-the-Department-of-work-and-Pensions_Redacted.pdf
Page 1 · response
Published 15 July 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

Issue all DWP staff a reminder about guidance concerning suicidal ideation.

Verbatim wording from the response

“Therefore as part of this continued review, we will now be taking the opportunity to issue a reminder to all DWP staff about the guidance related to suicidal ideation that has been described in this report.”

Source location

2016-0600-Response-from-the-Department-of-work-and-Pensions_Redacted.pdf
Page 4 · response
Published 15 July 2020

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 crew received adequate information about the patient’s suicidal intent despite one uncommunicated call-log detail.

Verbatim wording from the response

“The Trust can confirm the Emergency Medical Dispatcher (EMD) noted on the call log that the patient “wanted to die”, thereby indicating her suicidal intent, but this particular piece of information was not conveyed to the crew. Unfortunately, this was an individual error and all EMDs are trained to tag and pass pertinent information to the attending crew. However, the information which the crew were given was “Psychiatric/Abnormal behaviour/Suicide attempt; Trying to slit wrists; Armed with a weapon-glass,” therefore the crew were given adequate information of Faiza’s suicidal intent.”

Source location

2016-0600-Response-from-the-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 15 July 2020

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

Emergency response times and search limitations prevent provision of complete intelligence to first responders before arrival.

Verbatim wording from the response

“venue, victims, suspects etcetera is to read each of potentially very many information reports, Police National Computer records, Merlin entries, Crime reports, custody records and so on in detail. Since each one of these record types could run to many pages, this task is clearly not capable of being undertaken within the minutes or seconds available to assist our first responders.”

Source location

2016-0600-Response-from-the-Metropolitan-Police_Redacted.pdf
Page 12 · response
Published 15 July 2020

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

It is unclear whether sharing the previous sexual-assault report would have changed the police or ambulance response.

Verbatim wording from the response

“It is acknowledged that no officer present claims to have briefed the LAS crew regarding the details of the alleged sexual assault call from the previous day [para 4.13.21]. In fact, the only officers capable of doing this would have been PC ████████ and her colleague, as at this point the uniformed response officers were themselves unaware of the earlier call. This was arguably regrettable, as knowledge of the circumstances may have gone some way to explaining Ms Ahmed’s earlier call and attitude toward the proffered assistance on this second occasion. It is by no means clear however what difference, if any, this knowledge would have made to the practical options open on this second visit to either police or ambulance personnel.”

Source location

2016-0600-Response-from-the-Metropolitan-Police_Redacted.pdf
Page 7 · response
Published 15 July 2020

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Police could not lawfully force a person with sufficient capacity to engage or intervene absent an immediate need for care and control.

Verbatim wording from the response

“More recently the Mental Capacity Act 2005 gives officers some limited protections from liability should an individual officer, at the time of an incident, feel that ‘restraint’ (which encompasses both physical restraint and, for example, preventing a person leaving a particular place) is the only option to prevent a person from committing an immediate civil wrong or criminal act; but otherwise expressly confers no powers on police to deprive a person of their liberty, as the decision in Sessay v South London and Maudsley NHS Trust and Commissioner of Police for the Metropolis ([2011] EWHC 2617 (QB)) made clear.”

Source location

2016-0600-Response-from-the-Metropolitan-Police_Redacted.pdf
Page 8 · response
Published 15 July 2020

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

Training and technology can maximise rapport-building, but rapport cannot be guaranteed with every victim in all circumstances.

Verbatim wording from the response

“We must acknowledge however that even with an enhanced fast time intelligence capability, and our improved training of frontline officers in dealing with vulnerable persons, we are still bound by law to respect the autonomy of any innocent member of the public demonstrating sufficient capacity to decide not to engage with us, even if they have previously sought our aid. Through training and technology we can maximise the likelihood that rapport will be established and a working alliance established, and even, where other sources of evidence exist, and it is in the public interest to do so, pursue ‘victimless’ prosecutions. But we can never guarantee that rapport will be established with all victims in all circumstances.”

Source location

2016-0600-Response-from-the-Metropolitan-Police_Redacted.pdf
Page 14 · response
Published 15 July 2020

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

No opportunity to engage other organisations was missed because staff followed the agreed suicide and self-harm procedures based on available evidence.

Verbatim wording from the response

“Nevertheless, in this case we feel that the Departmental process around managing the threat of suicide and/or self harm were followed both diligently and correctly. In recognition of the risk, DWP staff took the necessary steps to invoke the agreed processes that would manage the risk appropriately. Importantly this action was based on the evidence that staff were presented with. It is not our view that any opportunity to engage with any other organisations was missed.”

Source location

2016-0600-Response-from-the-Department-of-work-and-Pensions_Redacted.pdf
Page 4 · response
Published 15 July 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