Lewis Charles Francis · Prevention of Future Deaths report

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Issued 23 Mar 2020•Exeter and Greater Devon

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
13

Named on the report

Responses found
2

Of 13 recipients

Stated actions
2

Described in responses

Recipients and published responses

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 raised2

  1. Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
    Part of recurring concern: Failure to recognise and respond to prisoners’ disability and neurodiversity-related needs
  2. Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
    Part of recurring concern: Unreliable Mental Health Act detention arrangements

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Avon and Somerset Constabulary

    Continue liaising with South West Provider Collaborative partners to help develop the regional Memorandum of Understanding.

  2. Wiltshire Police

    Work with other force areas and the South West Provider Collaborative to develop a Memorandum of Understanding.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Avon and Somerset Constabulary

    Training on autistic prisoners’ needs is directed solely to the Prison Service and does not require a response from the Chief Constable.

    Outside remitThe respondent said that this matter was outside its role or authority.
  2. Wiltshire Police

    Mental health service pathways are outside the Police Service’s remit.

    Outside remitThe respondent said that this matter was outside its role or authority.
  3. Wiltshire Police

    The Police rely on the NHS to provide diversion from limited criminal justice options.

    Redirects 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

Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum

Wider context from the report

“(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum ”

Is this part of a recurring concern?

Yes — Failure to recognise and respond to prisoners’ disability and neurodiversity-related needs.

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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

Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment

Wider context from the report

“(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies. ”

Is this part of a recurring concern?

Yes — Unreliable Mental Health Act detention arrangements.

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

Continue liaising with South West Provider Collaborative partners to help develop the regional Memorandum of Understanding.

Verbatim wording from the response

“Action 2: Further evidence at the inquest suggested that an initiative was underway through the good offices at Avon and Somerset Police to cooperate with the South West Provider Collaborative in the development of the Memorandum of Understanding detailed above. Confirmation on behalf of the named police forces is required that they are willing to work towards the development of such a Memorandum of Understanding.”

Source location

2020-0074-Response-from-Avon-and-Somerset-Police_Redacted
Page 3 · response
Published 9 April 2020

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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

Work with other force areas and the South West Provider Collaborative to develop a Memorandum of Understanding.

Verbatim wording from the response

“It has been identified there is an issue with the pathways within Mental Health Services and not within the Police Service. There are limited options using criminal justice powers and the Police are reliant on the NHS to divert from those. In line with Recommendation 6 (2) of the Coroner’s Regulation 28 report, Wiltshire Police is working with other force areas and the South West Provider Collaborative to develop the proposed Memorandum of Understanding.”

Source location

2020-0074-Response-from-Wiltshire-Police_Redacted
Page 1 · response
Published 9 April 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 on autistic prisoners’ needs is directed solely to the Prison Service and does not require a response from the Chief Constable.

Verbatim wording from the response

“Action 3: It appeared desirable that training with regards to the special needs and susceptibilities of those prisoners within the autistic spectrum be provided for prison officers, support staff and newly appointed prison officers undergoing training both in the form of face to face training and the provision of information through prison intranet systems.”

Source location

2020-0074-Response-from-Avon-and-Somerset-Police_Redacted
Page 3 · response
Published 9 April 2020

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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

Mental health service pathways are outside the Police Service’s remit.

Verbatim wording from the response

“It has been identified there is an issue with the pathways within Mental Health Services and not within the Police Service. There are limited options using criminal justice powers and the Police are reliant on the NHS to divert from those. In line with Recommendation 6 (2) of the Coroner’s Regulation 28 report, Wiltshire Police is working with other force areas and the South West Provider Collaborative to develop the proposed Memorandum of Understanding.”

Source location

2020-0074-Response-from-Wiltshire-Police_Redacted
Page 1 · response
Published 9 April 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 Police rely on the NHS to provide diversion from limited criminal justice options.

Verbatim wording from the response

“It has been identified there is an issue with the pathways within Mental Health Services and not within the Police Service. There are limited options using criminal justice powers and the Police are reliant on the NHS to divert from those. In line with Recommendation 6 (2) of the Coroner’s Regulation 28 report, Wiltshire Police is working with other force areas and the South West Provider Collaborative to develop the proposed Memorandum of Understanding.”

Source location

2020-0074-Response-from-Wiltshire-Police_Redacted
Page 1 · response
Published 9 April 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