PFD report

Ms Kerry Aldridge · Prevention of Future Deaths report

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Issued 10 Feb 2020•Inner South 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
5

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. Referral to Crisis Resolution and Home Treatment Teams depending on officers' recognition of urgency
    Part of recurring concern: Unreliable community Home Treatment Team care pathwaysPart of recurring concern: Unreliable mental health referral pathwaysPart of recurring concern: Unreliable urgent mental health referral and assessment pathways
  2. Insufficient mental health training for Sexual Offences Investigation Trained officers
    Part of recurring concern: Insufficient police training for safe recognition and response to mental-health and behaviour-related medical crises
  3. Lack of established links between police Safeguarding teams and NHS mental health teams
    Part of recurring concern: Unreliable operational liaison between police and mental health services for safety-critical risk management
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.2

  1. Action

    Operate a 24-hour mental-health advice and support line for the public, police and ambulance service, staffed by mental-health professionals who can initiate rapid joint assessment.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
  2. Action

    Employ two Metropolitan Police officers within main SLaM hospital sites to provide information, advice and support and liaise with borough safeguarding officers.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 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

Referral to Crisis Resolution and Home Treatment Teams depending on officers' recognition of urgency

Wider context from the report

“During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health. ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support. It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent, which may be a difficult judgment for officers, without professional mental health advice. ”

Is this part of a recurring concern?

Yes — Unreliable community Home Treatment Team care pathways; Unreliable mental health referral pathways; Unreliable urgent mental health referral and assessment pathways.

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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

Insufficient mental health training for Sexual Offences Investigation Trained officers

Wider context from the report

“During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health. ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support. It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent, which may be a difficult judgment for officers, without professional mental health advice. ”

Is this part of a recurring concern?

Yes — Insufficient police training for safe recognition and response to mental-health and behaviour-related medical crises.

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 established links between police Safeguarding teams and NHS mental health teams

Wider context from the report

“During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health. ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support. It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent, which may be a difficult judgment for officers, without professional mental health advice. ”

Is this part of a recurring concern?

Yes — Unreliable operational liaison between police and mental health services for safety-critical risk management.

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

Operate a 24-hour mental-health advice and support line for the public, police and ambulance service, staffed by mental-health professionals who can initiate rapid joint assessment.

Verbatim wording from the response

“South London & Maudsley NHS Trust has, since 2017, worked in partnership with the Metropolitan Police to provide a crisis and assessment service. The service enables mental health staff to work jointly with metropolitan police officers in the provision of early assessment and intervention. ████████, allocates officers to work within the Crisis and Assessment Team. The service also provides a 24 hour advice and support line to the public, 111 service, the police and London Ambulance Service. The advice line is staffed by mental health professionals who will advise officers and instigate rapid joint assessment if required. This joint arrangement between the police and South London & Maudsley NHS Foundation Trust offers a proactive joint response to the concerns that may face police officers who may have limited knowledge in relation to mental illness.”

Source location

2020-0055-Response-from-South-London-and-Maudsley-NHS-Foundation-Redacted
Page 2 · response
Published 18 March 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

Employ two Metropolitan Police officers within main SLaM hospital sites to provide information, advice and support and liaise with borough safeguarding officers.

Verbatim wording from the response

“Mental Health Support to Metropolitan Police Officers ████████ identified that the Metropolitan Police do not have a Safeguarding Adult Team, however, there are safeguarding strands attached to all 12 of the Borough Command Units. South London & Maudsley NHS Trust Foundation Trust employ two full time Metropolitan Police officers who work within our main hospital sites and liaise on a three monthly basis with the borough command safeguarding officers who all have mental health knowledge and experience. The officers employed within our mental health trust would usually act as a conduit for information, advice and support within our service but also their fellow officers in the borough command units”

Source location

2020-0055-Response-from-South-London-and-Maudsley-NHS-Foundation-Redacted
Page 2 · response
Published 18 March 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

    Operate a joint SLaM–Metropolitan Police crisis and assessment service providing early assessment and intervention across four boroughs.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
  2. 2

    Provide NHS mental-health workers embedded in the British Transport Police Vulnerability Unit to support police and coordinate with relevant health and social-care providers about vulnerable individuals.

    Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
  3. 3

    Hold preliminary discussions about commissioning Mental Health First Aid training for Metropolitan Police officers in designated suicide-prevention roles.

    Stated by South London and Maudsley NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 March 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

Operate a joint SLaM–Metropolitan Police crisis and assessment service providing early assessment and intervention across four boroughs.

Verbatim wording from the response

“South London & Maudsley NHS Trust has, since 2017, worked in partnership with the Metropolitan Police to provide a crisis and assessment service. The service enables mental health staff to work jointly with metropolitan police officers in the provision of early assessment and intervention. ████████, allocates officers to work within the Crisis and Assessment Team. The service also provides a 24 hour advice and support line to the public, 111 service, the police and London Ambulance Service. The advice line is staffed by mental health professionals who will advise officers and instigate rapid joint assessment if required. This joint arrangement between the police and South London & Maudsley NHS Foundation Trust offers a proactive joint response to the concerns that may face police officers who may have limited knowledge in relation to mental illness.”

Source location

2020-0055-Response-from-South-London-and-Maudsley-NHS-Foundation-Redacted
Page 2 · response
Published 18 March 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 NHS mental-health workers embedded in the British Transport Police Vulnerability Unit to support police and coordinate with relevant health and social-care providers about vulnerable individuals.

Verbatim wording from the response

“The British Transport Police Vulnerability Unit provides a joint partnership approach with an NHS Provider to actively reduce and prevent railway suicides. The NHS mental health workers are embedded in the team and provide mental health support and advice to British Transport Police and Metropolitan Police on request. The mental health workers will liaise with the police and the individual’s GP, local health, and social care provider to ensure that they are aware of the person’s vulnerability. This service has a wide geographical reach.”

Source location

2020-0055-Response-from-South-London-and-Maudsley-NHS-Foundation-Redacted
Page 3 · response
Published 18 March 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

Hold preliminary discussions about commissioning Mental Health First Aid training for Metropolitan Police officers in designated suicide-prevention roles.

Verbatim wording from the response

“The Provision of further Mental Health Training for Metropolitan Police Officers. In my discussion with ████████ I was informed that all Metropolitan Police officers receive training in mental health and mental capacity issues. We both acknowledged that there may be specific officers who would benefit from more focused training. She specifically identified officers who would have a dedicated role in suicide prevention. I was able to identify that as a mental health trust we are able to provide mental health awareness training to a range of community partners. Our Mental Health Promotion team provide Mental Health First Aid training and there is an option for the Metropolitan Police to commission this training package. Preliminary discussions are due to take place by the end of March 2020.”

Source location

2020-0055-Response-from-South-London-and-Maudsley-NHS-Foundation-Redacted
Page 1 · response
Published 18 March 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