PFD report

Matthew Brierley · Prevention of Future Deaths report

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Issued 8 Jan 2025•Cumbria

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
4

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
8

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 raised4

  1. Failure to provide proactive contact and support to men at elevated suicide risk
    Part of recurring concern: Failure to reliably follow up identified mental-health safety concernsPart of recurring concern: Unreliable interim mental health support during care transitions
  2. Markedly elevated suicide risk among men in comparable circumstances
  3. Failure to undertake detailed individual risk assessment when applying bail conditions
    Part of recurring concern: Failure to individualise bail conditions for vulnerable defendants
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.5

  1. Action

    Share the prevention report and recommendations with UK custody leads to strengthen suicide-risk consideration in investigative strategies and digital-device triage.

    Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
  2. Action

    Request qualitative information from relevant police forces and analyse returned data to identify post-release suicide-risk factors.

    Stated by National Police Chiefs’ CouncilStated plannedThe respondent said that this action was planned when they made their response on 13 January 2025.
  3. Action

    Complete research reviewing five years of post-custody suicide data to identify commonalities and inform prevention.

    Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    Investigating officers must apply individual circumstances to risk assessments and supervisors must ratify disposal decisions.

    Stated by National Police Chiefs’ CouncilRedirects 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

Failure to provide proactive contact and support to men at elevated suicide risk

Wider context from the report

“(3) Police acknowledged the increased risk and completed a standard assessment form when Matthew was released - he denied any risk and also declined referral to Liaison and Diversion service. A Family Contact Officer was also appointed but the onus remained on Matthew to seek help and there was no proactive contact which might have been helpful as men in Matthew's situation are less likely to seek help due to feelings of shame and embarrassment. ”

Is this part of a recurring concern?

Yes — Failure to reliably follow up identified mental-health safety concerns; Unreliable interim mental health support during care transitions.

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

Markedly elevated suicide risk among men in comparable circumstances

Wider context from the report

“(1) It is recognized that men in Matthew's circumstances are at a markedly elevated risk of suicide. Several papers refer to this - I found Kothari et al (Journal of Forensic and Legal Medicine, July 2021) particularly informative. They quote 3.2% of those arrested in operation Notarise committing suicide and explore reasons why this group is particularly vulnerable. ”

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

Failure to undertake detailed individual risk assessment when applying bail conditions

Wider context from the report

“(2) I was told that when released on bail Matthew was informed that examination of devices and a decision in his case might take up to 18 months. Being suspended from work and unable to live at home removed normality and stability from Matthew and likely impaired his ability to cope with his situation. The length of time taken to reach a decision seems excessive, prolonging the time Matthew would be at risk. I was told devices can be "triaged" within a matter of days or more quickly, surely ceases such as this should be dealt with more expeditiously? It seems that "standard" bail conditions are applied but I am not aware of any suggestion of a specific risk to Matthew's stepdaughter, might a more detailed individual assessment of risk be helpful? I should record that Matthew's phone was examined after his death and that images found were not of a grade that would have led to a prosecution. ”

Is this part of a recurring concern?

Yes — Failure to individualise bail conditions for vulnerable defendants.

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

Delays in examination of devices and case decisions prolonging risk during bail

Wider context from the report

“(2) I was told that when released on bail Matthew was informed that examination of devices and a decision in his case might take up to 18 months. Being suspended from work and unable to live at home removed normality and stability from Matthew and likely impaired his ability to cope with his situation. The length of time taken to reach a decision seems excessive, prolonging the time Matthew would be at risk. I was told devices can be "triaged" within a matter of days or more quickly, surely ceases such as this should be dealt with more expeditiously? It seems that "standard" bail conditions are applied but I am not aware of any suggestion of a specific risk to Matthew's stepdaughter, might a more detailed individual assessment of risk be helpful? I should record that Matthew's phone was examined after his death and that images found were not of a grade that would have led to a prosecution. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Share the prevention report and recommendations with UK custody leads to strengthen suicide-risk consideration in investigative strategies and digital-device triage.

Verbatim wording from the response

“I have shared a copy of this prevention of future deaths report with all custody leads within the UK, with a recommendation to ensure that the risk of suicide within cohorts such as Matthew’s, are included within the investigative strategies and particularly the triage of digital devices, and that risk assessments are tailored to the individual circumstances of the investigation.”

Source location

Response from National Police Chief's Council
Page 3 · response
Published 13 January 2025

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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

Request qualitative information from relevant police forces and analyse returned data to identify post-release suicide-risk factors.

Verbatim wording from the response

“The next phase of the research discussed today, will be for each force from which one of those deaths occurred, to answer further qualitative questions to identify commonalities. At present, we do not ask the key questions that identify the impact upon somebody’s life, following their arrest. Questions proposed include subjects such as:”

Source location

Response from National Police Chief's Council
Page 2 · response
Published 13 January 2025

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 research reviewing five years of post-custody suicide data to identify commonalities and inform prevention.

Verbatim wording from the response

“1 and 3 – A lot of research has been undertaken already, to try and identify any commonalities between instances of post custody suicide. The objective is to establish a post release risk assessment process that will identify those most at risk, and initiate a process to mitigate that risk, with further support such as a mandatory referral to support agencies. The current research has identified from a review of five years of data from the IOPC:”

Source location

Response from National Police Chief's Council
Page 1 · response
Published 13 January 2025

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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

Introduce an evidence-led post-release risk assessment process with mandatory referrals to partner support agencies for identified high-risk individuals.

Verbatim wording from the response

“1 and 3 – A lot of research has been undertaken already, to try and identify any commonalities between instances of post custody suicide. The objective is to establish a post release risk assessment process that will identify those most at risk, and initiate a process to mitigate that risk, with further support such as a mandatory referral to support agencies. The current research has identified from a review of five years of data from the IOPC:”

Source location

Response from National Police Chief's Council
Page 1 · response
Published 13 January 2025

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 comprehensive practitioner advice outlining measures to mitigate suicide risk among suspects of sexual offending.

Verbatim wording from the response

“increased risk of suicide (such as those matching Mr Brierley’s demographics). We have produced comprehensive practitioner advice for officers and staff that outlines a series of measures to mitigate against this risk and have also added the latest guidance document from the Faculty of Forensic and Legal Medicine on how to care for suspects of sexual assault in police custody. (Please find further details here).”

Source location

Response from College of Policing
Page 2 · response
Published 13 January 2025

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

Investigating officers must apply individual circumstances to risk assessments and supervisors must ratify disposal decisions.

Verbatim wording from the response

“Assessments of risk should always be individualised. Whilst there will be a question set used to conduct a pre-release risk assessment, the responses should be applied to the individual circumstances of the investigation, by the OIC and ratified by their supervisor when making a disposal decision. Bail conditions should only be applied where it is necessary and proportionate to do so. There is a”

Source location

Response from National Police Chief's Council
Page 2 · response
Published 13 January 2025

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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

The investigating officer must identify risks for digital-device submissions, which the Digital Forensics Unit uses to prioritise examinations.

Verbatim wording from the response

“2 – In relation to the examination of digital devices, timescales vary between forces, but it is not uncommon for those considered to be linked to lower risk investigations, not to be processed for many months. It will be for the officer in charge (OIC) of the investigation to identify all risks within their submission to their Digital Forensics Unit (or equivalent), which is then used to prioritise the examination of those devices. The factors in this investigation should have resulted in a much quicker interrogation of the device than the 18 months estimated. The fact that Matthew was on bail, should have seen the investigation progressed within the requisite bail periods, but I cannot comment upon any individual backlog or otherwise that the force concerned may have been managing.”

Source location

Response from National Police Chief's Council
Page 2 · response
Published 13 January 2025

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 police guidance readily available to forces clearly sets out actions to support detainees and prevent custody and post-custody suicides.

Verbatim wording from the response

“The Detention and Custody Authorised Professional Practice (APP) produced by the College of Policing (henceforth ‘the College’) sets the standards for police engagement with detainees after their arrest, including any offers of support. This includes operational advice on managing the risk of suicide for persons under investigation, such as Matthew. The College is independent of government; its role is to set high professional standards for policing; sharing what works best; acting as the national voice of policing; and ensuring police training and ethics is of the highest possible quality.”

Source location

Response from the Home Office
Page 1 · response
Published 13 January 2025

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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

The Home Office has no authority to intervene in operational policing matters or comment on police officers’ operational decisions.

Verbatim wording from the response

“How the APP is followed is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned.”

Source location

Response from the Home Office
Page 1 · response
Published 13 January 2025

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

Operational decisions about following custody guidance are the responsibility of individual police forces and their chief officers.

Verbatim wording from the response

“How the APP is followed is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned.”

Source location

Response from the Home Office
Page 1 · response
Published 13 January 2025

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

Individual police forces and case decision-makers determine device examinations, investigation scope and bail conditions according to operational context.

Verbatim wording from the response

“As operationally independent organisations, each police force will have provisions for the forensic examination of mobile phones and other digital devices. The context of each investigation will also shape the extent of both lines of enquiry and the depth or otherwise, of those examination processes, which will invariably have an impact on the time taken to complete those examinations. Similarly, the context of each case and presentation of risks would also help inform decision makers. Given the case specifics here, I would expect that officers appropriately recognise their responsibilities to safeguard children under Working Together 2023 and the Children Act 1989 and that this had a strong bearing on the bail conditions imposed.”

Source location

Response from College of Policing
Page 2 · response
Published 13 January 2025

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

Existing policing guidance, custody risk assessment and partnership arrangements are considered sufficient to address suicide and post-release support risks.

Verbatim wording from the response

“increased risk of suicide (such as those matching Mr Brierley’s demographics). We have produced comprehensive practitioner advice for officers and staff that outlines a series of measures to mitigate against this risk and have also added the latest guidance document from the Faculty of Forensic and Legal Medicine on how to care for suspects of sexual assault in police custody. (Please find further details here).”

Source location

Response from College of Policing
Page 2 · response
Published 13 January 2025

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

    Continue sharing relevant findings and guidance through strategic custody boards and regular communications to avoid delaying learning.

    Stated by National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025.
  2. 2

    Re-establish and regularly convene the healthcare providers working group on custody safety.

    Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
  3. 3

    Add current forensic and legal medicine guidance on caring for sexual-assault suspects in police custody.

    Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing Home Office policies and processes were considered appropriate for managing and supporting the employee following arrest.

    Stated by Home OfficeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 sharing relevant findings and guidance through strategic custody boards and regular communications to avoid delaying learning.

Verbatim wording from the response

“Answers to these and other questions, will be analysed to draw any statistical conclusions available, that can then be used to identify those most at risk in the future. The timetable for this next stage of research, is to submit the request to all forces by the end of April and allow 4 months for the return of the requested information. Once received, the analytical work will be undertaken, with a time estimate of 6 months. Whilst this work will take time to complete, communication with strategic custody leads is conducted via a quarterly strategic board meeting and the regular sharing of information and guidance such as the findings within this report and others, so as not to delay any learning.”

Source location

Response from National Police Chief's Council
Page 2 · response
Published 13 January 2025

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

Re-establish and regularly convene the healthcare providers working group on custody safety.

Verbatim wording from the response

“████████ and I, took over the Custody portfolio in October 2024 and the overarching priority behind all of our strategic objectives, is to make custody as safe as possible for detainees and those working within the custody environment. To that end, we are heavily involved with the healthcare providers and what is often referred to as, Liaison and Diversion services within custody. We recently re-established the healthcare providers working group and meet regularly with the IOPC, and also attend the Ministerial Board on Deaths in Custody, working to prevent both deaths in custody and post custody suicides.”

Source location

Response from National Police Chief's Council
Page 1 · response
Published 13 January 2025

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

Add current forensic and legal medicine guidance on caring for sexual-assault suspects in police custody.

Verbatim wording from the response

“increased risk of suicide (such as those matching Mr Brierley’s demographics). We have produced comprehensive practitioner advice for officers and staff that outlines a series of measures to mitigate against this risk and have also added the latest guidance document from the Faculty of Forensic and Legal Medicine on how to care for suspects of sexual assault in police custody. (Please find further details here).”

Source location

Response from College of Policing
Page 2 · response
Published 13 January 2025

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

Existing Home Office policies and processes were considered appropriate for managing and supporting the employee following arrest.

Verbatim wording from the response

“Hampshire Police informed Border Force officials of Matthew’s arrest on the weekend of 16 March 2024. Matthew was contacted by a Border Force Deputy Director and support was offered. Subsequently a welfare point of contact was identified. A decision was made to suspend Matthew on full pay, in line with HR guidance. This decision was explained to Matthew, whilst emphasising the importance of his welfare. Matthew was given assurances that the situation would be managed discreetly and confidentially.”

Source location

Response from the Home Office
Page 2 · response
Published 13 January 2025

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