PFD report

Joseph MARTIN · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 16 Nov 2021•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
3

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published 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.

Concerns raised3

  1. Failure to search all relevant records before returning safety-critical information
  2. Failure to communicate safety-critical mental-health and medical information to relevant agencies
    Part of recurring concern: Unreliable inter-agency information sharing for coordinated carePart of recurring concern: Unreliable multi-agency communication procedures
  3. Failure to record safety-critical contacts in missing-person and occurrence records
    Part of recurring concern: Unreliable missing-person responsePart of recurring concern: Unreliable recording of safety-critical police contacts
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 search all relevant records before returning safety-critical information

Wider context from the report

“Joseph Martin was reported as a person of concern to the PSNI on 28 May 2021 by staff at the hostel where he lived. His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others. The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further. However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed. I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer. Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts. Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back. I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given. There were individual errors, and more significantly a system that does not seem to have provided a safety net. ”

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 communicate safety-critical mental-health and medical information to relevant agencies

Wider context from the report

“Joseph Martin was reported as a person of concern to the PSNI on 28 May 2021 by staff at the hostel where he lived. His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others. The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further. However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed. I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer. Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts. Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back. I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given. There were individual errors, and more significantly a system that does not seem to have provided a safety net. ”

Is this part of a recurring concern?

Yes — Unreliable inter-agency information sharing for coordinated care; Unreliable multi-agency communication procedures.

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 record safety-critical contacts in missing-person and occurrence records

Wider context from the report

“Joseph Martin was reported as a person of concern to the PSNI on 28 May 2021 by staff at the hostel where he lived. His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others. The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further. However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed. I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer. Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts. Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back. I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given. There were individual errors, and more significantly a system that does not seem to have provided a safety net. ”

Is this part of a recurring concern?

Yes — Unreliable missing-person response; Unreliable recording of safety-critical police contacts.

Open source report
Back to top

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