PFD report

Jake Hickey Girton · Prevention of Future Deaths report

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Issued 29 Sep 2025•East 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
1

Of 1 recipient

Stated actions
6

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.

Report evidence summary

Concerns raised3

  1. Failure to inform the hospital of release from police custody
    Part of recurring concern: Failure of police operational communications to reliably share safety-critical informationPart of recurring concern: Unreliable sharing of safety-critical risk information between police, healthcare and probation services
  2. Failure to reflect on or remediate identified performance failings
    Part of recurring concern: Failure of police post-incident performance learning and remediation
  3. Failure to identify shortcomings in police performance
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.4

  1. Action

    Work with mental health partners to develop consistent London-wide arrangements, accountability lines and welfare escalation routes after release.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2025.
  2. Action

    Complete mapping of existing information-sharing pathways for releases from custody.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 3 October 2025.
  3. Action

    Develop guidance for custody and investigating officers on identifying risk, recording indicators and initiating referrals or notifications before release.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The DPS review was appropriate and went as far as expected because it identified no conduct, performance or organisational learning.

    Stated by Metropolitan Police ServiceNo action considered necessaryThe respondent said that no further action was needed.

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 inform the hospital of release from police custody

Wider context from the report

“1. Evidence heard from a Metropolitan Police Inspector at inquest indicated that the police officer who was investigating the offence for which Jake was arrested was under an obligation to inform that complainant (the hospital) of Jake’s release from custody. There is no evidence to suggest this was done. Evidence from the Psychiatric trust at inquest indicates that on the 17th January 2024, there were under the impression that Jake would remain in police custody, and had they known he was released, greater efforts may have occurred to support Jake in the community. ”

Is this part of a recurring concern?

Yes — Failure of police operational communications to reliably share safety-critical information; Unreliable sharing of safety-critical risk information between police, healthcare and probation services.

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 reflect on or remediate identified performance failings

Wider context from the report

“2. Despite a Directorate of Professional Standards review, there is no evidence that the MPS identified any shortcoming in their performance in dealing with Jake, consequently no evidence exists of any reflection or remediation of this failing. ”

Is this part of a recurring concern?

Yes — Failure of police post-incident performance learning and remediation.

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 identify shortcomings in police performance

Wider context from the report

“2. Despite a Directorate of Professional Standards review, there is no evidence that the MPS identified any shortcoming in their performance in dealing with Jake, consequently no evidence exists of any reflection or remediation of this failing. ”

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

Work with mental health partners to develop consistent London-wide arrangements, accountability lines and welfare escalation routes after release.

Verbatim wording from the response

“3. The MPS is working with Mental Health Trust Leads and the Joint Mental Health and Police Group (JMHPG) to develop consistent arrangements across London. This includes establishing clear lines of accountability and escalation routes where concerns arise about a person’s welfare post release.”

Source location

Response from Metropolitan Police
Page 4 · response
Published 3 October 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 mapping of existing information-sharing pathways for releases from custody.

Verbatim wording from the response

“A review has already been undertaken in relation to information sharing with Mental Health Trusts which has identified a gap in current arrangements. Specifically, there is no consistent mechanism to ensure Mental Health services are notified when an individual is released from custody. This gap can result in missed opportunities for early intervention and continuity of care.”

Source location

Response from Metropolitan Police
Page 4 · response
Published 3 October 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

Develop guidance for custody and investigating officers on identifying risk, recording indicators and initiating referrals or notifications before release.

Verbatim wording from the response

“4. Additional guidance is being developed for custody and investigating officers, supported by the MPS Mental Health Lead. This will reinforce the importance of identifying those at risk, recording relevant indicators and initiating the appropriate referral or notification before release.”

Source location

Response from Metropolitan Police
Page 4 · response
Published 3 October 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

Develop a protocol for lawful, prompt notification of appropriate mental health services when people in crisis are released from custody.

Verbatim wording from the response

“2. The MPS is developing a protocol, agreed through local partnership governance to ensure that when a person identified as being in mental health crisis or having been arrested in a mental health setting, is released from custody, relevant information can be shared promptly and lawfully with the appropriate Mental Health Trust or Community Mental Health Team, if known. This protocol is being aligned with data protection and safeguarding requirements under existing information governance frameworks.”

Source location

Response from Metropolitan Police
Page 4 · response
Published 3 October 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

The DPS review was appropriate and went as far as expected because it identified no conduct, performance or organisational learning.

Verbatim wording from the response

“The MPS Directorate of Professional Standards (DPS) conducted a comprehensive review into this matter as per their remit and standard operating procedure. It was determined that this incident did not meet the definition of a Death or Serious Injury¹ (DSI) following police contact as defined in the Independent Office for Police Conduct (IOPC) Statutory Guidance. Upon conducting DSI reviews, the expectation is for DPS to also consider whether there is an obvious conduct matter, performance matter or opportunity for individual or organisational learning. In this instance, the review did not identify any such learning.”

Source location

Response from Metropolitan Police
Page 5 · response
Published 3 October 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.2

  1. 1

    Monitor progress on partnership measures through the Joint Mental Health and Police Group.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2025.
  2. 2

    Obtain final approval and incorporate guidance on updates to affected businesses and organisations into the General Investigations Policy.

    Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 3 October 2025.

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

Monitor progress on partnership measures through the Joint Mental Health and Police Group.

Verbatim wording from the response

“The MPS is committed to strengthening partnership working with health services to prevent future deaths and ensure vulnerable individuals receive the right care and support at the earliest opportunity. The MPS will continue to monitor progress through the JMHPG.”

Source location

Response from Metropolitan Police
Page 5 · response
Published 3 October 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

Obtain final approval and incorporate guidance on updates to affected businesses and organisations into the General Investigations Policy.

Verbatim wording from the response

“The MPS are currently reviewing the GI policy and propose to include the following section to ensure there is clarity around the responsibility to provide updates to representatives of businesses and other enterprises:”

Source location

Response from Metropolitan Police
Page 3 · response
Published 3 October 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

Official responses located
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Data last updated 7 September 2026