PFD report

Caroline Louise Pilkington · Prevention of Future Deaths report

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Issued 25 Mar 2014•Manchester West

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
2

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

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Concerns raised1

  1. Lack of control and restraint training for ambulance service personnel
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8

  1. Position

    Training all ambulance staff in advanced control and restraint is not feasible because they could not maintain the specialised skills through regular practice.

    Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Lack of control and restraint training for ambulance service personnel

Wider context from the report

“North West Ambulance Service personnel are not trained in control and restraint techniques. Evidence was therefore given at the inquest that it was necessary for them to call the police service to assist them in dealing with patients who are unwell where the use of such techniques is required. This is so despite the fact that other clinical personnel, for example Mental Health nurses, are trained in such techniques. In the case of Miss Pilkington this resulted in three paramedics having to call for assistance from the police service. Evidence revealed that calling the police in these circumstances results in patients who are physically and/or mentally unwell being dealt with by the police service, who, although they are trained in control and restraint techniques, are not clinically trained to deal with such patients. In addition, further evidence was given that the involvement of the police service in these cases not only potentially results in inappropriate removal of police officers from their core policing duties, but also potentially results in harm to patients being caused by delaying their removal to hospital. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Training all ambulance staff in advanced control and restraint is not feasible because they could not maintain the specialised skills through regular practice.

Verbatim wording from the response

“• Advanced control and restraint is an extremely specialised skill, which, due to the risks involved, requires extensive training and regular practice. As ambulance staff are not commonly tasked with situations which require”

Source location

2014-0269-Response-by-Department-of-Health
Page 2 · response
Published 25 March 2014

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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

Collaborative ambulance-police working and police assistance provide the safest, timeliest and least restrictive response to patients requiring advanced restraint.

Verbatim wording from the response

“• A joint protocol was developed between the North West Region Police Forces and NWAS in March 2012 which supports inter-agency working and the appropriate use of shared resources to deliver the best possible care for patients who lack capacity. All five police forces in the North West have agreed to the protocol.”

Source location

2014-0269-Response-by-Department-of-Health
Page 2 · response
Published 25 March 2014

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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

Each ambulance service determines its paramedic personal-safety training content and frequency, including training relevant to controlling and restraining patients.

Verbatim wording from the response

“In respect of training for the ambulance service, my understanding is that paramedic staff must receive training in personal safety, which is a requirement through NHS Protect, and an obligation under health and safety at work responsibilities. However, the content of that training is not stipulated, and it is down to each service to determine the content and frequency of that training. I am unclear as to the extent to which their duty of care responsibilities are understood in relation to controlling and restraining patients. We find knowledge of the Mental Capacity Act and Mental Health Act is variable, and that some policies within the ambulance service and hospitals automatically refer incidents to police when they could take action themselves.”

Source location

2014-0269-Response-by-Greater-Manchester-Police
Page 2 · response
Published 25 March 2014

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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

Existing policies and training are considered sufficient, with police involvement decided case by case and no general need for change identified.

Verbatim wording from the response

“NWAS has confirmed that a regional protocol is in place that all police forces it works with, including Greater Manchester Police, have agreed to. This protocol is under review. However, at the most recent North West Police Regional Mental Health Forum, NWAS presented and discussed the findings from your request concerning the death of Caroline Pilkington. None of the police forces believed there was a need to change the current policy or reduce the involvement of the police in managing those patients who required more than minimal restraint.”

Source location

2014-0269-Response-by-Department-of-Health2
Page 2 · response
Published 25 March 2014

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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

Further advanced restraint training is not supported because its rarity would make safe skill maintenance difficult and could increase harm risks.

Verbatim wording from the response

“As the need for ambulance personnel to use restraint techniques is comparatively rare, NWAS believes that the need to train all ambulance staff in more advanced or specialised restraint techniques is not demonstrated. Even if all staff were to be trained, it would be difficult to maintain their skills sufficiently (because of the low incidence of use) to safely restrain these types of patients when the skills were called for. The risk is that poorly or inappropriately applied restraint techniques could cause harm to the patient or to staff.”

Source location

2014-0269-Response-by-Department-of-Health2
Page 2 · response
Published 25 March 2014

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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

Training ambulance staff in control and restraint is outside the Department of Health’s responsibility.

Verbatim wording from the response

“Firstly, it needs to be understood that the training of ambulance staff in control and restraint techniques is not a matter for which the Department of Health (DH) is responsible. Ambulance staff, for example emergency care assistants, emergency care practitioners and paramedics, are health professionals and are trained as such. The actual training that ambulance staff require and receive in control and restraint is a matter for the NHS Trust concerned, and not DH.”

Source location

2014-0269-Response-by-Department-of-Health2
Page 2 · response
Published 25 March 2014

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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 relevant NHS Trust is responsible for determining and providing ambulance staff control and restraint training.

Verbatim wording from the response

“Firstly, it needs to be understood that the training of ambulance staff in control and restraint techniques is not a matter for which the Department of Health (DH) is responsible. Ambulance staff, for example emergency care assistants, emergency care practitioners and paramedics, are health professionals and are trained as such. The actual training that ambulance staff require and receive in control and restraint is a matter for the NHS Trust concerned, and not DH.”

Source location

2014-0269-Response-by-Department-of-Health2
Page 2 · response
Published 25 March 2014

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 ambulance staff in advanced control and restraint is not feasible because incidents are rare and skills could not be maintained safely.

Verbatim wording from the response

“NWAS believes that ambulance staff should focus on the treatment of the presenting condition of their patients. Advanced control and restraint is an extremely specialised skill, which, due to the risks involved, requires extensive training and regular practice. It would not be feasible for our staff to be trained in such techniques since situations where control and restraint is required arise very rarely. Consequently, ambulance staff would not be able to maintain the skills at the necessary level to ensure appropriate patient care. We believe this has the potential to compromise, rather than improve, the safety of patients.”

Source location

2014-0269-Response-by-North-West-Ambulance-Service
Page 2 · response
Published 25 March 2014

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

    Revise officer safety training to emphasise recognising medical risks and treating relevant incidents as medical emergencies.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 25 March 2014.
  2. 2

    Establish and agree a joint ambulance-police protocol for safely managing incapacitated patients requiring restraint or police assistance.

    Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Sufficient paramedics and ambulance restraint equipment were available to manage the incident safely without police involvement.

    Stated by Greater Manchester PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Existing joint police and ambulance protocols and police assistance are considered the safest way to manage patients requiring advanced restraint.

    Stated by North West Ambulance Service NHS TrustExisting 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

Revise officer safety training to emphasise recognising medical risks and treating relevant incidents as medical emergencies.

Verbatim wording from the response

“I fully endorse the need for police involvement when health professionals are assaulted or threatened with violence by those who need dealing with through the criminal justice system. Clearly we enjoy good operational and professional relationships with our colleagues across the emergency services, and we have always supported requests for assistance without question in the past. However, I am increasingly concerned that we are becoming a default option if the correct medical response is not available, and are being drawn into high risk medical emergencies. It is difficult to justify the involvement of police officers in situations which are clearly medical emergencies, whether physical health or mental health. Our newly revised officer safety training programme has emphasised the need for officers to recognise the medical risks in situations such as those in Miss”

Source location

2014-0269-Response-by-Greater-Manchester-Police
Page 1 · response
Published 25 March 2014

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

Establish and agree a joint ambulance-police protocol for safely managing incapacitated patients requiring restraint or police assistance.

Verbatim wording from the response

“NWAS are acutely aware of the importance of delivering safe patient care and are constantly striving to improve our procedures. In March 2012 a joint protocol was developed, following consultation between the North West Region Police Forces and NWAS, which provides a framework to support inter-agency working and the appropriate use of resources to deliver the best possible care for patients who lack capacity. The aim of this protocol is to ensure patients who lack capacity and are refusing advice or treatment, receive care that is in their best interests using the least restrictive means necessary.”

Source location

2014-0269-Response-by-North-West-Ambulance-Service
Page 1 · response
Published 25 March 2014

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

Sufficient paramedics and ambulance restraint equipment were available to manage the incident safely without police involvement.

Verbatim wording from the response

“As you know, I have been concerned for some time about the increasing demand that is falling on police from gaps in health services. This is evident in many forms, from ‘concern for welfare’ reports through to police involvement in mental health and accident and emergency situations. The common theme is a tendency for health professionals to call police to deal with situations where health professionals already have the appropriate powers and medical skills, but appear to lack the confidence, will, and particular skills around incident resolution – which should obviate the need for police involvement. I note in this case that there were sufficient paramedics present to manage the incident safely without the need for police involvement, and I understand that the restraint equipment used is carried by ambulances crews for such purposes.”

Source location

2014-0269-Response-by-Greater-Manchester-Police
Page 1 · response
Published 25 March 2014

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 joint police and ambulance protocols and police assistance are considered the safest way to manage patients requiring advanced restraint.

Verbatim wording from the response

“NWAS are acutely aware of the importance of delivering safe patient care and are constantly striving to improve our procedures. In March 2012 a joint protocol was developed, following consultation between the North West Region Police Forces and NWAS, which provides a framework to support inter-agency working and the appropriate use of resources to deliver the best possible care for patients who lack capacity. The aim of this protocol is to ensure patients who lack capacity and are refusing advice or treatment, receive care that is in their best interests using the least restrictive means necessary.”

Source location

2014-0269-Response-by-North-West-Ambulance-Service
Page 1 · response
Published 25 March 2014

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