PFD report

Trystan Bryant · Prevention of Future Deaths report

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Issued 19 Oct 2018•Plymouth, Torbay and South Devon

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
1

Of 2 recipients

Stated actions
1

Described in 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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Report evidence summary

Concerns raised1

  1. Inability to lock stationary ambulance doors to prevent egress
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.1

  1. Action

    Write to all Chief Constables requesting a reminder that ambulances used under section 136 are non-secure environments.

    Stated by Dyfed-Powys PoliceStated completedThe respondent said that this action was complete when they made their response on 12 May 2019.

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

Inability to lock stationary ambulance doors to prevent egress

Wider context from the report

“Ambulance Doors When ambulances are stationary ambulance doors cannot be locked to prevent egress from inside the vehicle. This may affect police containment preparations when police officers are escorting individuals for the purposes of Section 136 of the Mental Health Act ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Write to all Chief Constables requesting a reminder that ambulances used under section 136 are non-secure environments.

Verbatim wording from the response

“Your Regulation 28 report Prevent Further Deaths (PFD) notice dated 19th October 2018 following the death of Trystan Bryant has been received and I note your concerns. Given the specifics involved, I have written to all Chief Constables asking them issue a reminder to all operational officers likely to use authorities to detain under s136 MHA that they treat all ambulances as non-secure environments and not to assume they are or can be as secure as police vehicles.”

Source location

2018-0382-Response-by-NPCC
Page 1 · response
Published 12 May 2019

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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