PFD report

Darren NEVILLE · Prevention of Future Deaths report

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Issued 10 Jun 2015•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.

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Concerns
1

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

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Concerns raised1

  1. Failure to give sufficient consideration to the risk of death associated with prolonged restraint of a person suffering from acute behavioural disturbance
    Part of recurring concern: Unsafe police restraint practices and controls
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.2

  1. Action

    Continue fast-tracking learning from the national mental-health restraint expert group into corporate officer-safety training.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2015.
  2. Action

    Deliver mandatory officer-safety training covering acute behavioural disorder, de-escalation, safer restraint, positional-asphyxia risks and medical implications of restraint.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 10 June 2015.

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 give sufficient consideration to the risk of death associated with prolonged restraint of a person suffering from acute behavioural disturbance

Wider context from the report

““Police did not give sufficient consideration to the risks associated with prolonged restraint to a person suffering from acute behavioural disturbance; more specifically, the risk of death following prolonged restraint. It is unclear the extent to which this single factor caused Darren’s death.” ”

Is this part of a recurring concern?

Yes — Unsafe police restraint practices and controls.

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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

Continue fast-tracking learning from the national mental-health restraint expert group into corporate officer-safety training.

Verbatim wording from the response

“The MPS is also promoting the newly formed National Mental Health Restraint Expert Reference Group, which is independently chaired by Lord Carlisle. This group of leading experts from partnership groups and organisations has been convened to help ensure a unified response to best practice across the UK. The OST learning outcomes from such groups will continue to be fast-tracked into corporate training as an on-going process of development, in line with College of Policing principles. For these reasons, work is ‘on-going’ from an OST perspective.””

Source location

2015-0220-Response-by-Metropolitan-Police
Page 6 · response
Published 10 June 2015

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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

Deliver mandatory officer-safety training covering acute behavioural disorder, de-escalation, safer restraint, positional-asphyxia risks and medical implications of restraint.

Verbatim wording from the response

“This resource sits alongside a continuing emphasis on de-escalation tactics in the OST sessions. The classroom element of the current cycle of the mandatory training includes a section called ‘Mental Health - Safety In Mind’, a DVD and tutor led interactive session. This has been developed in conjunction with South London & Maudsley Hospital (SLAM) and the LAS and is aimed at improving the management of a situation involving a person identified as vulnerable. This package discusses the importance of the VAF and ABCDE models; and offers practical guidance on de-escalation tactics using the ‘CARES’ model (see below.)”

Source location

2015-0220-Response-by-Metropolitan-Police
Page 5 · response
Published 10 June 2015

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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.4

  1. 1

    Adopt common acute behavioural disorder terminology across first-responding agencies.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 10 June 2015.
  2. 2

    Require officers to notify ambulance services through new CAD messages so actively restrained or suspected acute behavioural disorder patients receive emergency-priority responses.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 10 June 2015.
  3. 3

    Establish the MPS–LAS memorandum and joint-response arrangements for restrained or acute behavioural disorder incidents, supported by regular review meetings.

    Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 10 June 2015.
  4. 4

    Implement the Vulnerability Assessment Framework and ABCDE tool through mandatory officer-safety training, formal policy and accessible intranet guidance.

    Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2015.

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

Adopt common acute behavioural disorder terminology across first-responding agencies.

Verbatim wording from the response

“One of the first improvements in the response by police and other agencies to cases of possible ABD was the adoption of this phrase as a common terminology across first-responding agencies to describe the behaviours which might be exhibited in individuals with ABD. There were a number of implications for training, business processes and practice for all parties which flowed from this.”

Source location

2015-0220-Response-by-Metropolitan-Police
Page 2 · response
Published 10 June 2015

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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

Require officers to notify ambulance services through new CAD messages so actively restrained or suspected acute behavioural disorder patients receive emergency-priority responses.

Verbatim wording from the response

“Parts of this new approach which could be introduced rapidly were expedited. For example, on the 3rd December 2013 (a little more than a fortnight after the verdict in the Michael Sweeney inquest) an instruction to all officers was delivered (via the MPS intranet system), advising that from the following day, our partners in the LAS would treat all ‘ABD’ and/or ongoing restraint calls as medical emergencies, with a target response time of 8 minutes or less, a so-called ‘Red’ response.”

Source location

2015-0220-Response-by-Metropolitan-Police
Page 2 · response
Published 10 June 2015

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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

Establish the MPS–LAS memorandum and joint-response arrangements for restrained or acute behavioural disorder incidents, supported by regular review meetings.

Verbatim wording from the response

“I have set out below: (a) a summary of actions taken by the MPS since the conclusion of the Sweeney inquest, (covered in greater detail in our report to you on that case); together with (b) additional developments since the death of Mr Neville. It will be noted that some actions set in train immediately after the verdict in Mr Sweeney’s inquest, for example, developing the Memorandum of Understanding (MOU) between the MPS and the LAS were still ‘works in progress’ at the time of Mr Neville’s death. This work has now been completed as regards the joint response to any similar incidents which may occur in the future. I should make clear that the work which I have set out below has been carried out in consultation with subject experts in the relevant areas of police operations and policy.”

Source location

2015-0220-Response-by-Metropolitan-Police
Page 2 · response
Published 10 June 2015

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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

Implement the Vulnerability Assessment Framework and ABCDE tool through mandatory officer-safety training, formal policy and accessible intranet guidance.

Verbatim wording from the response

“Two complementary strategies are relevant here. The first was the introduction, in September 2013 (by the MPS Mental Health Team under the direction of Commander Christine Jones), of the Vulnerability Assessment Framework (VAF), and it’s associated ‘ABCDE’ risk-assessment tool.”

Source location

2015-0220-Response-by-Metropolitan-Police
Page 3 · response
Published 10 June 2015

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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