PFD report

Brian Thomas RINGROSE · Prevention of Future Deaths report

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Issued 1 Aug 2025•Milton Keynes

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
22

Raised in this report

Recipients
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
31

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 raised22

  1. Failure to communicate before dragging a restrained person by the arms
    Part of recurring concern: Unsafe police restraint practices and controls
  2. Failure to avoid extreme arm positioning during handcuffed restraint
    Part of recurring concern: Unsafe police restraint practices and controls
  3. Failure to check airways and breathing rate during restraint
    Part of recurring concern: Failure to recognise breathing emergencies during police encountersPart of recurring concern: Unsafe police restraint practices and controlsPart of recurring concern: Unsafe use and management of prone restraint
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.24

  1. Action

    Require immediate escalation of concerns to the treating medic or nurse in charge through the Operational Policy.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
  2. Action

    Deliver refresher and Human Factors training to support consistent application of safe-discharge principles.

    Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2025.
  3. Action

    Accept emergency-department referrals before medical clearance to enable earlier engagement, risk planning and support, with timely referral-response monitoring.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The discharge omissions were considered case-specific, not a systemic issue requiring wider policy or practice change.

    Stated by The TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 before dragging a restrained person by the arms

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unsafe police restraint practices and controls.

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 avoid extreme arm positioning during handcuffed restraint

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unsafe police restraint practices and controls.

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 check airways and breathing rate during restraint

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Failure to recognise breathing emergencies during police encounters; Unsafe police restraint practices and controls; Unsafe use and management of prone restraint.

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

Delays in mental health team assessment in the Emergency Department

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Failure of the Emergency Department mental health liaison assessment pathway to provide timely and safe assessment; Unreliable assessment of patients’ mental state.

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 move restrained people onto their side as soon as practicable

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unsafe police restraint practices and controls; Unsafe use and management of prone restraint.

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

Discharge documentation liable to be misinterpreted as an official discharge notice

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge documentation; Unreliable hospital discharge processes.

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

Reliance on delayed written clinical documentation in emergency settings

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 hand over critical restraint information

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unsafe police restraint practices and controls.

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 seek clinical advice during restraint

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unsafe use and management of prone restraint.

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 escalate concerns and arrange follow-up after incomplete mental health assessment

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Failure to provide timely continuing mental health reviews and follow-up; Failure to reliably follow up identified mental-health safety concerns.

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 listen to, interpret and respond to breathing during restraint

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Failure to recognise breathing emergencies during police encounters; Unsafe use and management of prone restraint.

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 provide timely final medical review before formal discharge

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unreliable clinical review and authorisation of discharge decisions; Unreliable hospital discharge processes.

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

Ambiguous and inadequately communicated discharge criteria

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge documentation; Unreliable hospital discharge processes.

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 concerns that a patient is not medically fit for discharge

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — 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 of officers to challenge inappropriate restraint

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unsafe police restraint practices and controls.

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

Premature discharge of patients who are not medically fit

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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 of senior clinical and nursing staff to intervene in observed restraint

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

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

Reference in hospital policy to a non-existent police-custody discharge form

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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 reassess restraint actions using the National Decision Model

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unsafe police restraint practices and controls; Unsafe use and management of prone restraint.

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 limit prolonged prone restraint

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unsafe police restraint practices and controls; Unsafe use and management of prone restraint.

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 raise concerns about changing pallor during restraint

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

Is this part of a recurring concern?

Yes — Unsafe police restraint practices and controls.

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

Inappropriate recommendation for reassessment in police custody despite medical instability

Wider context from the report

“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”

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

Require immediate escalation of concerns to the treating medic or nurse in charge through the Operational Policy.

Verbatim wording from the response

“c. Failure to Escalate Concerns We have strengthened our escalation pathways. A standing agenda item has been added to monthly cross-team meetings to review HLT practices. Our Operational Policy now explicitly requires immediate escalation of concerns to the treating medic or nurse in charge.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 4 August 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

Deliver refresher and Human Factors training to support consistent application of safe-discharge principles.

Verbatim wording from the response

“e. Inappropriate Discharge Recommendation We have reinforced the principle that discharge from ED should never proceed where there are unresolved concerns about a patient’s safety, whether related to physical or mental health. This has been reiterated in team meetings and supervision sessions. Refresher training and Human Factors Training are taking place to support consistent application of this principle.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 4 August 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

Accept emergency-department referrals before medical clearance to enable earlier engagement, risk planning and support, with timely referral-response monitoring.

Verbatim wording from the response

“a. Delay in Assessment We have revised our approach to ensure that referrals are accepted even when patients are not yet medically cleared. This enables earlier engagement, risk planning, and support. A key performance indicator for the HLT is timely response to referrals. In the past six months, over 95% of ED referrals have been responded to within one hour. This reflects not only operational improvements but a cultural shift towards proactive, parallel working with ED colleagues.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 4 August 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

Require escalation to emergency-department clinicians, continued emergency-department medical care and liaison-team availability for reassessment when patients cannot engage or remain medically unfit.

Verbatim wording from the response

“b. Inadequate Assessment Our revised protocol mandates that when a patient cannot engage due to intoxication (alcohol or drugs) or other factors rendering them unfit, the HLT must escalate concerns to the ED team, advise that the patient remains under ED care for ongoing medical management, and the HLT remain available for reassessment. This ensures continuity of care and avoids missed opportunities for intervention. This applies equally in cases where the patient is under police arrest within the ED.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 4 August 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

Reinforce that emergency-department discharge must not proceed when safety concerns remain, through team meetings and supervision.

Verbatim wording from the response

“e. Inappropriate Discharge Recommendation We have reinforced the principle that discharge from ED should never proceed where there are unresolved concerns about a patient’s safety, whether related to physical or mental health. This has been reiterated in team meetings and supervision sessions. Refresher training and Human Factors Training are taking place to support consistent application of this principle.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 4 August 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

Implement joint clinical entries, mandatory immediate verbal handovers and contemporaneous electronic documentation after assessments, with random quality audits.

Verbatim wording from the response

“d. Unsafe Communication Practices To enhance the robustness and integrity of our documentation process, we have implemented a joint entry protocol. Under this approach, both assessors will contribute directly: the second assessor will either formally approve the initial entry or provide a complementary entry to ensure a more comprehensive and balanced record. Verbal handovers to the treating medic, or to the Nurse in Charge if the medic is unavailable, are now mandatory immediately post-assessment, followed by contemporaneous entries in ECare summarising the handover with a more detailed entry to follow based on the SystmOne entry. These changes aim to improve the”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 4 August 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

Share learning from Brian’s case across the Emergency Department to raise awareness of unclear documentation and communication risks.

Verbatim wording from the response

“This is addressed in the Emergency Department SOP for the discharge of adult patients described above and appended at Appendix 2. The individuals involved in this case have reflected at great length about their actions and inactions. Brian’s death was a seminal event for the Trust and learning from it has been widely shared within the Emergency Department. Further learning events using Brian’s case (anonymised) will continue in the Emergency Department, both to raise awareness of risk of unclear documentation and communication, and to ensure that there is an enduring legacy of improvement following Brian’s death.”

Source location

Response from Milton Keynes University Hospitals
Page 10 · response
Published 4 August 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 and report an audit of discharge-compliance performance.

Verbatim wording from the response

“A recent audit on discharge compliance is included at Appendix 4 for information and assurance.”

Source location

Response from Milton Keynes University Hospitals
Page 11 · response
Published 4 August 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

Reiterate Toxbase guidance to Emergency Department clinicians and provide a quick guide through the Radar documentation system.

Verbatim wording from the response

“Brian should not have been discharged. This is accepted and actions described above have been taken to mitigate the risk of a similar event occurring again. Toxbase guidelines have been reiterated to all Emergency Department clinicians, with a quick guide available on the Radar documentation system.”

Source location

Response from Milton Keynes University Hospitals
Page 11 · response
Published 4 August 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

Continue anonymised learning events using Brian’s case in the Emergency Department to improve documentation and communication of risk.

Verbatim wording from the response

“This is addressed in the Emergency Department SOP for the discharge of adult patients described above and appended at Appendix 2. The individuals involved in this case have reflected at great length about their actions and inactions. Brian’s death was a seminal event for the Trust and learning from it has been widely shared within the Emergency Department. Further learning events using Brian’s case (anonymised) will continue in the Emergency Department, both to raise awareness of risk of unclear documentation and communication, and to ensure that there is an enduring legacy of improvement following Brian’s death.”

Source location

Response from Milton Keynes University Hospitals
Page 10 · response
Published 4 August 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

Implement the Emergency Department adult-discharge SOP defining discharge responsibilities, documentation requirements, safety-netting, and safeguards for higher-risk patients.

Verbatim wording from the response

“In the course of investigating Brian’s death and preparing for the inquest, the decision-making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.”

Source location

Response from Milton Keynes University Hospitals
Page 8 · response
Published 4 August 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

Amend the police-custody discharge SOP to reflect current Emergency Department and Thames Valley Police processes.

Verbatim wording from the response

“This concern refers to a Standard Operating Procedure (Police Custody – Care in and Discharge from ED) which was created using the Royal College of Emergency Medicine Guideline of the same name. I can assure you that it was not created in haste, but had not been updated to reflect work with Thames Valley Police which had continued to evolve and develop local processes and procedures after the guidelines had been published as a local SOP.”

Source location

Response from Milton Keynes University Hospitals
Page 1 · response
Published 4 August 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

Roll out Dynamic Documentation to the Emergency Department with associated discharge-process training and awareness activity.

Verbatim wording from the response

“Discharge summaries are also created in eCare for inpatients (adult and paediatric), day-cases and maternity cases. All currently use the older DEPART tool but the creation of the discharge summary and discharging of the patient from the system are carried out separately. Overtime we would expect all areas to migrate onto the newer Discharge Workflow mPage and associated Dynamic Documentation.”

Source location

Response from Milton Keynes University Hospitals
Page 7 · response
Published 4 August 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

Review the clinical restraint and restrictive-practices training programme under the redrafted policy.

Verbatim wording from the response

“The Trust’s Restraint and Restrictive Practices policy has been re-drafted post the inquest (appended at Appendix 3) to incorporate Emergency Department specific guidelines (NICE NG10) and to make the roles and responsibilities of healthcare staff during any restraint unambiguously clear. The Trust’s training programme on restraint and restrictive practices for clinical staff is being reviewed under the new draft policy (Appendix 3). Breakaway and”

Source location

Response from Milton Keynes University Hospitals
Page 10 · response
Published 4 August 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

Redraft the Trust restraint and restrictive-practices policy with Emergency Department-specific guidance and clearer staff roles and responsibilities.

Verbatim wording from the response

“The Trust’s Restraint and Restrictive Practices policy has been re-drafted post the inquest (appended at Appendix 3) to incorporate Emergency Department specific guidelines (NICE NG10) and to make the roles and responsibilities of healthcare staff during any restraint unambiguously clear. The Trust’s training programme on restraint and restrictive practices for clinical staff is being reviewed under the new draft policy (Appendix 3). Breakaway and”

Source location

Response from Milton Keynes University Hospitals
Page 10 · response
Published 4 August 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

Mandate and roll out Safer Restraint e-learning on prolonged restraint, welfare monitoring, situational awareness and safety-officer responsibilities, with completion actively monitored.

Verbatim wording from the response

“In mid-March 2025, ACC Bunt delivered a force wide communication to all officers and staff. This included changes to training and guidance as a consequence of the death of Mr Ringrose. All police officers and police staff detention officers were mandated to complete an online E-Learning package titled ‘Safer Restraint.’ This training covers the medical issues that can arise with prolonged restraint, welfare monitoring, situational awareness and the importance of the role of Safety Officer. The completion of this learning is being actively monitored and to date 4760 Officers and Detention Officers have completed this training (95% of the target audience).”

Source location

Response from Thames Valley Police
Page 5 · response
Published 4 August 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

Review and publish mobile Snap Guides covering safety-officer duties, welfare monitoring, restraint, spit guards, acute behavioural disturbance and prone ground-pin risks.

Verbatim wording from the response

“TVP have also reviewed and published the following Snap Guides. These are summary documents available to officers through their mobile devices and are designed to be used whilst operationally deployed. They address identified matters such as ineffective welfare monitoring; inadequate application of police restraint training and risks associated with handcuffing to the rear and prone restraint.”

Source location

Response from Thames Valley Police
Page 2 · response
Published 4 August 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

Update trainer notes for prone handcuffing and ground-pin techniques, clarifying arm restraint and prohibiting arm elevation or lowering for compliance.

Verbatim wording from the response

“Following review, TVP have made changes to their handcuffing from prone trainer notes and their ground pin trainer notes. This will provide further clarity on how a subject’s arms are to be restrained during and after the application of handcuffs.”

Source location

Response from Thames Valley Police
Page 2 · response
Published 4 August 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

Introduce positional-asphyxia training for student officers covering risks, signs, symptoms, situational awareness, communication and response.

Verbatim wording from the response

“TVP have introduced a PowerPoint presentation on positional asphyxia into our Foundation Training for student officers. This presentation covers the definition of positional asphyxia, the position it may occur in including the increased risk around prone restraint, signs and symptoms and officer response. Officer response is centred on situational awareness, communication and decision-making. These areas promote the use of a safety officer where numbers permit.”

Source location

Response from Thames Valley Police
Page 2 · response
Published 4 August 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

Introduce online Time on Tasks training covering management of subjects restrained in the prone position.

Verbatim wording from the response

“During this training and between the physical exposition and practice, TVP have introduced online training known as Time on Tasks. Mandated topic areas include managing a subject being restrained in the prone position.”

Source location

Response from Thames Valley Police
Page 3 · response
Published 4 August 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

Roll out Upstander e-learning to officers and staff, teaching practical Direct, Distract, Delegate and Delay strategies for speaking up.

Verbatim wording from the response

“In addition, in June 2025, TVP rolled out the College of Policing’s ‘Upstander’ E-Learning to all officers and staff, designed to encourage people to ‘speak up and speak out’. A key part of this training is the 4Ds model, which provides practical strategies for being an effective upstander.”

Source location

Response from Thames Valley Police
Page 5 · response
Published 4 August 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

Expand operational guidance defining when safety officers are used, their responsibilities and officers’ duty to challenge welfare concerns.

Verbatim wording from the response

“TVP have reviewed and expanded its operational guidance on the role of the safety officer. This can found within Mental Health Operational Guidance and follows a section on Acute Behavioural Disorder.”

Source location

Response from Thames Valley Police
Page 2 · response
Published 4 August 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

Include communication and handover protocols in training scenarios and instruct officers to engage actively with medical staff during incidents.

Verbatim wording from the response

“Training scenarios now include communication and handover protocols. Officers are instructed to actively engage with medical staff during incidents.”

Source location

Response from Thames Valley Police
Page 5 · response
Published 4 August 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

Implement scenario-based PPST Foundation and Recertification programmes assessing restraint, decision-making, communication, subject welfare and safety-officer use.

Verbatim wording from the response

“It is of note that there has been considerable National development of PPST by the College of Policing and NPCC, with new Recertification and Foundation programmes, introduced into TVP in November 2023 and April 2024 respectively. The introduction of these training programmes has seen the PPST portfolio evolve significantly since the time of the incident.”

Source location

Response from Thames Valley Police
Page 3 · response
Published 4 August 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 discharge omissions were considered case-specific, not a systemic issue requiring wider policy or practice change.

Verbatim wording from the response

“In the course of investigating Brian’s death and preparing for the inquest, the decision-making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.”

Source location

Response from Milton Keynes University Hospitals
Page 8 · response
Published 4 August 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

Training does not teach elevating or lowering the arms of a handcuffed person to achieve compliance or control.

Verbatim wording from the response

“Following review, TVP have made changes to their handcuffing from prone trainer notes and their ground pin trainer notes. This will provide further clarity on how a subject’s arms are to be restrained during and after the application of handcuffs.”

Source location

Response from Thames Valley Police
Page 2 · response
Published 4 August 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.7

  1. 1

    Embed trauma-informed care through RESPOND training and disseminate Side-by-Side guidance for hospital settings.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
  2. 2

    Add review of liaison-team practices as a standing agenda item at monthly cross-team meetings.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
  3. 3

    Update and share the Mental Health Liaison Team Operational Policy with hospital staff and discuss its changes in staff and interface meetings.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
  4. 4

    Discuss clinical matters in regular individual supervision and multidisciplinary team meetings.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
  5. 5

    Hold a monthly interface meeting with hospital senior management and liaison-team consultants to provide oversight.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
  6. 6

    Review the adult-discharge SOP when Dynamic Documentation is introduced in the Emergency Department to ensure alignment.

    Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 4 August 2025.
  7. 7

    Convene a cross-functional Gold Group to implement organisational learning and monitor the IOPC investigation.

    Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 4 August 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

Embed trauma-informed care through RESPOND training and disseminate Side-by-Side guidance for hospital settings.

Verbatim wording from the response

“We have also embedded trauma-informed care principles through RESPOND training and the dissemination of the Side-by-Side guidance for hospital settings, ensuring staff are equipped to act decisively and collaboratively.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 4 August 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

Add review of liaison-team practices as a standing agenda item at monthly cross-team meetings.

Verbatim wording from the response

“c. Failure to Escalate Concerns We have strengthened our escalation pathways. A standing agenda item has been added to monthly cross-team meetings to review HLT practices. Our Operational Policy now explicitly requires immediate escalation of concerns to the treating medic or nurse in charge.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 4 August 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

Update and share the Mental Health Liaison Team Operational Policy with hospital staff and discuss its changes in staff and interface meetings.

Verbatim wording from the response

“I am responding to the concerns in the order that you have raised them. I would also like to make you aware that the Mental Health Liaison Team (HLT) Operational Policy has been updated and shared with Milton Keynes University Hospital (MKUH). The updates have been discussed at all staff meetings and interface meetings in June and July 2025 to ensure shared understanding.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 4 August 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

Discuss clinical matters in regular individual supervision and multidisciplinary team meetings.

Verbatim wording from the response

“All clinical matters are discussed in regular supervision with individual clinicians and in multidisciplinary team meetings. There is a monthly interface meeting with MKUK attended by senior management and Consultants from the Hospital Liaison Team for oversight.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 4 August 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

Hold a monthly interface meeting with hospital senior management and liaison-team consultants to provide oversight.

Verbatim wording from the response

“All clinical matters are discussed in regular supervision with individual clinicians and in multidisciplinary team meetings. There is a monthly interface meeting with MKUK attended by senior management and Consultants from the Hospital Liaison Team for oversight.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 4 August 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

Review the adult-discharge SOP when Dynamic Documentation is introduced in the Emergency Department to ensure alignment.

Verbatim wording from the response

“In the course of investigating Brian’s death and preparing for the inquest, the decision-making, documentation and processes surrounding his discharge were an area of focus for the Trust in the context of the individual decision making and the actions and inactions of the healthcare professionals involved in his care. To be plain, the omissions were felt to be particular to this case and not a systemic issue requiring a change in wider policy and practice. The forensic level of examination of this issue at inquest enabled the Trust to reflect further on this and to consider whether wider change was in fact necessary to improve safety and make professional expectations explicit in a local context. To that end, the Emergency Department has developed and implemented a Standard Operating Procedure for the discharge of adult patients. This is appended at Appendix 2.”

Source location

Response from Milton Keynes University Hospitals
Page 8 · response
Published 4 August 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

Convene a cross-functional Gold Group to implement organisational learning and monitor the IOPC investigation.

Verbatim wording from the response

“Following the death of Mr Ringrose, a Gold Group was convened and chaired by Assistant Chief Constable Christian Bun. This group had a number of objectives including responding to the investigation conducted by the Independent Office for Police Conduct (IOPC) and the implementation of organisational learning. This group brings together supervisory and specialist staff from relevant policing business areas including Learning and Development, Professional Standards, Response Policing Supervisors and Legal Services. This group also monitors and responds to the investigation conducted by the IOPC.”

Source location

Response from Thames Valley Police
Page 1 · response
Published 4 August 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

Data last updated 7 September 2026