Oladeji Omishore
PFD Report
Partially Responded
Ref: 2025-0160
308 days overdue · 1 response outstanding
Response Status
Responses
1 of 2
56-Day Deadline
20 May 2025
308 days past deadline — 1 response outstanding
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns AI summary
Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial lack of consideration for the individual's mental health state during interaction.
Responses
The MetCC Academy is reviewing and updating training for call handlers to include mental health information earlier. The MPS launched a Taser-specific Community Scrutiny Panel in 2024 and operates a comprehensive Taser use review system to embed de-escalation techniques and learn from deployments.
AI summary
View full response
Dear
Report to Prevent Future Deaths: Mr Oladeji Adeyemi Omishore
On behalf of the Commissioner of Police of the Metropolis, I write to provide a response to the matters of concern addressed to the Metropolitan Police Service (MPS) in your Report to Prevent Future Deaths dated 25th March 2025 following the inquest into the tragic death of Mr Oladeji Adeyemi Omishore.
On behalf of the MPS, may I first of all express my sincere condolences to the family and friends of Mr Omishore and those affected by his death.
I can confirm that the matters of concern you set out within your Regulation 28 report have been carefully considered by senior leaders and practitioners within the MPS and I would now like to formally respond to as follows.
Please note that the MPS response to Matters of Concern 1, 2 5 and 6 is the same.
Matter of Concern 1
“That there is an inconsistency [sic] of approach between call handlers/first responders in the recording of information passed to them by members of the public that may represent a training issue; in this case the mental health matters reported to them”.
MPS Response
The MetCC Academy is currently reviewing the relevant content for First Contact training and will be updating lesson plans to ensure where Mental Health is believed or indicated, the operator will ensure this information is included in the remarks at the earliest opportunity.
Deputy Assistant Commissioner New Scotland Yard Victoria Embankment London SW1A 2JL
2
The MetCC Senior Leadership Team are reviewing whether an amendment should be considered to include this within the “golden line”. A risk assessment will be undertaken before any guidance is implemented.
The MetCC Academy will advise that the National Incident Category List (NICL) code for Mental Health can be used where concerns are raised but not yet confirmed. The changes introduced will focus on reinforcing the importance of including Mental Health indicators in both remarks and NICL codes. This will be implemented in May 2025 for the First Contact Training Course.
Matter of Concern 2
“That the call handlers/ first responders may have a training issue in relation to the importance of recording this information in manner which is likely to be passed on to responding officers by dispatchers, for example in the NICL codes and/ or “golden line”.
MPS Response
See response to Matter of Concern 1.
Matter of Concern 3
“That the above concern of potential training need is highlighted by the increased use of taser in black men and those suffering mental health issues and so the real need for this information to be recorded and passed on in the most effective form. Whilst training for first responders appears to include advice as how to communicate with persons suffering with mental health issues, it does not appear to contain any advice in relation to the importance of such information to be recorded especially in relation to black men”.
MPS Response
The mental health NICL code is sufficient and has a definition attached it, the operator records on both the Computer Aided Despatch (CAD) and Contact Handling System (CHS) along with the ethnicity of the individual as this is a normal practice by our operators, CAD is passed to despatch and forms part of the information relayed to officers. The MetCC Academy are in the process of reviewing their Mental Health training content, additionally operators will be briefed on their Professional Development Days around the importance of the Golden line and specific questioning when dealing with Mental Health related calls and ensuring all information is captured and passed to officers. However, please note that it is more for officers on the frontline to be appraised and aware around use of force against black men with mental health issues than communication officers, who follow a Standard Operating Procedure when dealing with calls, irrespective of race/gender. ‘In addition to this, the MPS Specialist Firearms Command collate data on Taser activations from the mandatory completion of Use of Force Forms when a Taser is drawn or discharged and therefore a person has force exerted on them. This, therefore, includes when a Taser officer does one of the following:
• Red dot
• Drawn
• Arcing
• Drive stun
3
• Firing
• Aimed
• Angle drive stun
The form includes details of the ethnicity of the subject, their gender and whether the subject appears to have a mental health condition. This information is reviewed and the Taser analyst and the Performance and Taser Engagement Team monitor trends which are then fed back into training.’
Matter of Concern 4
“That the limitation of 3 NICL codes makes it difficult to record mental health as a qualifier in incidents such as this where the main risk factor is the weapon”.
MPS Response
The use of three NICL codes is sufficient to record Mental Health in an incident such as this, using the National Standard for Incident Recording (NSIR) Code for Mental Health (O612). This qualifier can be used to endorse an incident involving a person who has or appears to be suffering from a mental health disorder or mental impairment including learning difficulties.
The use of the qualifier above negates the need to use O625 (Believed Mental Health) in conjunction with O612 (Mental Health) as this is covered by “appears to be suffering”. Any additional information surrounding mental health can be added to the remarks.
Adding an additional ‘Opening Code’ field to the Command and Control (C&C) system is a technical piece of work involving multiple platforms. We are in contact with our C&C IT Support Unit and are scoping out the project to determine if this can be applied to our system.
The 2011 NSIR document and the new proposed NSIRA is still under review by the National Police Chiefs’ Council (NPCC) and describes the qualifier for Mental Health.
Matter of Concern 5
“That call handlers/first responders may need training as to where to record such information
i.e. in the “golden line” or NCIL code, as long as of course it is reported to them before the “golden line” and NICL code has gone out”.
MPS Response
See response to Matter of Concern 1.
Matter of Concern 6
“That use of THRIVE usually requires time that is not available in I grade calls and does not mitigate the need to circulate promptly information as to mental health issues, in the format most likely to digested and passed on by dispatchers that is “golden line” or NICL codes”.
MPS Response
See response to Matter of Concern 1.
Matter of Concern 7
4
“That the lack of NICL code “mental health believed” compounds this”.
MPS Response
The NSIR 2011 document and the new proposed NSIRA (National Standard of Incident Reporting and Assessment) document are still under review by the NPCC and describes the qualifier for Mental Health as follows:
“Mental Health qualifier – this Qualifier can be used to endorse an incident involving a person who has, appears to be suffering from a mental health disorder or mental health impairment including learning difficulties”.
The use of the qualifier negates the need to use O625 (Believed) in conjunction with O612 (Mental Health) as this is covered by “appears to be suffering” and any additional information/justification for using this code can be added to the ‘remarks’. There is no requirement to introduce a new code for “Mental Health Believed”.
Matter of Concern 8
“That dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health”.
MPS Response
We acknowledge the importance of despatchers being fully aware of and training in recognising and relaying possible mental health concerns. Lesson plans for the MetCC Academy Despatch Course will be updated to explicitly emphasise the importance of passing on such information over the airwaves, particularly in light of the increased use of Taser involving black men and individuals suffering from mental ill health.
This will include ensuring that despatchers are trained to pass on mental health concerns (believed or otherwise) to officers at the earliest opportunity. Training leads will be instructed to make the relevant updates to course materials, and copies of lesson plans and change logs will be provided to all parties once finalised.
MetCC Academy will work alongside our Operational Support Teams to support the development of a briefing pack to roll out to staff. This will be implemented in May 2025 which is the start of the Despatch Course.
Matter of Concern 9
“That dispatchers may require training in relation to what to pass out more generally given the confusion in the evidence about other units being assigned by CAD, which dispatchers themselves did not seen to appreciate and understand let alone pass such information out to responding officers”.
MPS Response
We recognise the need for greater clarity and understanding among despatchers regarding what information needs to be communicated more generally. Training will be enhanced to address the confusion identified in the evidence, specifically in relation to other units being assigned via Computer Aided Despatch (CAD) and the necessity for despatchers to fully understand and communicate this to responding officers. Lesson plans will be updated accordingly.
5
The Despatch Course Leads met in April 2025 to review and discuss the incorporation of this content into the new Academy Despatch Course. This included ensuring that despatchers are trained to pass on mental health concerns (believed or otherwise) to officers at the earliest opportunity.
We have amended our internal Despatch Policy to state that despatchers should circulate over the radio the call signs of off-Basic Command Units (BCUs) assigned to calls. This is to ensure units assigned from the BCU where the incident originated, are aware of off-BCU units having been assigned as they will have been despatched via a different radio channel.
Training leads will be instructed to make the relevant updates to course materials, and copies of lesson plans and change logs will be provided to all parties once finalised.
MetCC Academy will be working alongside Operation Support to support the development of a briefing pack for current staff, and will explore the possibility of including this within Professional Development Days. This will be implemented in May 2025 at the start of the Despatch Course.
Matter of Concern 10
“That there are apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves, given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call”.
MPS Response
We note the concerns regarding the potential systemic failures within the individual pods within despatch. Training will be updated to ensure despatchers are equipped to pass on key information, including mental health concerns and the number of units en route, given the importance of this information in informing officers’ application of the National Decision Model. This will also be incorporated into revised lesson plans.
Training leads will be instructed to make the relevant updates to course materials, and copies of lesson plans and change logs will be provided to all parties once finalised.
MetCC Academy will work alongside our Operational Support Teams to support the development of a briefing pack to roll out to staff, as the start of the Despatch Course in May
2025.
Matter of Concern 11
“That training for response officers may require review in relation to tactical options used to de-escalate prior to taser deployment, in appropriate circumstances, given the increased use of taser in black men with mental health issues; and in particular, training in relation to deploying with taser drawn and pointed with accompanying commanding language where the subject may be suffering with mental ill-health”.
MPS Response
The Metropolitan Police Service acknowledges the concerns raised regarding the tactical options employed by response officers, particularly with respect to the deployment of Tasers in circumstances involving black men with mental health issues. We appreciate the opportunity
6
to address the matters relating to officer training and the measures taken to ensure the de- escalation of situations prior to Taser deployment. Personal & Public Safety Training (PPST) The foundation of all officer training begins with the Personal & Public Safety Training (PPST), which equips officers with essential skills in the use of force, their powers under the law, and de-escalation techniques. These are delivered comprehensively during an officer’s initial training and are reinforced annually through mandatory refresher sessions. Within Module 6 of the Personal Safety Manual (PSM) officers are taught possible indicators of mental ill health and strategies for de-escalation as a key element in resolving conflicts peacefully. They are taught the ICRC model (Intervention, Calm, Rapport & Control) and are assessed on their ability to apply these techniques in various scenarios. Taser Training as an additional tactical option The training for Taser deployment builds upon the existing framework provided through PPST. Officers are required to successfully complete the foundational training before applying and being considered to be a Specially Trained Officer (aka Taser equipped officer). This ensures that the principles of de-escalation are firmly embedded prior to their introduction to Taser as an additional tactical option. Taser training emphasizes that Tasers are one of many tools available and not as a panacea for conflicts. The application process to become a Taser trained officer includes being supported by first and second line managers and finally approval from their Chief Superintendent (or deputy) before they can attempt to complete the training. Enhanced Focus on De-escalation Techniques In recent years, significant enhancements have been made to the Taser curriculum to further emphasise de-escalation and conflict management. These efforts align with guidance outlined by the College of Policing, as detailed on their Conflict Management Skills page. The Taser training incorporates these principles, including the mnemonic BUGEE, which encourages officers to:
• Be prepared to back off
• Use of effective cover
• Give space and time if possible
• Early negotiation
• Evacuate immediate area Officers are thoroughly trained to apply BUGEE as part of their decision-making process, and as additional training to support and reaffirm what they are taught in their PPST Findings from the TASERD Study The TASERD paper, commissioned by the National Police Chiefs’ Council (NPCC) in 2019 and conducted by Keele University, highlighted the importance of enhancing de-escalation training for all officers, not solely those qualified in Taser deployment. The study recommended that additional de-escalation training would be a benefit for all officers across the service and not just Taser equipped officers. Integration of PPST and Taser Training
7
The suggestion to rebrand Taser training as "PPST Part 2" has been positively received by the working party examining improvements in Taser training. This approach underscores the continuity of officer education and reinforces the concept that de-escalation remains a cornerstone of all tactical decision-making. By positioning Taser training as an extension of PPST, officers are reminded of their fundamental duty to seek peaceful resolutions wherever possible. It also highlights to external partners that Taser training is not stand-alone training; it is one part of a range of training delivered to police officers around dealing with persons with mental ill health, conflict management skills and use of forces powers. Ongoing Curriculum Development The College of Policing is actively pursuing a comprehensive review of the Taser curriculum. The latest iteration, Version 7, which commenced in the MPS on 31st March 2025, places additional emphasis on de-escalation techniques. Scenario-based assessments now include specific criteria for dealing with individuals in Emotional or Mental Distress (EMD) or vulnerable persons. Officers are evaluated on their ability to use BUGEE and other conflict management skills to de-escalate situations effectively. This ensures that officers are not only trained but rigorously assessed in their capability to handle sensitive and challenging circumstances. Commitment to Continuous Improvement The Metropolitan Police Service remains committed to ensuring the highest standards in officer training. We recognize the importance of adapting to emerging challenges and societal concerns, and we are continuously refining our training programs to meet these needs. Our collaboration with the College of Policing and adherence to evidence-based research, such as the TASERD study, demonstrates our dedication to embedding de-escalation techniques in all aspects of officer training. In 2024 the MPS launched a Taser specific Community Scrutiny Panel to allow Taser incidents and use to be viewed by a panel from the community and feed back into training. This has led towards the MPS being more transparency and accountable. The views of the panel are fed back to the officer. This is particularly powerful feedback as it informs the officer as to how a jury may perceive their actions and use, particularly when the justification has not been properly explained. The MPS also have a comprehensive Taser use review system where a dedicated team review every Taser activation, any Taser use on under 18’s, at height, subjects running away, in custody, and over 65years. In addition to this the team review all uses on the Basic Command Units (BCU) each month (meaning each BCU has all their Taser use reviewed once a year). Where Taser use falls outside of training not accounted for, not justifiable or not appropriate then officers (list is not exhaustive) then the incident is flagged and can be dealt with in a range of ways from a learning debrief to referral to the DPS. The MPS acknowledge the vital importance of ensuring that tactical decisions made by our officers prioritise safety and fairness for all individuals, particularly those from vulnerable communities or those experiencing mental health crises. By enhancing de-escalation training and embedding these principles into both PPST and Taser training, we aim to reduce the need for Taser deployment and build greater trust within the communities we serve. I hope this correspondence addresses the concerns set out within your report and please do not hesitate to contact me should you require further information from the MPS. In closing, please may I extend, once again, my deepest sympathies to the family and friends of Mr Omishore.
8
Report to Prevent Future Deaths: Mr Oladeji Adeyemi Omishore
On behalf of the Commissioner of Police of the Metropolis, I write to provide a response to the matters of concern addressed to the Metropolitan Police Service (MPS) in your Report to Prevent Future Deaths dated 25th March 2025 following the inquest into the tragic death of Mr Oladeji Adeyemi Omishore.
On behalf of the MPS, may I first of all express my sincere condolences to the family and friends of Mr Omishore and those affected by his death.
I can confirm that the matters of concern you set out within your Regulation 28 report have been carefully considered by senior leaders and practitioners within the MPS and I would now like to formally respond to as follows.
Please note that the MPS response to Matters of Concern 1, 2 5 and 6 is the same.
Matter of Concern 1
“That there is an inconsistency [sic] of approach between call handlers/first responders in the recording of information passed to them by members of the public that may represent a training issue; in this case the mental health matters reported to them”.
MPS Response
The MetCC Academy is currently reviewing the relevant content for First Contact training and will be updating lesson plans to ensure where Mental Health is believed or indicated, the operator will ensure this information is included in the remarks at the earliest opportunity.
Deputy Assistant Commissioner New Scotland Yard Victoria Embankment London SW1A 2JL
2
The MetCC Senior Leadership Team are reviewing whether an amendment should be considered to include this within the “golden line”. A risk assessment will be undertaken before any guidance is implemented.
The MetCC Academy will advise that the National Incident Category List (NICL) code for Mental Health can be used where concerns are raised but not yet confirmed. The changes introduced will focus on reinforcing the importance of including Mental Health indicators in both remarks and NICL codes. This will be implemented in May 2025 for the First Contact Training Course.
Matter of Concern 2
“That the call handlers/ first responders may have a training issue in relation to the importance of recording this information in manner which is likely to be passed on to responding officers by dispatchers, for example in the NICL codes and/ or “golden line”.
MPS Response
See response to Matter of Concern 1.
Matter of Concern 3
“That the above concern of potential training need is highlighted by the increased use of taser in black men and those suffering mental health issues and so the real need for this information to be recorded and passed on in the most effective form. Whilst training for first responders appears to include advice as how to communicate with persons suffering with mental health issues, it does not appear to contain any advice in relation to the importance of such information to be recorded especially in relation to black men”.
MPS Response
The mental health NICL code is sufficient and has a definition attached it, the operator records on both the Computer Aided Despatch (CAD) and Contact Handling System (CHS) along with the ethnicity of the individual as this is a normal practice by our operators, CAD is passed to despatch and forms part of the information relayed to officers. The MetCC Academy are in the process of reviewing their Mental Health training content, additionally operators will be briefed on their Professional Development Days around the importance of the Golden line and specific questioning when dealing with Mental Health related calls and ensuring all information is captured and passed to officers. However, please note that it is more for officers on the frontline to be appraised and aware around use of force against black men with mental health issues than communication officers, who follow a Standard Operating Procedure when dealing with calls, irrespective of race/gender. ‘In addition to this, the MPS Specialist Firearms Command collate data on Taser activations from the mandatory completion of Use of Force Forms when a Taser is drawn or discharged and therefore a person has force exerted on them. This, therefore, includes when a Taser officer does one of the following:
• Red dot
• Drawn
• Arcing
• Drive stun
3
• Firing
• Aimed
• Angle drive stun
The form includes details of the ethnicity of the subject, their gender and whether the subject appears to have a mental health condition. This information is reviewed and the Taser analyst and the Performance and Taser Engagement Team monitor trends which are then fed back into training.’
Matter of Concern 4
“That the limitation of 3 NICL codes makes it difficult to record mental health as a qualifier in incidents such as this where the main risk factor is the weapon”.
MPS Response
The use of three NICL codes is sufficient to record Mental Health in an incident such as this, using the National Standard for Incident Recording (NSIR) Code for Mental Health (O612). This qualifier can be used to endorse an incident involving a person who has or appears to be suffering from a mental health disorder or mental impairment including learning difficulties.
The use of the qualifier above negates the need to use O625 (Believed Mental Health) in conjunction with O612 (Mental Health) as this is covered by “appears to be suffering”. Any additional information surrounding mental health can be added to the remarks.
Adding an additional ‘Opening Code’ field to the Command and Control (C&C) system is a technical piece of work involving multiple platforms. We are in contact with our C&C IT Support Unit and are scoping out the project to determine if this can be applied to our system.
The 2011 NSIR document and the new proposed NSIRA is still under review by the National Police Chiefs’ Council (NPCC) and describes the qualifier for Mental Health.
Matter of Concern 5
“That call handlers/first responders may need training as to where to record such information
i.e. in the “golden line” or NCIL code, as long as of course it is reported to them before the “golden line” and NICL code has gone out”.
MPS Response
See response to Matter of Concern 1.
Matter of Concern 6
“That use of THRIVE usually requires time that is not available in I grade calls and does not mitigate the need to circulate promptly information as to mental health issues, in the format most likely to digested and passed on by dispatchers that is “golden line” or NICL codes”.
MPS Response
See response to Matter of Concern 1.
Matter of Concern 7
4
“That the lack of NICL code “mental health believed” compounds this”.
MPS Response
The NSIR 2011 document and the new proposed NSIRA (National Standard of Incident Reporting and Assessment) document are still under review by the NPCC and describes the qualifier for Mental Health as follows:
“Mental Health qualifier – this Qualifier can be used to endorse an incident involving a person who has, appears to be suffering from a mental health disorder or mental health impairment including learning difficulties”.
The use of the qualifier negates the need to use O625 (Believed) in conjunction with O612 (Mental Health) as this is covered by “appears to be suffering” and any additional information/justification for using this code can be added to the ‘remarks’. There is no requirement to introduce a new code for “Mental Health Believed”.
Matter of Concern 8
“That dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health”.
MPS Response
We acknowledge the importance of despatchers being fully aware of and training in recognising and relaying possible mental health concerns. Lesson plans for the MetCC Academy Despatch Course will be updated to explicitly emphasise the importance of passing on such information over the airwaves, particularly in light of the increased use of Taser involving black men and individuals suffering from mental ill health.
This will include ensuring that despatchers are trained to pass on mental health concerns (believed or otherwise) to officers at the earliest opportunity. Training leads will be instructed to make the relevant updates to course materials, and copies of lesson plans and change logs will be provided to all parties once finalised.
MetCC Academy will work alongside our Operational Support Teams to support the development of a briefing pack to roll out to staff. This will be implemented in May 2025 which is the start of the Despatch Course.
Matter of Concern 9
“That dispatchers may require training in relation to what to pass out more generally given the confusion in the evidence about other units being assigned by CAD, which dispatchers themselves did not seen to appreciate and understand let alone pass such information out to responding officers”.
MPS Response
We recognise the need for greater clarity and understanding among despatchers regarding what information needs to be communicated more generally. Training will be enhanced to address the confusion identified in the evidence, specifically in relation to other units being assigned via Computer Aided Despatch (CAD) and the necessity for despatchers to fully understand and communicate this to responding officers. Lesson plans will be updated accordingly.
5
The Despatch Course Leads met in April 2025 to review and discuss the incorporation of this content into the new Academy Despatch Course. This included ensuring that despatchers are trained to pass on mental health concerns (believed or otherwise) to officers at the earliest opportunity.
We have amended our internal Despatch Policy to state that despatchers should circulate over the radio the call signs of off-Basic Command Units (BCUs) assigned to calls. This is to ensure units assigned from the BCU where the incident originated, are aware of off-BCU units having been assigned as they will have been despatched via a different radio channel.
Training leads will be instructed to make the relevant updates to course materials, and copies of lesson plans and change logs will be provided to all parties once finalised.
MetCC Academy will be working alongside Operation Support to support the development of a briefing pack for current staff, and will explore the possibility of including this within Professional Development Days. This will be implemented in May 2025 at the start of the Despatch Course.
Matter of Concern 10
“That there are apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves, given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call”.
MPS Response
We note the concerns regarding the potential systemic failures within the individual pods within despatch. Training will be updated to ensure despatchers are equipped to pass on key information, including mental health concerns and the number of units en route, given the importance of this information in informing officers’ application of the National Decision Model. This will also be incorporated into revised lesson plans.
Training leads will be instructed to make the relevant updates to course materials, and copies of lesson plans and change logs will be provided to all parties once finalised.
MetCC Academy will work alongside our Operational Support Teams to support the development of a briefing pack to roll out to staff, as the start of the Despatch Course in May
2025.
Matter of Concern 11
“That training for response officers may require review in relation to tactical options used to de-escalate prior to taser deployment, in appropriate circumstances, given the increased use of taser in black men with mental health issues; and in particular, training in relation to deploying with taser drawn and pointed with accompanying commanding language where the subject may be suffering with mental ill-health”.
MPS Response
The Metropolitan Police Service acknowledges the concerns raised regarding the tactical options employed by response officers, particularly with respect to the deployment of Tasers in circumstances involving black men with mental health issues. We appreciate the opportunity
6
to address the matters relating to officer training and the measures taken to ensure the de- escalation of situations prior to Taser deployment. Personal & Public Safety Training (PPST) The foundation of all officer training begins with the Personal & Public Safety Training (PPST), which equips officers with essential skills in the use of force, their powers under the law, and de-escalation techniques. These are delivered comprehensively during an officer’s initial training and are reinforced annually through mandatory refresher sessions. Within Module 6 of the Personal Safety Manual (PSM) officers are taught possible indicators of mental ill health and strategies for de-escalation as a key element in resolving conflicts peacefully. They are taught the ICRC model (Intervention, Calm, Rapport & Control) and are assessed on their ability to apply these techniques in various scenarios. Taser Training as an additional tactical option The training for Taser deployment builds upon the existing framework provided through PPST. Officers are required to successfully complete the foundational training before applying and being considered to be a Specially Trained Officer (aka Taser equipped officer). This ensures that the principles of de-escalation are firmly embedded prior to their introduction to Taser as an additional tactical option. Taser training emphasizes that Tasers are one of many tools available and not as a panacea for conflicts. The application process to become a Taser trained officer includes being supported by first and second line managers and finally approval from their Chief Superintendent (or deputy) before they can attempt to complete the training. Enhanced Focus on De-escalation Techniques In recent years, significant enhancements have been made to the Taser curriculum to further emphasise de-escalation and conflict management. These efforts align with guidance outlined by the College of Policing, as detailed on their Conflict Management Skills page. The Taser training incorporates these principles, including the mnemonic BUGEE, which encourages officers to:
• Be prepared to back off
• Use of effective cover
• Give space and time if possible
• Early negotiation
• Evacuate immediate area Officers are thoroughly trained to apply BUGEE as part of their decision-making process, and as additional training to support and reaffirm what they are taught in their PPST Findings from the TASERD Study The TASERD paper, commissioned by the National Police Chiefs’ Council (NPCC) in 2019 and conducted by Keele University, highlighted the importance of enhancing de-escalation training for all officers, not solely those qualified in Taser deployment. The study recommended that additional de-escalation training would be a benefit for all officers across the service and not just Taser equipped officers. Integration of PPST and Taser Training
7
The suggestion to rebrand Taser training as "PPST Part 2" has been positively received by the working party examining improvements in Taser training. This approach underscores the continuity of officer education and reinforces the concept that de-escalation remains a cornerstone of all tactical decision-making. By positioning Taser training as an extension of PPST, officers are reminded of their fundamental duty to seek peaceful resolutions wherever possible. It also highlights to external partners that Taser training is not stand-alone training; it is one part of a range of training delivered to police officers around dealing with persons with mental ill health, conflict management skills and use of forces powers. Ongoing Curriculum Development The College of Policing is actively pursuing a comprehensive review of the Taser curriculum. The latest iteration, Version 7, which commenced in the MPS on 31st March 2025, places additional emphasis on de-escalation techniques. Scenario-based assessments now include specific criteria for dealing with individuals in Emotional or Mental Distress (EMD) or vulnerable persons. Officers are evaluated on their ability to use BUGEE and other conflict management skills to de-escalate situations effectively. This ensures that officers are not only trained but rigorously assessed in their capability to handle sensitive and challenging circumstances. Commitment to Continuous Improvement The Metropolitan Police Service remains committed to ensuring the highest standards in officer training. We recognize the importance of adapting to emerging challenges and societal concerns, and we are continuously refining our training programs to meet these needs. Our collaboration with the College of Policing and adherence to evidence-based research, such as the TASERD study, demonstrates our dedication to embedding de-escalation techniques in all aspects of officer training. In 2024 the MPS launched a Taser specific Community Scrutiny Panel to allow Taser incidents and use to be viewed by a panel from the community and feed back into training. This has led towards the MPS being more transparency and accountable. The views of the panel are fed back to the officer. This is particularly powerful feedback as it informs the officer as to how a jury may perceive their actions and use, particularly when the justification has not been properly explained. The MPS also have a comprehensive Taser use review system where a dedicated team review every Taser activation, any Taser use on under 18’s, at height, subjects running away, in custody, and over 65years. In addition to this the team review all uses on the Basic Command Units (BCU) each month (meaning each BCU has all their Taser use reviewed once a year). Where Taser use falls outside of training not accounted for, not justifiable or not appropriate then officers (list is not exhaustive) then the incident is flagged and can be dealt with in a range of ways from a learning debrief to referral to the DPS. The MPS acknowledge the vital importance of ensuring that tactical decisions made by our officers prioritise safety and fairness for all individuals, particularly those from vulnerable communities or those experiencing mental health crises. By enhancing de-escalation training and embedding these principles into both PPST and Taser training, we aim to reduce the need for Taser deployment and build greater trust within the communities we serve. I hope this correspondence addresses the concerns set out within your report and please do not hesitate to contact me should you require further information from the MPS. In closing, please may I extend, once again, my deepest sympathies to the family and friends of Mr Omishore.
8
Action Should Be Taken
It is for each addressee to respond to matters relevant to them.
Report Sections
Investigation and Inquest
From 3rd March to 24th March 2025, evidence was heard before a jury touching the death of Mr Oladeji Adeyemi Omishore. He had died on the 4th June 2022, aged 41 years, in ITU at St Thomas’s Hospital. He had died following an incident involving police officers on Chelsea Bridge during which he was tasered a number of times and then jumped into the River Thames.
Medical Cause of Death
1 a. Complications arising from drowning
How, when, where and in what circumstances the deceased came by his death; and conclusions as recorded by the jury [in this case by combining boxes 3 and 4 of the Record of Inquest] : on 4th June 2022, Mr Omishore was suffering with a relapse of schizoaffective disorder/psychosis. In October 2019 he had suffered his first episode of schizoaffective disorder/psychosis based on medical evidence we have heard and accepted. He continued to receive care and deemed stable by the health care team in March 2022. Recent cannabis use likely caused or contributed to this relapse of his illness. We have considered and noted his previous behaviour when psychiatrically unwell. Mr Omishore left his home on the morning of 4th June 2022 shouting in the middle of the road and waving what is now known to be a firelighter. This prompted a number of 999 calls from members of the public. Amongst other things, the public raised shouting religious remarks, a perceived weapon, aggressive behaviour and that he seemed mentally unwell.
The call handlers determined critical information and passed to dispatchers which included location, weapon and description, with all calls being graded I grade (immediate response). Responding police officers were told by dispatchers the location, suspicious circumstances, weapons and a brief description via the airwaves. Mental health (MH) was not passed over the airwaves. We note from witnesses this should and could have been passed over the airwaves. The call was accepted by the responding officers at 09:03:54. It was accepted 20 seconds after it was put over the airwaves. The response officers understood they were responding to an I grade call on Chelsea Bridge Road, which they were aware had at least 3 I grades. When the response officers arrived, Mr Omishore was in the middle of the road on the North side of Chelsea Bridge when the officers first saw him. The officers perceived him to be holding a screwdriver. The taser trained officer gave evidence to say he did not initially consider possible MH issues. The non-taser trained officer gave evidence he did consider MH issues during the incident. The response officers gave evidence that they believed this was a genuine threat and took a risk assessment in line with NDM. The response officers arrived at 09:05:43 and the taser officer got out the car with taser drawn and shouted commands to identify himself as a police officer and to draw attention to the taser. Following lack of compliance to drop the object, the taser officer fired the first taser at 09:06:15, in response to non-compliance and movement in the direction of the ono-taser officer. Mr Omishore dropped to the ground and dropped the object. Following the first taser, Mr Omishore was rolling around on the ground and was not under control. The non-taser officer kicked the object away from reach. Mr Omishore attempted to get up and swiped towards the non taser officer and there was a second discharge. The second taser did not allow control of Mr Omishore. Following the third taser discharge, Mr Omishore got up and jumped over the pedestrian barrier. The non-taser officer followed. Mr Omishore swung his hand towards the non-taser officer and knocked the handcuffs out of his hand. The taser officer deployed the second and final cartridge to stop Mr Omishore. Mr Omishore jumped off Chelsea Bridge and into the River Thames at 09:06:53-55. He was rescued at 09:18 and was given CPR and taken to St Thomas’s Hospital. He was recognised as life extinct on ITU at St Thomas’s Hospital at 20:29 on 4th June 2022.
Matters that we find possibly caused or contributed to the death.
Despite the response officers having all required training, the use of the taser did not achieve full NMI. Had the officers been able to achieve full NMI, there is a possibility they could have gained control of Mr Omishore and therefore the inability to achieve full NMI and gain control of Mr Omishore possibly contributed to his death.
Information from members of the public (that in their opinion Mr Omishore was suffering from a mental health crisis) was not passed to responding officers before they arrived at the scene. We have heard evidence that such information should and could have been passed on. We have also heard evidence from the responding officers that such information would not have changed their approach.
The majority of the jury find that, had mental health concerns been passed over the airwaves, it is possible this may have had an impact on the sequence of events that may have contributed to Mr Omishore’s death.
Probable Causes
Mr Omishore had suffered a relapse of schizoaffective disorder/psychosis and was severely unwell. This illness affected his understanding and was the likely cause of his actions on Chelsea Bridge Road and Chelsea Bridge prior to and after the arrival of the police. It is likely that he was frightened by what he was seeing and what he thought he was seeing and lacked insight.
Whilst the body worn and phone footage show him running away from police after he had been tasered for the third time, it cannot be concluded that the actions of the police probably caused his death. Evidence relevant to the matters of concern.
Extensive evidence was taken and exhibited and some potential regulation 28 matters explored. Please see the detailed findings of the jury laid out above. Of relevance to this report:
1. Mr Omishore had been observed by multiple members of the public on Chelsea Bridge Road and then on Chelsea Bridge, in the minutes leading up to the incident behaving in a manner that suggested he was mentally unwell. There were 7 calls by members of the public to the Metropolitan Police to report concerns and in 3 out of 7 of these calls the member of the public told the call handlers/first responders that Mr Omishore appeared mentally unwell. This was only recorded by one call handler on the CHS system and passed to the CAD and thus dispatchers in “remarks.” This information was never transmitted over the airwaves to the responding officers and so could not have been considered in their NDMs prior to their arrival at the scene. The responding officers had no access to CADs to undertake their own assessment prior to arriving at the incident due to a combination of lack of time to start their computer tablet and to load and search CADs due to the immediacy of their arrival and the IVMA was not working. They were thus reliant on the information passed to them over the radio. Only one radio channel was used in this incident.
2. Extensive evidence was taken in relation to this matter. In summary: call handlers stated that given the main threat was that Mr Omishore had been reported as carrying a weapon, either knife or screwdriver, they regarded mental health as a secondary matter and did not put the information in the “golden line”, and indeed two did not record it all. Neither was the information recorded in the NICL codes. The main reasons given for this was that in their views, the NICL codes should list the main risk factors, only three are available and if a mental health NICL code was recorded then it would need a further code qualifying it as “believed” as the information was unconfirmed as reported by a member of the public rather than a health care professional, or relative with first-hand knowledge of the subject. There was also mention of the officers’ duties to consider such matters once they have arrived at the scene of an incident.
3. Several witnesses stated that a code “mental health believed” would be of assistance as then there would likely have been enough NICL codes available for it to be used. There was some inconsistency therefore between whether it should be recorded at all, and if so where it should have been recorded.
4. To be clear it was accepted in the evidence that mental health should have been recorded and passed out over the airwaves to responding officers as it would have assisted those officers in their NDM considerations.
5. The evidence from dispatchers based at AWS, was that the information in relation to possible mental health matters should have been recorded and passed to them to put out. It was clear from the evidence that the information that was passed to dispatchers was not put out in error-it was simply missed.
6. These dispatchers described how they relied on information in the “golden line” and NICL codes to get information out onto the radio asap, and so it could be inferred that had information in relation to mental health issues been recorded either in the “golden line” or NICL codes it would have been likely to have been transmitted by them.
7. Analysis of various CADs as part of the evidence also showed that several units (up to 6, it was difficult to understand) had been allocated to respond to this incident in addition to three units heard to respond over the airwave radio. None of this potentially important information was passed over the airwaves, and again therefore could not have been considered by responding officers and thus feed into their NDMs.
8. The incident was being monitored in dispatch AWS by a controller performing multiple tasks who had also missed the remarks in relation to mental health and not passed on information over the airwaves in relation to units assigned by CAD from another geographic dispatch pod (AWC) over the airwave radio.
9. Evidence was also taken in relation to the increased use of taser in black men and those persons with mental health needs and the training given to staff and officers in relation to these matters.
10. Evidence was taken in relation to THRIVE .
11. In relation to the response of the officers, the taser armed officer deployed with his taser drawn and pointed at Mr Omishore and did not consider mental health as a possible cause for Mr Omishore’s actions until after the first use of the taser. However, had he been provided with information that Mr Omishore appeared to be suffered with mental ill health prior to his arrival at the scene, this could have fed into his NDM and may have affected the manner of his deployment. This may have reduced the risk of escalation arsing not only from sight of the taser but also the training requirement to use clear and commanding language to a subject once a taser has been deployed. Such language is different in tone and style to that taught to officers to use when attempting to de-escalate a situation where the subject is suffering mental distress. These matters could not be found to have likely affected the outcome in this case. Matters of Concern
1. That there is an inconsistancy of approach between call handlers/first responders in the recording of information passed to them by members of the public that may represent a training issue; in this case the mental health matters reported to them.
2. That the call handlers/ first responders may have a training issue in relation to the importance of recording this information in manner which is likely to be passed on to responding officers by dispatchers, for example in the NICL codes and/ or “golden line”.
3. That the above concern of potential training need is highlighted by the increased use of taser in black men and those suffering mental health issues and so the real need for this information to be recorded and passed on in the most effective form. Whilst training for first responders appears to include advice as how to communicate with persons suffering with mental health issues, it does not appear to contain any advice in relation to the importance of such information to be recorded especially in relation to black men.
4. That the limitation of 3 NICL codes makes it difficult to record mental health as a qualifier in incidents such as this where the main risk factor is the weapon.
5. That call handlers/first responders may need training as to where to record such information i.e. in the “golden line” or NCIL code, as long as of course it is reported to them before the “golden line” and NICL code has gone out.
6. That use of THRIVE usually requires time that is not available in I grade calls and does not mitigate the need to circulate promptly information as to mental health issues, in the format most likely to digested and passed on by dispatchers that is “golden line” or NICL codes.
7. That the lack of NICL code “mental health believed” compounds this.
8. That dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health.
9. That dispatchers may require training in relation to what to pass out more generally given the confusion in the evidence about other units being assigned by CAD, which dispatchers themselves did not seen to appreciate and understand let alone pass such information out to responding officers.
10. That there are apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves, given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call.
11. That training for response officers may require review in relation to tactical options used to de-escalate prior to taser deployment, in appropriate circumstances, given the increased use of taser in black men with mental health issues; and in particular, training in relation to deploying with taser drawn and pointed with accompanying commanding language where the subject may be suffering with mental ill-health.
Medical Cause of Death
1 a. Complications arising from drowning
How, when, where and in what circumstances the deceased came by his death; and conclusions as recorded by the jury [in this case by combining boxes 3 and 4 of the Record of Inquest] : on 4th June 2022, Mr Omishore was suffering with a relapse of schizoaffective disorder/psychosis. In October 2019 he had suffered his first episode of schizoaffective disorder/psychosis based on medical evidence we have heard and accepted. He continued to receive care and deemed stable by the health care team in March 2022. Recent cannabis use likely caused or contributed to this relapse of his illness. We have considered and noted his previous behaviour when psychiatrically unwell. Mr Omishore left his home on the morning of 4th June 2022 shouting in the middle of the road and waving what is now known to be a firelighter. This prompted a number of 999 calls from members of the public. Amongst other things, the public raised shouting religious remarks, a perceived weapon, aggressive behaviour and that he seemed mentally unwell.
The call handlers determined critical information and passed to dispatchers which included location, weapon and description, with all calls being graded I grade (immediate response). Responding police officers were told by dispatchers the location, suspicious circumstances, weapons and a brief description via the airwaves. Mental health (MH) was not passed over the airwaves. We note from witnesses this should and could have been passed over the airwaves. The call was accepted by the responding officers at 09:03:54. It was accepted 20 seconds after it was put over the airwaves. The response officers understood they were responding to an I grade call on Chelsea Bridge Road, which they were aware had at least 3 I grades. When the response officers arrived, Mr Omishore was in the middle of the road on the North side of Chelsea Bridge when the officers first saw him. The officers perceived him to be holding a screwdriver. The taser trained officer gave evidence to say he did not initially consider possible MH issues. The non-taser trained officer gave evidence he did consider MH issues during the incident. The response officers gave evidence that they believed this was a genuine threat and took a risk assessment in line with NDM. The response officers arrived at 09:05:43 and the taser officer got out the car with taser drawn and shouted commands to identify himself as a police officer and to draw attention to the taser. Following lack of compliance to drop the object, the taser officer fired the first taser at 09:06:15, in response to non-compliance and movement in the direction of the ono-taser officer. Mr Omishore dropped to the ground and dropped the object. Following the first taser, Mr Omishore was rolling around on the ground and was not under control. The non-taser officer kicked the object away from reach. Mr Omishore attempted to get up and swiped towards the non taser officer and there was a second discharge. The second taser did not allow control of Mr Omishore. Following the third taser discharge, Mr Omishore got up and jumped over the pedestrian barrier. The non-taser officer followed. Mr Omishore swung his hand towards the non-taser officer and knocked the handcuffs out of his hand. The taser officer deployed the second and final cartridge to stop Mr Omishore. Mr Omishore jumped off Chelsea Bridge and into the River Thames at 09:06:53-55. He was rescued at 09:18 and was given CPR and taken to St Thomas’s Hospital. He was recognised as life extinct on ITU at St Thomas’s Hospital at 20:29 on 4th June 2022.
Matters that we find possibly caused or contributed to the death.
Despite the response officers having all required training, the use of the taser did not achieve full NMI. Had the officers been able to achieve full NMI, there is a possibility they could have gained control of Mr Omishore and therefore the inability to achieve full NMI and gain control of Mr Omishore possibly contributed to his death.
Information from members of the public (that in their opinion Mr Omishore was suffering from a mental health crisis) was not passed to responding officers before they arrived at the scene. We have heard evidence that such information should and could have been passed on. We have also heard evidence from the responding officers that such information would not have changed their approach.
The majority of the jury find that, had mental health concerns been passed over the airwaves, it is possible this may have had an impact on the sequence of events that may have contributed to Mr Omishore’s death.
Probable Causes
Mr Omishore had suffered a relapse of schizoaffective disorder/psychosis and was severely unwell. This illness affected his understanding and was the likely cause of his actions on Chelsea Bridge Road and Chelsea Bridge prior to and after the arrival of the police. It is likely that he was frightened by what he was seeing and what he thought he was seeing and lacked insight.
Whilst the body worn and phone footage show him running away from police after he had been tasered for the third time, it cannot be concluded that the actions of the police probably caused his death. Evidence relevant to the matters of concern.
Extensive evidence was taken and exhibited and some potential regulation 28 matters explored. Please see the detailed findings of the jury laid out above. Of relevance to this report:
1. Mr Omishore had been observed by multiple members of the public on Chelsea Bridge Road and then on Chelsea Bridge, in the minutes leading up to the incident behaving in a manner that suggested he was mentally unwell. There were 7 calls by members of the public to the Metropolitan Police to report concerns and in 3 out of 7 of these calls the member of the public told the call handlers/first responders that Mr Omishore appeared mentally unwell. This was only recorded by one call handler on the CHS system and passed to the CAD and thus dispatchers in “remarks.” This information was never transmitted over the airwaves to the responding officers and so could not have been considered in their NDMs prior to their arrival at the scene. The responding officers had no access to CADs to undertake their own assessment prior to arriving at the incident due to a combination of lack of time to start their computer tablet and to load and search CADs due to the immediacy of their arrival and the IVMA was not working. They were thus reliant on the information passed to them over the radio. Only one radio channel was used in this incident.
2. Extensive evidence was taken in relation to this matter. In summary: call handlers stated that given the main threat was that Mr Omishore had been reported as carrying a weapon, either knife or screwdriver, they regarded mental health as a secondary matter and did not put the information in the “golden line”, and indeed two did not record it all. Neither was the information recorded in the NICL codes. The main reasons given for this was that in their views, the NICL codes should list the main risk factors, only three are available and if a mental health NICL code was recorded then it would need a further code qualifying it as “believed” as the information was unconfirmed as reported by a member of the public rather than a health care professional, or relative with first-hand knowledge of the subject. There was also mention of the officers’ duties to consider such matters once they have arrived at the scene of an incident.
3. Several witnesses stated that a code “mental health believed” would be of assistance as then there would likely have been enough NICL codes available for it to be used. There was some inconsistency therefore between whether it should be recorded at all, and if so where it should have been recorded.
4. To be clear it was accepted in the evidence that mental health should have been recorded and passed out over the airwaves to responding officers as it would have assisted those officers in their NDM considerations.
5. The evidence from dispatchers based at AWS, was that the information in relation to possible mental health matters should have been recorded and passed to them to put out. It was clear from the evidence that the information that was passed to dispatchers was not put out in error-it was simply missed.
6. These dispatchers described how they relied on information in the “golden line” and NICL codes to get information out onto the radio asap, and so it could be inferred that had information in relation to mental health issues been recorded either in the “golden line” or NICL codes it would have been likely to have been transmitted by them.
7. Analysis of various CADs as part of the evidence also showed that several units (up to 6, it was difficult to understand) had been allocated to respond to this incident in addition to three units heard to respond over the airwave radio. None of this potentially important information was passed over the airwaves, and again therefore could not have been considered by responding officers and thus feed into their NDMs.
8. The incident was being monitored in dispatch AWS by a controller performing multiple tasks who had also missed the remarks in relation to mental health and not passed on information over the airwaves in relation to units assigned by CAD from another geographic dispatch pod (AWC) over the airwave radio.
9. Evidence was also taken in relation to the increased use of taser in black men and those persons with mental health needs and the training given to staff and officers in relation to these matters.
10. Evidence was taken in relation to THRIVE .
11. In relation to the response of the officers, the taser armed officer deployed with his taser drawn and pointed at Mr Omishore and did not consider mental health as a possible cause for Mr Omishore’s actions until after the first use of the taser. However, had he been provided with information that Mr Omishore appeared to be suffered with mental ill health prior to his arrival at the scene, this could have fed into his NDM and may have affected the manner of his deployment. This may have reduced the risk of escalation arsing not only from sight of the taser but also the training requirement to use clear and commanding language to a subject once a taser has been deployed. Such language is different in tone and style to that taught to officers to use when attempting to de-escalate a situation where the subject is suffering mental distress. These matters could not be found to have likely affected the outcome in this case. Matters of Concern
1. That there is an inconsistancy of approach between call handlers/first responders in the recording of information passed to them by members of the public that may represent a training issue; in this case the mental health matters reported to them.
2. That the call handlers/ first responders may have a training issue in relation to the importance of recording this information in manner which is likely to be passed on to responding officers by dispatchers, for example in the NICL codes and/ or “golden line”.
3. That the above concern of potential training need is highlighted by the increased use of taser in black men and those suffering mental health issues and so the real need for this information to be recorded and passed on in the most effective form. Whilst training for first responders appears to include advice as how to communicate with persons suffering with mental health issues, it does not appear to contain any advice in relation to the importance of such information to be recorded especially in relation to black men.
4. That the limitation of 3 NICL codes makes it difficult to record mental health as a qualifier in incidents such as this where the main risk factor is the weapon.
5. That call handlers/first responders may need training as to where to record such information i.e. in the “golden line” or NCIL code, as long as of course it is reported to them before the “golden line” and NICL code has gone out.
6. That use of THRIVE usually requires time that is not available in I grade calls and does not mitigate the need to circulate promptly information as to mental health issues, in the format most likely to digested and passed on by dispatchers that is “golden line” or NICL codes.
7. That the lack of NICL code “mental health believed” compounds this.
8. That dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health.
9. That dispatchers may require training in relation to what to pass out more generally given the confusion in the evidence about other units being assigned by CAD, which dispatchers themselves did not seen to appreciate and understand let alone pass such information out to responding officers.
10. That there are apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves, given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call.
11. That training for response officers may require review in relation to tactical options used to de-escalate prior to taser deployment, in appropriate circumstances, given the increased use of taser in black men with mental health issues; and in particular, training in relation to deploying with taser drawn and pointed with accompanying commanding language where the subject may be suffering with mental ill-health.
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