National Police Chiefs Council
PFD Addressee
Reports: 54
Earliest: Apr 2015
Latest: 30 Mar 2026
100% 2-year response rate (above 83% average). 32% of classified responses show concrete action taken.
PFD Reports
54 resultsFelicity Clough
Partially Responded
2021-0402
26 Nov 2021
Dorset
Alcohol, drug and medication related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, both posing risks to patient and public safety.
Action Taken
(AI summary)
The Secretary of State for Health and Social Care reports that Yeovil District Hospital has implemented measures to ensure staff can access pre-hospital information, including converting information from other systems into PDF documents and saving it within their existing system (Trakcare) in the Emergency Department from January 6 2022.
Gary Williams
All Responded
2021-0401
26 Nov 2021
Liverpool and Wirral
Police related deaths
Concerns summary (AI summary)
Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use of restraint and exacerbating a patient's distress.
Action Taken
(AI summary)
The NPCC states that following a previous similar case, the Self Defence Arrest and Restraint (SDAR) working group has already reviewed and updated training materials to include guidance on Acute Behavioural Disorder (ABD), and the updated package was circulated to forces in March 2021.
Leon Briggs
All Responded
2021-0330
4 Oct 2021
Bedfordshire and Luton
Emergency services related deaths
Mental Health related deaths
Police related deaths
Concerns summary (AI summary)
The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on recognizing medical emergencies, the effects of restraint, and monitoring detainees.
Noted
(AI summary)
EEAST has approved (November 2021) the National Ambulance s.136 Guidance, is developing and implementing a new mental health care service model, and has developed a specific training session in relation to Acute Behavioural Disorder, including positional asphyxia for frontline staff. Bedfordshire Police is updating its local section 136 multi-agency policy, with a revised version due to be signed off this year and is incorporating guidance from a national ABD policy review into existing guidance for relevant policing areas. AACE confirms that the national S136 guidance has recently been revised, updated, and issued nationally and that on 1st February 21 they updated the acute behavioural disturbance guidance with wording to emphasise the need for close monitoring of a patient when restraint is used.
Hamish Howitt
All Responded
2021-0320
23 Sep 2021
West Sussex
Police related deaths
Concerns summary (AI summary)
Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading to a missed traumatic brain injury. Training needs to mandate hospital referral for such individuals.
Action Planned
(AI summary)
Avon and Somerset Constabulary circulated a memorandum to all officers with guidance on head injury risk, sent guidance to first aid trainers, and added guidance to first aid training modules. They also incorporated training on head injury response into Taser, Public Safety, and Public Order training, all completed in October 2021. The Home Office has consulted with the College of Policing and NPCC, and the College will address the coroner's concerns about police first aid training through its formal governance routes. The College of Policing and NPCC will raise concerns about alcohol's impact and head injury assessment in first aid training at the next First Aid Forum meeting in December to assess feasibility of addressing them within the FALP licence scope. The College is also reviewing high-level learning outcomes within the FALP to emphasize life-saving elements, considering acute alcohol intoxication, intentional overdoses, and extending head injury learning to Module 2.
Anthony Preston
Historic (No Identified Response)
2021-0319
23 Sep 2021
Essex
Mental Health related deaths
Police related deaths
Concerns summary (AI summary)
The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.
David Ormesher
All Responded
2021-0192
4 Jun 2021
City of Brighton and Hove
Police related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns about emergency response safety.
Noted
(AI summary)
The National Police Chiefs' Council acknowledges receipt of the letter and notes its contents. Sussex Police reviewed policies and procedures on radio use and found policy 594/2021 sufficiently robust. They have a Driver Behaviour Working Group reviewing trends and a point system for interventions. A training package is in development to remind staff of radio responsibilities.
Samantha Gould and Christine Gould
All Responded
2021-0184
Cambridgeshire and Peterborough
Alcohol, drug and medication related deaths
Child Death
Community health care and emergency services related deaths
Concerns summary (AI summary)
Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance for police on communicating with such vulnerable minors.
Action Planned
(AI summary)
The NPCC has implemented an immediate addition to the Authorised Professional Practice (APP) guidance for all UK Police Forces, focusing on police engagement with reluctant victims/witnesses and ongoing support strategies. The NPCC Lead is also communicating this change to Local Safeguarding Children Partnerships. Cambridgeshire County Council has launched the 'Strong Families Strong Communities' strategy (March 2021) and the YOUnited partnership (July 2021) to enhance emotional health and wellbeing services for children and young people, focusing on clear referral pathways and multi-agency support. The Trust is reviewing its AWOL policy (completion by Oct 2021), undertaking a full policy review over six months, reminding doctors of ICD 11 changes, and developing a new joint protocol for overnight assistance for high-need adolescent mental health patients.
Zeyna Partington
All Responded
2021-0181
27 May 2021
Manchester North
Police related deaths
Suicide
Concerns summary (AI summary)
GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR system for vehicle tracking is not fully implemented, leading to missed alerts.
Action Planned
(AI summary)
Greater Manchester Police acknowledges concerns about the use of PNC markers and ANPR data. They are reviewing the use of high priority markers for vulnerable missing persons and are working to connect to the new National ANPR Service.
Joe Robinson
Partially Responded
2021-0074
15 Mar 2021
Greater Manchester South
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether lessons learned regarding policing such events have been effectively shared.
Noted
(AI summary)
The Home Office acknowledges the concerns and outlines the police powers to deal with illegal raves, but states that decisions about deployment are operational matters for the police. They highlight funding to tackle drug supply, treatment services, and Project ADDER.
Katrina O’Hara
All Responded
2020-0051
3 Mar 2020
Dorset
Other related deaths
Concerns summary (AI summary)
Outdated police policy led to a high-risk 999 call being downgraded, and officers failed to recognise the increased danger to the victim when the perpetrator expressed suicidal intent. The victim was also left without a replacement phone after hers was seized for evidence.
Noted
(AI summary)
The NPCC has undertaken a major refresh of the National Contact Management Strategy since 2015, with revised principles and practice that cover the issue of inappropriate channel selection. The report will be raised at the next meeting of the National Contact Management Steering Group. The Home Office is working to pilot and evaluate approaches to identifying and tackling high risk offenders, including adding suicide indicators to the list of potential risk indicators. Work is ongoing to review findings from domestic homicide reviews and academic research with a view to more accurately identifying key characteristics and risk factors for domestic homicides.
Anthony Carroll
All Responded
2020-0018
8 Jan 2020
Liverpool and Wirral
Emergency services related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The public may misunderstand police emergency vehicle speed limits. Additionally, a lack of visual indicators led officers to mistakenly believe sirens were active, highlighting a safety flaw.
Noted
(AI summary)
The NPCC provides clarification on police vehicle speed limits and emergency equipment operation, stating that there's no national proposal to add further equipment activation indicators due to potential driver distraction.
Douglas Oak
All Responded
2019-0352
24 Oct 2019
Dorset
Other related deaths
Concerns summary (AI summary)
There is a critical lack of national guidance for Ambulance Services on using chemical sedation for patients with Acute Behavioural Disturbance, despite its effectiveness for safe treatment and transport.
Noted
(AI summary)
The Department of Health and Social Care acknowledges the report but states that a response will be delayed due to an upcoming General Election. They will contact the office to agree on a new deadline once a new administration is in place. The College of Policing and NPCC are working with forces and medical service partners to address concerns related to Acute Behavioural Disturbance, including raising awareness and consistency in recognition and response. The Chair of the NPCC will write to all Chief Constables to bring the content of the PFD to their attention. Joint guidance between ambulance services and police forces is in development, overseen by a joint committee. AACE will share operational considerations with the National Directors of Operations Group (NDOG) for ambulance services, and will discuss the report at future meetings. St John Ambulance is providing additional Continuous Professional Development training around Acute Behavioural Disturbance. They have also raised the topic for inclusion in the latest version of the First Aid Manual.
Michael Hoolickin
All Responded
2019-0292
29 Aug 2019
Manchester (North)
Other related deaths
Concerns summary (AI summary)
The coroner is reporting to prevent future serious further offence reviews following a death.
Noted
(AI summary)
The NPCC acknowledges the concerns and explains its role in encouraging collaboration between forces, stating that it will share the report and IOM guidance with chief constables across the country, but does not have the authority to direct action. The Probation Service acknowledges the need for learning and improvement. The Greater Manchester IOM Framework is currently subject to review and your concerns will be considered as part of this review. Where deemed necessary further guidance or clarification including templates such as draft agenda, minutes and action logs will be included. Response contains no text. Response contains no text.
Lucy Lee
Historic (No Identified Response)
2019-0509
15 Jul 2019
Surrey
Other related deaths
Concerns summary (AI summary)
A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of shotgun certificate applicants, including undeclared conditions and inadequate FEO skills, create risks.
Christine Lee
Historic (No Identified Response)
2019-0509-wp27242
15 Jul 2019
Surrey
Other related deaths
Concerns summary (AI summary)
The absence of mandatory national training for Firearms Enquiry Officers risks incorrect certification decisions. Additionally, the medical assessment system for shotgun certificates is flawed, with officers lacking skills to evaluate complex health conditions.
Leroy Medford
Partially Responded
2019-0233
9 Jul 2019
Berkside
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
The coroner expresses concern that officers were unaware of a requirement in the Drugs SOP for an officer to be within the cell with a detained person, and recommends a national review of how training is delivered and monitored within the police service.
Action Planned
(AI summary)
Thames Valley Police have initiated a quarterly Drug Concealment Working Group and are refreshing guidance for superintendents on managing drugs concealment cases (target Nov 2019). They are developing healthcare pathways and simpler guidance, accessible on officer's mobile phones. Special Points of Contact (SPOCs) have been introduced to improve communication of new guidance. The NPCC is closely involved in the College of Policing’s work on a national strategy for police learning, which may address concerns around training. The NPCC has shared the coroner's report with chief constables, encouraging them to review training delivery within their own forces.
Donna Williamson
Partially Responded
2019-0111
27 Mar 2019
London Inner (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies failures in repairing and securing a door, informing the victim of the suspect's release on bail, and the MARAC process's inability to protect chaotic, non-engaging individuals, alongside concerns about GPs' knowledge of disclosing confidential information.
Noted
(AI summary)
The Royal College of General Practitioners highlights existing guidance on information sharing and safeguarding, and the LGA has highlighted the importance of learning from Domestic Homicide Reviews at a national level. The LGA is seeking further information on the legal duty to repair doors of private rented accommodation.
Meirion James
Historic (No Identified Response)
2019-0460
4 Mar 2019
Pembrokeshire & Camarthenshire
Mental Health related deaths
State Custody related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and transporting individuals to a place of safety under MHA 1983 also require review.
Karl Brunner
Partially Responded
2018-0310
29 Oct 2018
Bedfordshire & Luton
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review of procedures for managing such medical emergencies.
Noted
(AI summary)
Bedfordshire Police states that their officer training includes a module on managing choking detainees, and they issue officers with personal Pocket Face Masks. They believe their training complies with IOPC recommendations and College of Policing standards.
Trystan Bryant
Partially Responded
2018-0382
19 Oct 2018
Plymouth, Torbay and South Devon
Community health care and emergency services related deaths
Mental Health related deaths
Concerns summary (AI summary)
Stationary ambulance doors that cannot be locked pose a risk to police containment of individuals detained under the Mental Health Act, potentially allowing egress from the vehicle.
Action Taken
(AI summary)
The National Police Chiefs' Council issued a reminder to all Chief Constables to treat all ambulances as non-secure environments when detaining individuals under S136 of the Mental Health Act.
Eugeniusz Niedziolko
Historic (No Identified Response)
10 Jul 2018
Wiltshire and Swindon
Alcohol, drug and medication related deaths
Mental Health related deaths
Concerns summary (AI summary)
Police lacked appropriate options for managing a heavily intoxicated individual, leading to them being left alone in a public lavatory on a cold night, resulting in death.
Keiron Bould
Partially Responded
2018-0178
13 Jun 2018
Birmingham and Solihull
Police related deaths
Concerns summary (AI summary)
Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays in handling a missing person report.
Action Taken
(AI summary)
Warwickshire Police has updated its working practice guidance to require call handlers to follow up a transfer of a missing person report to another force with a telephone call to confirm receipt of information. They have also re-circulated College of Policing guidance on ownership of missing persons.
Richard Davies
Partially Responded
2017-0325
24 Jul 2017
Cambridgeshire and Peterborough
Police related deaths
Concerns summary (AI summary)
A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a clear bullet mass retention specification.
Action Taken
(AI summary)
The BCH APU is no longer using the un-bonded 5.56mm ammunition which was used in the present case and has amended its system of record-keeping to ensure that all decisions relating to the selection of ammunition are recorded on a single electronic system.
Darran Hunt
Historic (No Identified Response)
2017-0038
1 Mar 2017
Carmarthenshire and Pembrokeshire
Police related deaths
Concerns summary (AI summary)
The report identifies confusion regarding police training in situations where a detained person puts a harmful substance in their mouth, specifically concerning the use of PAVA spray and forced searches, with inconsistencies across different police forces and conflicting guidance.
Philmore Mills
Partially Responded
2016-0110
17 Mar 2016
Berkshire
Police related deaths
Concerns summary (AI summary)
Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers that restraint take-down procedures can carry a risk of death, only focusing on minor injuries.
Action Planned
(AI summary)
The College of Policing will add specific reference to 'containment' to the ABD/PA chapter of the National Personal Safety Manual and clarify that, in certain circumstances, prone restraint carries a risk of death, within the next scheduled update.