Metropolitan Police Service

Noted (AI summary) • Operational reminders have been issued reminding Custody Officers to ensure medical requests are made. • A new protocol for 'case finding' was implemented in November 2025, where the HCP on duty runs through the custody whiteboard with the Grip Sergeant and checks if there are any detainees who may have unmet medical needs.

Noted (AI summary) The Metropolitan Police Service will deliver learning to staff and officers highlighting the importance of strict location sharing and compliance with standard operating procedures. Surrey Police reviewed records of calls and concluded that calls were handled correctly and promptly passed to the MPS. They agree with MPS that there was no failure in communication between Surrey Police and MPS.

Noted (AI summary) Outlook Care has implemented an action plan including external feedback, stakeholder inclusion in reviews, and collaborative working with LBWF. They've revised their Missing Person policy, provided staff training, and conducted spot checks on 1:1 support, issuing guidance on maintaining a 'line of sight'. Future actions include business continuity tests, audits of risk management, and revised induction formats. The CQC reviewed information on Waterside Lodge Recovery Centre and requested a copy of Outlook Care's response to the coroner, noting changes across their remaining nine locations including review of missing person policy, training for staff, additional risk assessments and spot checks on community visits, and will request and review evidence of completion of these actions. The London Borough of Waltham Forest explains its processes for monitoring commissioned supported living services and managing parks/open spaces. They state that the support worker was not employed or commissioned by them. They outline referral pathways for vulnerable adults, rough sleeping monitoring, and vegetation management but do not commit to specific changes. The Metropolitan Police state that they have been unable to identify any other deaths in the area that would suggest any specific or ongoing risk to public safety, or significant criminal activity. They confirm that ongoing work is being undertaken with the respective local authorities and there is strategic police/partnership joint working to focus on rough sleeping and have increased engagement with local residents to encourage reporting of rough sleeping.

Noted (AI summary) NHS England acknowledges the concerns, states that it is not the appropriate organisation to respond to many of them, but will consider the Trust's response and has been sighted on the Trust’s Patient Safety Serious Incident Review Report. It also draws attention to NHS England’s national Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme. The MPS has the Affinity Protocol in place since 2021 and will undertake work as part of the implementation of the Right Care, Right Person to ensure policies of all parties align and there is a clear understanding of definitions and terminology used. The Home Office describes the Right Care Right Person (RCRP) approach to assist police decision making. It states that the investigation of a missing person report is an operational decision for individual police forces and refers to the MPS Affinity Protocol. The Trust has updated its Missing and AWOL policy, reviewed procedures for patients leaving acute wards, and changed observation guidance. They will review their Risk Assessment policy and the Grab Pack's alignment with local policies, including seeking external expert opinion, with a 3-6 month timescale.

Noted (AI summary) The NPCC and College of Policing state that missing persons APP sets out clear processes and procedures and that current ACT instructions should be followed with an instruction to STOP in similar cases. NPCC will raise the issues apparent in the case through appropriate portfolio areas. The Metropolitan Police Service is developing a training package on ANPR and ACT reports, to be rolled out within 12 months. A new Service Level Agreement will require higher authorisation for ACT reports and nominated contacts for updates. The Home Office acknowledges the concerns and states that the College of Policing sets standards for police investigations, including ACT reports. They have consulted with the College, Metropolitan Police and NPCC and are satisfied that current guidance is in place.

Noted (AI summary) Amazon includes a warning on e-scooter product pages stating they are prohibited on public roads in the UK, makes the warning prominent with bold font and a link to government guidance, sends communications to selling partners to remove references to public road use, and publishes education for selling partners on local legal restrictions. Escooterclinic attributes the incident to reckless user behavior, not the vehicle itself. They advise legalizing scooters with regulations and compulsory protective gear/insurance, citing confusion caused by legal rental scooters. Selfridges ensures there are clearly visible messages in stores and on their website stating that e-scooters may not be lawfully ridden on public highways. The legal team has issued reminders to stores and digital teams regarding this matter and are exploring system-based solutions for safety advisory requirements. Halfords advises potential buyers about the legal restrictions on e-scooter use at all stages of the sales process, both in-store and online, using prominent signage, legal statements on price tickets and warranties, and colleague training. They are also pushing for regulation in any Transport Bill. The MPS has published information on the MPS public website regarding the illegality of e-scooters, provides a flowchart to officers on how to deal with illegal e-scooter use and sends letters to e-scooter retailers asking them to display prominent signs about the legality of e-scooters. The MPS disputes that there is a correlation between legal enforcement of e-scooters and number of deaths and states that policy regarding head protection for licensed e-scooters was a decision made by the Department for Transport and Transport for London. Harrods is preparing notices for display in the Technology department and on their website, clarifying the illegality of e-scooter use on public roads. They also recommend helmets to customers and are implementing age verification checks. TfL highlights safety measures in the e-scooter rental trials, including speed limits, always-on lights, and minimum wheel size. They also promote safety guidance and have worked with the MPS to raise awareness of the law regarding private e-scooters. Onboards displays helmets with scooters, offers helmet discounts, encourages helmet use in-store, and features helmeted riders in online media. They display a sign about the illegality of private e-scooter use, include a disclaimer on invoices and website footer, and do not sell scooters to under-18s. The DVSA has been conducting market surveillance and has sent warning letters to retailers selling e-scooters without proper warnings about illegal use on public land. The government encourages helmet use for e-scooter trials and will consult on helmet wearing for future regulation. Evolve Skateboards is reviewing safety and legal compliance globally, including the UK, with expected rollout by June 2023. They are also a founding member of a PMD safety group advising the Land Transport Safety and Regulation Bureau in Queensland, Australia.

Noted (AI summary) The Royal College of Emergency Medicine states that provision of medical cover to police custodial units does not fall within its remit. The IOPC will not be undertaking an investigation but is satisfied that the reflective practice review process can be used effectively to prompt reflection and insight into this incident. The Metropolitan Police Service will implement the Reflective Practice Review Process (RPRP) for the officer in question, which will include an opportunity to reflect on the missed opportunity to offer an apology to Mr. Taylor's family; the officer's line manager will also identify any additional training needs. The Department of Health and Social Care outlines the process and considerations involved in allowing police officers to carry salbutamol inhalers, noting it would require a change in legislation, and would need to be initiated by the Home Office, after consulting the Commission on Human Medicines (CHM) and undertaking public consultation; it also highlights NHS England's focus on preventer inhalers and monitoring by GPs.