Metropolitan Police Service
PFD Addressee
Reports: 61
Earliest: Sep 2013
Latest: 20 Feb 2026
91% 2-year response rate (above 83% average). 48% of classified responses show concrete action taken.
PFD Reports
61 resultsAgnès Marchessou
Historic (No Identified Response)
2020-0255
26 Nov 2020
Inner North London
Mental Health related deaths
Suicide
Concerns summary (AI summary)
Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to search police systems for relevant history, and did not reflect on their procedural errors.
Imane Bouasbia
Partially Responded
2020-0234
12 Nov 2020
East London
Police related deaths
Suicide
Concerns summary (AI summary)
Police failures included inadequate communication of suicidal ideation during handover, absence of a risk assessment for self-harm, and a limited, non-expedited response to a direct suicidal text message.
Action Taken
(AI summary)
The MPS emailed all SOIT officers and Public Protection Department managers with the instruction that SOIT and investigating officers must inform a supervising officer if they receive any contact from a victim that causes them concern. Continuous Professional Development events for SOIT officers will include suicide awareness and a contribution from Hostage and Crisis negotiator regarding how to more effectively engage with a person in a mental health crisis.
Chelsie Greatorex
All Responded
2021-0018
11 Nov 2020
East London
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.
Action Planned
(AI summary)
The Home Office is conducting a review of the criminal justice response to rape, consulting on a new Victims’ Law, and investing in rape support centers and Independent Sexual Violence Advisers (ISVAs). The MPS is developing a Suicide Prevention Policy Document and Toolkit, including information on suicide prevention, support services, risk indicators, contacts and best practice, with a draft expected by the end of December 2020; they are also improving training and guidance for officers and staff, including an investigative standards document and meeting with other forces to share good practice.
Kerry Aldridge
Partially Responded
2020-0055
10 Feb 2020
London Inner South
Mental Health related deaths
Railway related deaths
Suicide
Concerns summary (AI summary)
Police safeguarding teams lack established links with NHS mental health services and officers need further training to appropriately assess and refer individuals requiring urgent mental health support.
Action Planned
(AI summary)
The trust acknowledges the concerns and will have preliminary discussions regarding providing Mental Health First Aid training to specific Metropolitan Police officers in designated roles by the end of March 2020. They also highlight existing mental health support services available to police officers, including a crisis and assessment team and a Pan London S.136 telephone advice line.
Thiago Araujo
Partially Responded
2021-0132
29 Jan 2020
East London
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Noted
(AI summary)
The Trust has implemented an additional recommendation that discharge of Crisis Team service users due to non-engagement must be discussed in a multidisciplinary meeting with senior overview, and clearly communicated to relevant parties. Legal advice has been sought and guidance circulated to staff regarding potentially dangerous packages. Royal Mail asserts that their processes for handling restricted and prohibited items are adequate and appropriate, given the legal restrictions on interfering with postal packets. They state that they do not intend to take any action in response to the report. The MPS is developing a Suicide Prevention Policy Document and Toolkit. An investigative standards document is also under development as guidance for police first responders. The Department of Health and Social Care describes actions taken to limit the availability of chemicals used in suicides, including working with a chemical supplier to identify suppliers on online retail platforms and noting eBay's global prohibition of the sale of the chemical. It also notes work with the media to improve suicide reporting and the publication of an Online Harms White Paper. The Home Office is aiming to establish a consultation this summer on possible amendments to the Poisons Act, which will include more obligations on online marketplaces including reporting suspicious transactions within 24 hours.
Nimo Younis
Historic (No Identified Response)
2019-0394
20 Nov 2019
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
There was a critical communication breakdown between mental health ward staff and police regarding a missing patient, with staff lacking understanding of police protocols and information requirements, leading to delayed high-risk classification.
London Bridge & Borough Market Terror Attack
All Responded
2019-0332
1 Nov 2019
London Inner (South)
Other related deaths
Concerns summary (AI summary)
The coroner identified matters of concern which are being reported to the addressees, after taking into account submissions from the bereaved.
Noted
(AI summary)
The City of London Police (CoLP) are working with partner agencies to test interoperability of communications and enhance training scenarios, including a 7 day live trial in February 2020 to station staff in the MPS control room, with a review in Autumn 2020, and are engaging with the MPS in ICCS and CAD upgrade projects, planning an interim solution until upgrades are complete. The BVRLA has worked with the DfT and law enforcement to prevent the use of rental vehicles in terrorist attacks, providing training, guidance and engagement opportunities to members, and has included additional criteria within member audits from Jan 2020 to monitor awareness, training and compliance against the Rental Vehicle Security Scheme. The LAS is planning a live trial for seven days in February 2020, with LAS and LFB staff based in the MPS control room, and will analyze the outcome and consider a recommendation for approval by Autumn 2020; it is also working with its emergency service partners and increased visibility of the HART and TRU teams. The Home Office acknowledges the coroner's concerns and provides context, stating that the issues raised are technical and will be considered by the police in collaboration with the Emergency Services Network programme. It also mentions ongoing work led by the National Police Chiefs' Council. The MPS is trialing a "London Emergency Services Contact Centre" with representatives from the LFB and LAS deployed within the Specialist Operations Room, with a table top exercise followed by a real-life 7-day trial planned for early 2020.
Anna Hedman
Historic (No Identified Response)
2019-0321
25 Sep 2019
London Inner (West)
Alcohol, drug and medication related deaths
Other related deaths
Concerns summary (AI summary)
A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call an ambulance, even when prompted, in an emergency situation.
Edir DA Costa
All Responded
2019-0211
27 Jun 2019
London (East)
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
Many police officers are not up-to-date with mandatory Emergency Life Support training, and monitoring compliance is difficult, leading to critical delays in commencing CPR.
Action Taken
(AI summary)
The Metropolitan Police have reduced the number of officers who need mandatory Emergency Life Support training. They have also circulated a reminder to all staff via a weekly MetCC Operational Update bulletin regarding policy compliance and will emphasise this policy in MetCC initial call handler training and Personal Development Days in October 2019.
Tyereece Johnson
All Responded
2019-0166
23 May 2019
London Inner (West)
Child Death
Emergency services related deaths
Police related deaths
Concerns summary (AI summary)
The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.
Action Planned
(AI summary)
The MPS will review the roles and responsibilities of the police pursuits pod to ensure they are maximising information/intelligence opportunities. They will consider a mandatory checklist of indices at the start of a pursuit and ensure Pan London courses and refresher training include an input on information and intelligence gathering. This review will be completed by 31st October 2019.
Catherine Horton
All Responded
2019-0143
15 Jan 2019
London (South)
Mental Health related deaths
Concerns summary (AI summary)
Multiple failures in a missing persons investigation, including incorrect closure due to severe understaffing and high workload in the police missing persons unit.
Action Taken
(AI summary)
The MPS has updated investigator toolkits on mobile devices, provides safeguarding officers in BCU Operations Rooms, delivers mandatory week-long training to officers posted to MPUs, and increased staffing levels in the South Area MPU.
Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; PC Keith Palmer.
All Responded
2018-0304
19 Dec 2018
London Inner (West)
Other related deaths
Concerns summary (AI summary)
A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.
Noted
(AI summary)
The Parliamentary Authorities confirm that they already plan to consider the automation of Carriage Gates and their general ease of use as part of the ongoing renewal project; and external reviewers have already been extensively involved in the New Palace Yard project, and will continue to be involved. The MPS will revise Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices; MPS is working with MO19 and the National Police Chief’s Council to provide additional training on de-escalation techniques; and the MPS will ensure that there is appropriate input from tactical advisers at challenge panels, and the newly appointed PaDP OFC Sergeant will ensure that AFOs fully understand not only relevant changes to post instructions but also the rationale behind the changes. The BVRLA has increased counter terrorism training and guidance made available to vehicle rental and leasing firms, and routinely shares data and intelligence with police and counter terrorist authorities. The Department for Transport launched its Rental Vehicle Security Scheme in December 2018. The MCA states sufficient guidance already exists in the public domain for operating commercial vessels and leisure boats on navigable rivers and canals, referring to existing codes and training courses. The Home Office states the government accepts the Chief Coroner's recommendations and has taken action. The Department for Transport (DfT) launched the Rental Vehicle Security Scheme (RVSS) on 6th December 2018, and an industry led Advisory Panel was launched in January to oversee the development of the scheme. The London Ambulance Service states that the Chief Coroner found no matters of concern regarding their actions, so they will not be taking any further action. TfL implemented internal changes in October 2017 to improve communication of security advice. TfL is currently reviewing the height of all its bridge parapets to identify those that are below 1m high, with high priority bridges expected to be completed by April 2019.
Suleyman Yalcin
All Responded
2018-0368
20 Nov 2018
London (North)
Alcohol, drug and medication related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology for communicating urgency posed risks during critical incidents.
Action Taken
(AI summary)
The Metropolitan Police Service provides refresher driver training every three to five years. They will remind staff to clarify the urgency of requests and this will be incorporated in Met CC professional development days and initial training. The Metropolitan Police Service highlights that all MPS officers now undertake refresher training every 3 to 5 years. The Command and Control Centre (MetCC) has informed all call handlers to clarify the reason for their request. Call despatch courses now include a session on clarifying terminology.
Thomas McAuley
Partially Responded
2018-0309
29 Oct 2018
London Inner (South)
State Custody related deaths
Concerns summary (AI summary)
Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean vulnerable individuals' medical assessments are not consistently reviewed by prison medical staff.
Action Planned
(AI summary)
The MPS is working to implement a communication network (N3) and hardware into all custody suites, to provide healthcare professionals with access to NHS Summary Care Records and is required for an EMRS, anticipated within a year. A new PER will be introduced in April 2019 and the MPS will introduce the EMRS platform within one year.
Rosario Cordero-Sanz
All Responded
2018-0307
29 Oct 2018
London Inner (North)
Community health care and emergency services related deaths
Concerns summary (AI summary)
Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and inability to access critical information meant a high-risk patient's status was missed, delaying appropriate action.
Action Taken
(AI summary)
The MPS purchased and distributed 100 tablet devices for MSC officers in September 2018 and completed the rollout in November 2018. Local learning was implemented for MSC officers and a CAD operator regarding communication failures.
Jeroen Ensink
Historic (No Identified Response)
2018-0235
19 Jul 2018
London (Inner) North
Police related deaths
Concerns summary (AI summary)
Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner of mental health concerns or family-reported history.
Charles Rashan
All Responded
2018-0210
29 Jun 2018
London Inner (North)
Police related deaths
Concerns summary (AI summary)
Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent choking, and highlight the need to manage public intervention.
Action Taken
(AI summary)
The MPS has recommended changes to the Personal Safety Manual, Module 12 'Management of Persons Suspected of Concealing Items in Mouth', now requiring that where possible the subjects head should be tilted forward; the MPS continues to review and refine existing first aid techniques.
Olaseni Lewis
All Responded
2017-0205
28 Jun 2017
London (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Police related deaths
Concerns summary (AI summary)
Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged restraint." Additionally, there was a critical lack of clarity and training on inter-agency roles and responsibilities between police and healthcare staff.
Action Planned
(AI summary)
The Metropolitan Police Service describes updated training for officers regarding restraint techniques, Acute Behavioural Disturbance (ABD), and mental health, including de-escalation techniques and communication skills. It also notes the implementation of a national MOU about when police can be asked to attend mental health settings. The South London and Maudsley NHS Trust outlined actions to address training compliance, including immediate action requests and potential service suspension if training levels fall below minimum safety standards.
Valdas Jasiunas
Historic (No Identified Response)
2017-0062
8 Mar 2017
London (East)
Police related deaths
State Custody related deaths
Concerns summary (AI summary)
Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further complicated by a lack of multi-language support for safety information.
James Fox
All Responded
2017-0014
2 Feb 2017
London (North)
Police related deaths
Concerns summary (AI summary)
Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for officers.
Disputed
(AI summary)
The Metropolitan Police defends its officers' actions and states that there is no indication of misconduct. The IPCC investigation reported no matters of organisational learning other than a positive comment with regard to the use of body worn video.
Michelle Lawrence
Historic (No Identified Response)
2016-0412
8 Nov 2016
London Inner (West)
Other related deaths
Concerns summary (AI summary)
Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.
Olawale Adelusi
Historic (No Identified Response)
22 Jul 2016
London (West)
State Custody related deaths
Concerns summary (AI summary)
There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, as detailed observations of distress were not included in formal handover documents.
Henry Hicks
All Responded
2016-0244
4 Jul 2016
London Inner (North)
Police related deaths
Concerns summary (AI summary)
Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, implying non-compliance with the Metropolitan Police Service's standard operating procedure.
Noted
(AI summary)
The Metropolitan Police states that the existing pursuit policy remains unchanged but will be fully explored in the context of a formal disciplinary process for the officers involved, and notes that their guidance is kept under constant review and revision.
Faiza Ahmed
All Responded
2016-0600
20 Jan 2016
Inner North London
Emergency services related deaths
Mental Health related deaths
Concerns summary (AI summary)
No specific concerns are detailed in the provided text, which refers only to the jury's determination.
Action Planned
(AI summary)
The DWP believes its processes were followed correctly but will issue a reminder to all staff about guidance related to suicidal ideation. Following the incident, the involved crew undertook Reflective Learning, and a Clinical Update reinforcing the assessment of Capacity was published. A new Operational Management Structure was implemented, including Stakeholder Engagement Manager and Quality Assurance & Governance Manager roles, as well as funding for Mental Health Nurses in the control room. The Metropolitan Police will ensure that the future structure and resourcing model of Sapphire teams meets the demands of increased reporting levels and promotes a supportive working environment, and invest in training for first responders and investigators.
Dean Joseph
All Responded
2015-0319
12 Aug 2015
London Inner (North)
Police related deaths
Concerns summary (AI summary)
Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public confidence.
Action Taken
(AI summary)
The MPS has directed the post incident manager (PIM) to consult with the DPS and the IPCC to decide on what reference materials are proposed to be used by officers when giving their accounts, and the PIM is trained to record his or her decision and reasoning.