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
43 resultsTyereece 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. 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. 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. 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.
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.
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.
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.
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.
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.
Paul Kalnins
All Responded
2015-0278
15 Jul 2015
London (East)
Other related deaths
Concerns summary (AI summary)
Communications officers lacked current training and struggled with a complex database where critical risk information was not easily accessible or prominently displayed, jeopardising vulnerable persons.
Action Planned
(AI summary)
The Metropolitan Police Service will implement mandatory refresher training for communications officers on the Merlin database by March 31st 2016, focusing on the 'red flag' marker and incident reports. Line managers have been instructed to monitor training completion.
Wiktoria Was
All Responded
2015-0271
13 Jul 2015
London (Inner South)
Police related deaths
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately learned or disseminated. Officers lacked sufficient and rigorous refresher training.
Action Taken
(AI summary)
The Metropolitan Police Service has rolled out an RT Operators Course since 2011 to selected elements of the uniformed workforce and since July 2014 to all new recruits. They are also planning to implement enhanced driver training, pending release of funds, and are working to ensure officers serving prior to the course introduction may have an opportunity to take the course in the near future, most likely re-worked as a computer-delivered package.
Darren Neville
All Responded
2015-0220
10 Jun 2015
London Inner (North)
Police related deaths
Concerns summary (AI summary)
Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing acute behavioural disturbance.
Noted
(AI summary)
The Metropolitan Police acknowledge the concerns and detail the challenges of responding to Acute Behavioural Disorder (ABD) incidents, highlighting existing training and the need for officers to act decisively. They assert that measures have been introduced since 2013 and in response to the death to refine training and equip officers.
Arsema Dawit
All Responded
2014-0442
13 Oct 2014
London (Inner South)
Police related deaths
Concerns summary (AI summary)
Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting for non-adults and a reluctance to use interpreting services.
Action Taken
(AI summary)
The Metropolitan Police Service has made improvements in training and reference materials for staff, investigator accreditation & quality assurance, supervision, and provision of support resources; it has broadened the function of the civilian Station Reception Officer to 'PAO' -Public Access Officer, developed a supervisor training package, updated the MPS 'Supervision Toolkit', increased the number of accredited PIP level 2 investigators, and invested heavily in providing translation services.
Lauren Barfoot
All Responded
2014-0385
28 Aug 2014
London (Inner South)
Other related deaths
Concerns summary (AI summary)
Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification and an ineffective search for the deceased. Social Services also failed to maintain comprehensive contact lists and hold timely strategy meetings.
Action Taken
(AI summary)
Bexley Children's Services have implemented lessons learned into social work practice, and a triage system is in place for when looked after children go missing. A risk assessment report is required in preparation for strategy meetings for missing looked after children, and strategy meetings are held within three days of a child going missing. Greenwich Police enclosed a report detailing their actions, addressing information sharing and risk assessment, as well as their broader response to the serious case review that followed the death. Their response has been reviewed to ensure that measures introduced following the serious case review account for issues raised in the report and are fully embedded in current practice. Ethelbert Childrens Services has implemented steps to address concerns regarding the collation of information, risk assessment, and contact details. They now complete a Met Police Missing Person Reporting Form upon a child's arrival and provide details by phone when reporting a child missing. Ethelbert Childrens Services has implemented steps to address concerns regarding the collation of information, risk assessment, and contact details. They now complete a Met Police Missing Person Reporting Form upon a child's arrival and provide details by phone when reporting a child missing.
Mark Duggan
All Responded
2014-0182
29 May 2014
London (North)
Police related deaths
Concerns summary (AI summary)
Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.
Noted
(AI summary)
The IPCC acknowledges the coroner's concerns, particularly regarding access to intelligence materials, and states it is best placed to determine who within the IPCC investigation should have access. The IPCC considers that there should be a clear legal right of access by IPCC investigations to all relevant intelligence material. The Home Office acknowledges the concerns raised, particularly regarding the IPCC's resources at the scene and access to intelligence. The response explains the existing legal framework for investigations and information disclosure, highlighting the need to balance transparency with national security. The National Armed Policing Portfolio has commenced work to determine whether the introduction of body worn video (BWV), might be included in armed policing operations. The National Policing portfolios will ensure liaison with the College of Policing to incorporate, reiterate and reflect issues relating to cordon management and evidence preservation in its post incident management and operational training. The National Crime Agency notes the concerns raised and states it has undertaken a thorough internal review of its operating procedures regarding intelligence gathering, development, and dissemination. Following this review, the Agency believes that no more could have realistically been done to avoid the incident. The MPS will adopt a procedure for all future police shootings whereby a Garage Sergeant or Collision Investigator is called by the DPS to download the IDR at the scene, which will then be available to police; the IPCC and any subsequent legal proceedings
Michael Sweeney
All Responded
2013-0236
23 Sep 2013
London North (Inner)
Community health care and emergency services related deaths
Police related deaths
Concerns summary (AI summary)
Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term to 'extreme agitation' is needed.
Disputed
(AI summary)
The Metropolitan Police Service has addressed potential information gaps for civil staff with practice notes and in-house training, and developed a detailed joint agency call-handling protocol with the London Ambulance Service. The Medical Director will encourage the adoption of shared terminology and increase awareness in emergency departments. The London Ambulance Service does not agree with the recommendation to use the term 'extreme agitation', preferring 'acute behavioural disturbance' (ABD). They have engaged with police and reviewed guidance, and raised the issue of terminology with the national Ambulance Service Mental Health Working Group, which will issue a position statement after consulting the Royal College of Psychiatrists. They will also share their response with the Pan London Emergency Department Consultants Group.