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 results
Anne Wilson
Partially Responded
2015-0293 21 Jul 2015 London (South)
Community health care and emergency services related deaths
Concerns summary (AI summary) Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on managing mental health requests, leading to critical information not being acted upon or shared with the requesting GP.
Action Planned (AI summary) A Control Services Bulletin will be issued by the end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to a vulnerable patient closed prior to assessment. Joint meeting governance arrangements are to be reviewed to ensure they are robust.
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.
Finnulla Martin
Historic (No Identified Response)
2015-0173 29 Apr 2015 London North (Inner)
Suicide
Concerns summary (AI summary) The psychiatry liaison team at Whittington Hospital appeared unclear on protocols for receiving information from police officers bringing patients in voluntarily, and did not adequately explore suicide risk or obtain collateral history; also, the police call handler did not record critical information.
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
Lee MacPherson
Historic (No Identified Response)
2014-0097 3 Mar 2014 London (West)
State Custody related deaths
Concerns summary (AI summary) Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
Daniel Maurice McMahon
Partially Responded
2013-0271 21 Nov 2013 London
Railway related deaths
Concerns summary (AI summary) The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms for patients on S17 MHA leave; amending the rule book to require trains to stop when a potentially unwell person is trespassing; and reviewing guidance on lung decompression needles for the ambulance service.
Disputed (AI summary) The London Ambulance Service reviewed the use of one-way valves on needle chest decompressions and concluded that their current approach of not using them is appropriate, citing expert opinions and consensus statements. The Department of Health is reviewing the advice in the 'Code of Practice Mental Health Act 1983', including the chapter on leave of absence under section 17 and references to care planning, using this case to assist that review.
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.