College of Policing
PFD Addressee
Reports: 48
Earliest: Jan 2014
Latest: 30 Mar 2026
83% 2-year response rate (matches average). 32% of classified responses show concrete action taken.
PFD Reports
48 resultsOliver Roberts
All Responded
2026-0184
30 Mar 2026
Dorset
Emergency services related deaths
Mental Health related deaths
Concerns summary (AI summary)
There is a lack of practical guidance for police officers on applying their powers to obtain communications data under the Investigatory Powers Act 2016, especially regarding urgent Grade 2 requests.
Noted
(AI summary)
• The College of Policing provides eLearning training for investigators on the national ‘College Learn’ platform.
• These learning packages “Introduction to Communications Data,” sit within the Digital Media Investigators (DMI) modules.
• This training is available for all police officers and staff across England and Wales.
[REDACTED]
Response Pending
2026-0178
25 Mar 2026
Inner West London
Child Death
Concerns summary (AI summary)
Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and lost forensic opportunities.
Katie Overd
All Responded
2025-0517
15 Oct 2025
Manchester North
Accident at Work and Health and Safety related deaths
Community health care and emergency services related deaths
Concerns summary (AI summary)
A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking emergency assistance, misunderstanding response times.
Noted
(AI summary)
The RCRP Strategic Partnership Board acknowledges the concerns and explains that Right Care: Right Person (RC:RP) is an internal process for directing calls to the most appropriate service. They state that they will discuss call transfer and external communications with partner agencies. The Deputy Mayor will further consider with relevant agencies the options that will best meet the needs of the public, recognising that NWAS would not have powers of entry and would have to call GMFRS in the described scenario. They wish to take the time to consider the various options that will best meet the needs of the public. The College of Policing explains that Right Care Right Person (RCRP) focuses on internal triage processes between agencies, not on directing the public to specific services when calling for emergency assistance. They state they will continue to monitor emerging themes and risks with partner agencies.
Ann Laskowsky
All Responded
2025-0502
7 Oct 2025
West Yorkshire Western
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to a failure to recognise severe medical needs.
Action Planned
(AI summary)
The College of Policing will formally raise the case of Ms. Laskowsky at the next meeting of the NPCC First Aid Forum on 4 December 2025, to ensure that national learning is disseminated and embedded. They will produce national learning summaries and practice notes, update Authorised Professional Practice (APP) and training materials, and engage with force training leads and clinical governance advisors. West Yorkshire Police has posted an intranet briefing reminding staff about the YAS Partner Triage Line, included details in operational briefings, updated training and guidance material, and tasked the Right Care Right Person team with monitoring its usage. First Aid trainers will also remind officers of the YAS Partner Triage Line during annual training. The NPCC has recommended that West Yorkshire Police implement clinical governance arrangements consistent with NPCC guidance and has offered support in implementing this. They confirm that assessment of breathing and responsiveness levels are mandated in Learning Outcome 1.3. of Police First Aid Learning Programme.
Kaine Fletcher
All Responded
2025-0383
25 Jul 2025
Nottinghamshire
Emergency services related deaths
Mental Health related deaths
Police related deaths
Concerns summary (AI summary)
Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite rejection by psychiatric bodies.
Action Planned
(AI summary)
The Trust is providing training for all acute facing mental health staff on ABD in August and October 2025 and signs and symptoms, clinical assessment and escalation processes are now included within the Trust Fundamentals of Care training for mental health staff. The Trust has updated Internal Working Instructions and established a strategy group and works across the system to strategically plan access and treatment for people with dual diagnosis needs. The NPCC clinical panel is reviewing existing guidance developed by the Faculty of Legal and Forensic Medicine regarding Acute Behavioural Disturbance. The College of Policing provides the Mental Health Approved Professional Practice (APP) to assist forces in developing their policies and responses to incidents relating to people with mental ill health. The Department and NHS England are finalising the Co-occurring Mental Health and Substance Use Delivery framework to improve delivery of integrated, person-centred care across drug and alcohol treatment and mental health services.
Sean Fitzgerald
Partially Responded
2025-0341
8 Jul 2025
Coventry and Warwickshire
Police related deaths
Concerns summary (AI summary)
Inadequate national training and guidance on the timing of "armed police" announcements during tactical operations creates ambiguity, increasing risks of confusion and fatal consequences.
Action Taken
(AI summary)
The College of Policing drafted additional guidance for inclusion within the APP on armed policing and post-incident procedures and published it in a NPCC national circular. The amended guidance has been included in a scenario for the national Post Incident Manager training.
Elaine Tarbuck
All Responded
2025-0342
7 Jul 2025
Manchester West
Police related deaths
Concerns summary (AI summary)
The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting in inappropriate first responder attendance.
Action Planned
(AI summary)
GMP are implementing measures to mitigate risks around the evaluation and assessment of concern for welfare calls, including mandatory briefings, enhanced training, revision of risk assessment tools, and a review of the escalation process, overseen by the FCCO Senior Leadership Team. NWAS and GMP have implemented collaborative measures including targeted training, review of incident logs, visits by GMP supervisors to the NWAS control room, and ongoing meetings between leadership teams, to address the issue of calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare. The College of Policing will highlight the issue of forced entry at the next meeting of the National RCRP Tactical Delivery Board to ensure national learning is shared; the College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews.
Muhammad Qasim
All Responded
2025-0446
25 Jun 2025
Birmingham and Solihull
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led to the absence of a crucial forensic collision report.
Action Planned
(AI summary)
The IOPC will update internal guidance to investigators about securing full Forensic Collision Investigation Reports, including early contact with the Coroner, and will update internal written guidance within six weeks. The College of Policing will amend the Police Pursuit APP to replace 'spontaneous pursuit' with clearer guidance aligned with the National Decision Model, aiming to publish revised guidance by December 2025.
Amy Levy
All Responded
2025-0289
10 Jun 2025
Avon
Emergency services related deaths
Mental Health related deaths
Police related deaths
Concerns summary (AI summary)
Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying location and aid for a critically ill individual.
Action Planned
(AI summary)
The College of Policing will support national sharing of best practice on voicemail protocols, update the national Contact Management Curriculum to address voicemail guidance in emergencies, and ensure forces align training programs by March 2026. Surrey Police has updated its procedure to include guidance on leaving voicemails, is incorporating this guidance into training for new recruits and detectives, and will evaluate the effectiveness of the training. Avon and Somerset Constabulary will introduce a dedicated force policy and procedure for 'suicidal' cases, update the Concern for Welfare policy to mandate leaving voicemails or text messages, and provide training to all communications staff on the updated policies.
Oladeji Omishore
Partially Responded
2025-0160
25 Mar 2025
Inner West London
Mental Health related deaths
Police related deaths
Concerns summary (AI summary)
Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial lack of consideration for the individual's mental health state during interaction.
Action Taken
(AI summary)
The Metropolitan Police is updating training for call handlers to ensure mental health information is included in remarks, reviewing policy on amending the "golden line" to include mental health, updating Mental Health training, refreshing Personal Safety Training with de-escalation techniques, and launched a Taser specific Community Scrutiny Panel.
Marta Vento
All Responded
2025-0137
11 Mar 2025
Dorset
Mental Health related deaths
Other related deaths
Concerns summary (AI summary)
No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. Additionally, national guidance is lacking for ensuring continuity of care for released prisoners with mental health needs.
Action Planned
(AI summary)
NHS England required ICBs to review community mental health services by September 2024. NHS England understands that NHS Dorset would actively support the expansion of this work to support sharing of mental health care plans. The DCR Partnership is looking to have the capability to share information with others using the NRL from March 2026 onwards. The College of Policing acknowledges concerns about the lack of a bespoke risk assessment tool for violence in MOSOVO units. They will consult with the NPCC Lead for MOSOVO and relevant subject matter experts to improve guidance and direction and will liaise with Dorset Constabulary to ensure they are fully sighted on current guidance. The NPCC will request the College of Policing to review APP and training material to highlight violence risk assessment more strongly within risk management plans; they have also reiterated a request for a full review of the ARMS process. NHS Dorset supported a learning event led by NHSE regarding mental health needs, and will work with SWAST to enable access to the Dorset Care Record. They have also opened a risk on the system risk register to scrutinise the accessibility of information across system partners. HM Prison and Probation Service acknowledges concerns about sharing risk information from prison with sentencing courts and highlights the establishment of immediate release pathfinders in three prisons to develop multi-agency approaches. They will task the Safety Group in HMPPS to consider this specific area when reviewing the Prison Safety Policy Framework later in 2025-26.
Robert Evans
All Responded
2025-0120
4 Mar 2025
Liverpool and Wirral
Police related deaths
Concerns summary (AI summary)
A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing drugs during a street search if not arrested, creating a critical gap in care compared to those in custody.
Noted
(AI summary)
The NPCC Stop & Search portfolio will review the Regulation 28 document and work to ensure officers are equipped to resolve incidents such as these; they will work with other portfolios and stakeholders to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them. The College of Policing asserts that its Authorised Professional Practice (APP) on Detention and Custody adequately addresses concerns about medical attention for individuals suspected of swallowing drugs, pointing to existing guidance on immediate medical response, arrest procedures, risk assessment, and information sharing.
Anugrah Abraham
All Responded
2025-0024
14 Jan 2025
Manchester North
Police related deaths
Suicide
Concerns summary (AI summary)
Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers disclosing suicidal thoughts, and student officer training causes stress without adequate progress tracking.
Action Planned
(AI summary)
West Yorkshire Police has reflected on the events, and has already taken or is planning to take the following actions: The OH answerphone message should include advice for the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, Discussions between the clinical team regarding risk should be documented, Frequency of suicidal ideation should be recorded, Protective factors should be recorded, the OH page should include the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, contact Force Legal Services to provide inquest feedback, the service level agreement target is to be abandoned as unrealistic, Introduction of 90mins appointments, and Escalation to Force Medical Advisor for student officers referred due to their mental health. The College of Policing will review APP on suicide prevention to incorporate Anugrah Abraham's case and will also create a central repository of information on suicide prevention. They will also ensure the sharing of information about concerns with performance and any associated processes that are commenced will be referenced.
Matthew Brierley
All Responded
2025-0008
8 Jan 2025
Cumbria
Police related deaths
Suicide
Concerns summary (AI summary)
Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support fail to address their elevated risk.
Noted
(AI summary)
The College of Policing outlines existing guidance and practitioner advice for officers and staff regarding suspects of child sexual exploitation and risk assessment processes following release from custody, noting Mr. Brierley declined support offered. The Home Office acknowledges the report and expresses condolences, notes the relevant guidance provided by the College of Policing, and states that a review concluded appropriate support was provided to Mr. Brierley by Border Force. The NPCC is undertaking research to identify commonalities in post-custody suicides to establish a post-release risk assessment process and mandatory referral to support agencies, and has shared the PFD report with all UK custody leads with recommendations for investigative strategies. The Ministry of Justice believes the report should have been directed to the Home Secretary, as it relates to police investigative procedures, bail conditions, and Border Force (Home Office) matters.
Chad Allford
All Responded
2024-0585
25 Oct 2024
Derby and Derbyshire
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe interventions and failure to warn suspects of life-threatening choking risks.
Action Planned
(AI summary)
Derbyshire Constabulary has designed and implemented a lesson plan covering concealment of items in a subject’s mouth and mandated that safety training includes a scenario covering this topic. They have also contacted the College of Policing to inform them of the concerns raised. The College of Policing is revising the Personal Safety Manual to include guidance on informing a subject about the risk to their life when swallowing drugs. In the interim, communication will be sent nationally to advise forces of this recommendation.
Sean Heath
All Responded
2024-0524
2 Oct 2024
Manchester South
Mental Health related deaths
Suicide
Concerns summary (AI summary)
Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.
Noted
(AI summary)
NHS England acknowledges the coroner's concerns regarding connectivity between mental health services abroad and in the UK, but notes that information sharing cannot be mandated for overseas healthcare providers. They highlight the work of the Regulation 28 Working Group in sharing learnings from PFD reports. The Home Office outlines the Right Care, Right Person (RCRP) approach, which GMP is rolling out, to ensure the right agencies respond to people in need of support, but defers to the College of Policing and GMP for specific issues. NWAS has provided feedback and reflection to the Mental Health Practitioner involved in the incident. They continue to deploy mental health Trust practitioners in NWAS control rooms and directly employ mental health practitioners for triaging calls. The DHSC acknowledges concerns about training for police officers, notification of carers for Mental Health Act admissions, connectivity between international and UK mental health services, GP practice list removals, and communication between mental health agencies, deferring to other bodies on some points and explaining existing policy on others. GMMH has emphasized the notification of carers following admission under the Mental Health Act through daily staff huddles and implemented a process to ensure written information is provided to carers within 72 hours of admission. GMMH will also carry out an audit to ensure staff are following guidance on safe transfers between teams by the end of March 2025. The College of Policing highlights the national 'Right Care Right Person' (RCRP) framework, supported by Authorised Professional Practice (APP) and a toolkit, along with a bespoke e-learning training package. They are in contact with Greater Manchester Police, who are implementing RCRP. The CQC acknowledges the concerns but states that they fall outside of its regulatory remit, particularly regarding GP practices and information sharing between agencies. It outlines its inspection methodology but takes no direct action. Trafford Council has reinforced expectations within Adult Social Care that staff must verify if the Police are responding to a call, reviewed and strengthened safeguarding processes, and invested in mental health management and practitioner capacity. Single agency recommendations from the Safeguarding Adults Review have been actioned. Response contains only blank pages.
Kevin Cashin
All Responded
2024-0345
21 Jun 2024
Manchester North
Other related deaths
Concerns summary (AI summary)
Police officers lacked understanding of agonal breathing and how to recognize early cardiac arrest, causing a significant delay in intervention. Their first aid training curriculum is insufficient in these critical areas.
Action Taken
(AI summary)
The College of Policing has updated its First Aid Learning Programme (FALP) to include specific reference to recognising agonal gasps and has developed new Public and Personal Safety Training (PPST) for forces to implement.
Tcherno Bari
All Responded
2024-0296
3 Jun 2024
Birmingham and Solihull
Suicide
Concerns summary (AI summary)
Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor information sharing, lack of staff awareness regarding procedures, and ineffective challenge processes between mental health services and police.
Noted
(AI summary)
This is an appendix to the BSMHFT response, specifically the Trust's Missing Patient Policy. It outlines the actions to be taken when a patient is missing or AWOL, relating to Informal inpatients, Detained patients who are AWOL and patients in the community, read in line with National Partnership Agreement: Right Care, Right Person (RCRP). NHS England will issue guidance to health systems on reviewing Serious Incident investigations to ensure lessons are learned and changes agreed upon. A national oversight group has been set up to review concerns and issues with RCRP, and this group feeds into a ministerial working group. West Midlands Police (WMP) has provided additional RCRP training to call handlers and officers and produced an exhibit detailing the escalation point of contact for partner agencies to West Midlands Police. WMP has also emphasised the need for officers to gather information from all sources and record the rationale for decisions made, particularly regarding vulnerable people. The National Police Chiefs' Council clarifies the aims of Right Care Right Person (RCRP) and states that it appears the situation concerning Mr. Bari was treated as a missing person case from the outset by West Midlands Police, and therefore RCRP principles would not apply. BSMHFT has updated their Missing Persons Policy in line with Right Care Right Person (RCRP) changes, incorporating feedback from the inquest, and a new Executive Director of Quality and Safety/Chief Nursing Officer will be accountable for the policy. The updated policy includes a revised Appendix C form focusing on the reasoning for critical concern and requires formal notification from the police with their decision and reasoning if they have decided not to deploy immediately. The APCC provides background on its role and the role of PCCs in local policing, noting that it has developed guidance for members on the Right Care, Right Person approach. It states that the NPCC is reviewing the report to identify relevant national learning. The Department of Health and Social Care acknowledges the concerns raised, noting that local policies should align with the Mental Health Act Code of Practice and that local partners should reassess joint processes on risk assessment, communication, and escalation. They emphasise the importance of collaboration between policing and health partners. The College of Policing is undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process. They are also working to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. The Home Office outlines the rationale and purpose of the National Partnership Agreement (NPA) and notes that decisions on implementation of Right Care Right Person (RCRP) are for individual Chief Constables. They state that missing persons cases are outside the scope of RCRP and existing police procedures should continue to operate.
Ashley Crews
Partially Responded
2024-0216
23 Apr 2024
Manchester City
Other related deaths
Concerns summary (AI summary)
The absence of a local policy regarding the use of handcuffs when executing arrest warrants raises a safety concern.
Noted
(AI summary)
Greater Manchester Police acknowledges the absence of a specific policy on handcuffing during search warrant executions, but states that use of force is a case-by-case decision guided by legislation, the National Decision Model, and consideration of occupants' vulnerabilities.
Samuel Curless
All Responded
2024-0089
19 Feb 2024
Manchester South
Suicide
Concerns summary (AI summary)
Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary first aid refresher training for life-preservation.
Noted
(AI summary)
The College of Policing updated the First Aid Learning Programme (FALP) in 2020, increasing recommended training time for both refresher and initial training for public-facing officers, now including basic life support and airway techniques. Annual refresher training is a core requirement of the FALP license. Response is a placeholder document.
Lee Bowman
All Responded
2024-0109
8 Nov 2023
South Yorkshire East
Other related deaths
Concerns summary (AI summary)
Police made significant assumptions about a missing person, focusing on past addiction rather than prioritizing crucial family information regarding his current mental state and usual daily contact.
Action Planned
(AI summary)
The College of Policing will update its Missing Persons APP to alert police officers and staff to the need to avoid imprecise terms such as 'chaotic lifestyle' and instead set out clearly what matters and issues have been identified that have a bearing on the assessment of risk.
Carl Fullalove
Partially Responded
2023-0408
25 Oct 2023
Cheshire
Other related deaths
Concerns summary (AI summary)
Inadequate police training on identifying nuanced symptoms of Acute Behavioural Disturbance (ABD) and the risks of prone restraint for drug-intoxicated individuals led to fatal outcomes.
Action Taken
(AI summary)
The College of Policing updated their First Aid Learning Programme (FALP) in April 2024 to include updated guidance on Acute Behavioural Disturbance (ABD), including de-escalation and communication strategies.
John Condron
Partially Responded
2023-0374
6 Oct 2023
Cheshire
Suicide
Concerns summary (AI summary)
There is no agreed national protocol or specified timescale for police to inform suspects of a decision to take no further action, creating a risk of further self-inflicted deaths.
Action Taken
(AI summary)
Cheshire Constabulary has reviewed its suspect policy and procedure, introduced in August 2023, and now specifies that when a decision is made not to take further action against a suspect, they must be updated at the earliest practicable opportunity or within 48 hours.
Nicholas Ledger
All Responded
2023-0314
31 Aug 2023
Inner North London
Suicide
Concerns summary (AI summary)
The report refers to evidence from the investigating officer and an investigator from the Metropolitan Police’s Directorate of Professional Standards.
Action Planned
(AI summary)
The College of Policing outlines that updated statutory guidance, e-learning, and knowledge products have been released regarding pre-charge bail, and specific guidance on safeguarding those subject to RUI has been issued. It also highlights existing guidance on risk assessments for those released from custody, and custody training aimed at reducing the risks of post detention suicides. The Metropolitan Police Service plans to implement a new policy by April 2024 requiring a risk assessment to be completed by the OIC no earlier than fourteen days prior to issuing the PCR for suspects charged with a recordable offence. This assessment will be supervised by line management and form part of the PCR process.
Andre Moura
All Responded
2023-0348
3 Jul 2023
Manchester South
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed the safety officer role, and relied on subjective assessments instead of objective AVPU checks.
Action Planned
(AI summary)
The College of Policing has revised its First Aid Learning Programme (FALP) and the new Public and Personal Safety Training (PPST) training implementation went live in 2023, and the revised ABD training package will be published mid-September 2023. The NPCC is revising the Body Worn Video (BWV) guidance to include that BWV should be left running during periods of prisoner transport. This guidance will be published in October.