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.

Response Status (last 2 years, 18 reports)
Responded 15 Pending 1
AI Classification
Action Taken 32%
Action Planned 45%
Noted 22%
Disputed 1%
Based on 148 classified responses
PFD Reports Received by Quarter
Clear
PFD Reports
31 results
Hamish Howitt
All Responded
2021-0320 23 Sep 2021 West Sussex
Police related deaths
Concerns summary (AI summary) Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading to a missed traumatic brain injury. Training needs to mandate hospital referral for such individuals.
Action Planned (AI summary) Avon and Somerset Constabulary circulated a memorandum to all officers with guidance on head injury risk, sent guidance to first aid trainers, and added guidance to first aid training modules. They also incorporated training on head injury response into Taser, Public Safety, and Public Order training, all completed in October 2021. The Home Office has consulted with the College of Policing and NPCC, and the College will address the coroner's concerns about police first aid training through its formal governance routes. The College of Policing and NPCC will raise concerns about alcohol's impact and head injury assessment in first aid training at the next First Aid Forum meeting in December to assess feasibility of addressing them within the FALP licence scope. The College is also reviewing high-level learning outcomes within the FALP to emphasize life-saving elements, considering acute alcohol intoxication, intentional overdoses, and extending head injury learning to Module 2.
Katrina O’Hara
All Responded
2020-0051 3 Mar 2020 Dorset
Other related deaths
Concerns summary (AI summary) Outdated police policy led to a high-risk 999 call being downgraded, and officers failed to recognise the increased danger to the victim when the perpetrator expressed suicidal intent. The victim was also left without a replacement phone after hers was seized for evidence.
Noted (AI summary) The NPCC has undertaken a major refresh of the National Contact Management Strategy since 2015, with revised principles and practice that cover the issue of inappropriate channel selection. The report will be raised at the next meeting of the National Contact Management Steering Group. The Home Office is working to pilot and evaluate approaches to identifying and tackling high risk offenders, including adding suicide indicators to the list of potential risk indicators. Work is ongoing to review findings from domestic homicide reviews and academic research with a view to more accurately identifying key characteristics and risk factors for domestic homicides.
Marc Cole
All Responded
2020-0087 6 Feb 2020 Cornwall and the Isle of Scilly
Alcohol, drug and medication related deaths Police related deaths
Concerns summary (AI summary) There is insufficient independent data and understanding regarding the lethality and incremental risks of multiple Taser activations, potentially leading to deficient police training and unsafe use.
Noted (AI summary) The College of Policing explains its role and details existing guidance and learning material addressing the risks associated with Taser use, particularly multiple activations, and highlights the role of SACMILL in advising on medical issues. The Home Office acknowledges the concerns about Taser use and refers to existing policy, guidance, training, and scrutiny mechanisms. It states satisfaction that current measures are adequate but acknowledges every death in police custody is a tragedy.
Deborah Lamont
All Responded
2020-0008 20 Jan 2020 South Wales Central
Suicide Wales prevention of future deaths reports
Concerns summary (AI summary) Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual in a hotel room. This highlights a need for clearer guidance on how such temporary accommodations are classified under the Act.
Action Planned (AI summary) The College of Policing will amend its guidance in respect of the use of s136 powers, circulate a summary of the issue to all police force mental health leads, and work with the Home Office to assess the need for changes to national guidance regarding the use of s136 and hotel rooms. The Chief Constable of South Wales has asked that the Force Mental Health Lead fully consider the use of hotel rooms and s.136, subject to a specific note upon force guidance and within training. The College of Policing will circulate a summary of the issue to all police force mental health leads and has raised the issue with the Home Office to assess the need for changes to national guidance.
Douglas Oak
All Responded
2019-0352 24 Oct 2019 Dorset
Other related deaths
Concerns summary (AI summary) There is a critical lack of national guidance for Ambulance Services on using chemical sedation for patients with Acute Behavioural Disturbance, despite its effectiveness for safe treatment and transport.
Noted (AI summary) The Department of Health and Social Care acknowledges the report but states that a response will be delayed due to an upcoming General Election. They will contact the office to agree on a new deadline once a new administration is in place. The College of Policing and NPCC are working with forces and medical service partners to address concerns related to Acute Behavioural Disturbance, including raising awareness and consistency in recognition and response. The Chair of the NPCC will write to all Chief Constables to bring the content of the PFD to their attention. Joint guidance between ambulance services and police forces is in development, overseen by a joint committee. AACE will share operational considerations with the National Directors of Operations Group (NDOG) for ambulance services, and will discuss the report at future meetings. St John Ambulance is providing additional Continuous Professional Development training around Acute Behavioural Disturbance. They have also raised the topic for inclusion in the latest version of the First Aid Manual.
Matthew Lewis
All Responded
2019-0048 13 Feb 2019 South Wales Central
Emergency services related deaths Suicide Wales prevention of future deaths reports
Concerns summary (AI summary) Confusing and inconsistent call handler instructions to police officers during a hanging incident created ambiguity between scene preservation and life preservation, risking unsuccessful rescue attempts.
Action Planned (AI summary) South Wales Police have developed a procedure for call handlers that incorporates guidance highlighting the presumption that 'life is not extinct' in hanging scenarios. This procedure is now part of call handler training. The College of Policing will amend learning standards for contact management staff within the next month to reflect the importance of preserving life. They have also asked for a summary of the issue to be circulated to heads of contact management across England and Wales.