Police related deaths

Concerns summary Despite national recommendations, Lincolnshire lacks an established protocol to treat suspected Acute Behavioural Disturbance (ABD) as a medical emergency. The NHS Pathways system also inadequately categorises ABD cases.

Concerns summary Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers to escalate safety concerns during searches.

Concerns summary Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff or monitor the detainee adequately.

Concerns summary Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also did not apply the National Decision Model or challenge inappropriate techniques, contributing to the death.

Concerns 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.

Concerns summary Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk of further harm due to the absence of bail conditions or driving disqualification.

Concerns summary A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for Section 136 detentions creates significant risks for vulnerable individuals.

Concerns 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.

Concerns 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.

Concerns summary Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, hindering full risk assessment and decision-making for vulnerable individuals.

Concerns 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.

Concerns 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.

Concerns summary Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, leaving vulnerable people at risk.

Concerns summary Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare concerns, a known recurring issue.

Concerns summary Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter locked premises, and leading to dangerous delays in supervisor reviews.

Concerns summary The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among officers regarding the time required for pursuit authorization decisions.

Concerns summary The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest by lacking objective evidence crucial for future learning and policy development.

Concerns 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.

Concerns summary A significant delay in commencing CPR occurred due to a lack of shared understanding of its urgency and an uncoordinated response among detention officers and a nurse. No clear protocols define emergency roles.

Concerns summary Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about the quality of their internal review and learning from incidents.

Concerns 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.

Concerns summary Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs or asked about scene presence, led to significant delays in patient care. The lack of police-to-hospital conveyance options for urgent cases is also a concern.

Concerns summary Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented their death.

Concerns summary Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling issues, increasing the risk of harm to vulnerable patients.

Concerns summary Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police delays, expose individuals to significant harm before assessment.