Police related deaths

Concerns summary Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.

Concerns 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.

Concerns 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.

Concerns summary Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating a disparity in access to healthcare support compared to those in custody.

Concerns summary Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training and communication with paramedics regarding patients with fluctuating capacity who abscond from treatment.

Concerns summary Significant and unexplained delays in an internal police disciplinary process are concerning, failing to meet the expectation of timely resolution and potentially contributing to a future death.

Concerns summary Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially reported, hindering their ability to ensure safety in critical situations.

Concerns 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.

Concerns summary Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled with a lack of comprehensive analysis from the CJLD assessment.

Concerns summary Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support and unimplemented alternative services.

Concerns summary Custody sergeants lacked understanding of Liaison and Diversion team processes, available information, and how to complete pre-release risk assessments. This indicates a training need for recognizing vulnerability at discharge.

Concerns summary There's a lack of emergency access protocols for consular officers to detained British nationals, especially those in mental health crisis. FCDO travel advice is insufficient regarding the specific consequences of detention in Dubai.

Concerns summary Severe understaffing in the domestic abuse unit meant cases were not investigated, leaving high-risk victims vulnerable to ongoing violence and threats due to a lack of effective police action.

Concerns summary Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a vulnerable individual who expressed suicidal ideation and required physical assistance.

Concerns summary Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of readily available entry equipment and poor document management practices.

Concerns summary Ongoing risks exist due to delayed training for Domestic Abuse Team staff and supervisors on updated policies. There is also no system for effective supervisory review of initial risk assessments and safeguarding plans.

Concerns summary A lack of comprehensive statistical data prevents adequate review of police pursuit risks and effectiveness. The current system places an onerous burden on drivers and limits pursuit managers' real-time oversight.

Concerns summary Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.

Concerns summary Police investigations were marred by a significant number of "very serious and very basic investigative failings," including a profound lack of curiosity and errors, with terrible consequences.

Concerns summary Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical history was inaccessible, hindering treatment.

Concerns summary A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an urgent need to review S.136 procedures.

Concerns summary Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate risk grading and no plan to rectify this critical issue.

Concerns summary Police training materials do not include guidance on managing 'Ictal automatism' from temporal lobe epilepsy, risking inappropriate use of restraint and exacerbating a patient's distress.

Concerns summary Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, both posing risks to patient and public safety.

Concerns summary Critical mental health information from MARAC was not accurately recorded or cascaded to police, leading to officers being unaware of the deceased's EMD status. There was also confusion and a lack of coordination during CPR efforts.