Police related deaths

PFD Category
Reports: 152 Areas: 51 Earliest: Sep 2013 Latest: 6 Jan 2026

87% response rate (above 63% average). 46% of classified responses show concrete action taken.

PFD Reports
108 results
Paul Taylor
All Responded
2024-0710 24 Dec 2024 Nottingham and Nottinghamshire
Nottinghamshire Police
Concerns summary (AI 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.
Action Planned (AI summary) Nottinghamshire Police is revising its policy to ensure consistent procedures for supporting suspects of relevant offences, irrespective of whether they are arrested or attend voluntarily. The revised policy will include an automatic referral to Liaison and Diversion (healthcare services) and is planned for implementation by 1st March 2025.
Sebastian ‘Benji’ Oliver
All Responded
2024-0589 30 Oct 2024 Birmingham and Solihull
West Midlands Police
Concerns summary (AI summary) Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training and communication with paramedics regarding patients with fluctuating capacity who abscond from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.
Action Taken (AI summary) West Midlands Police have taken several actions including: implementing a new THRIVE+ risk assessment, adding a prompt regarding mental health capacity, creating a prompt to evidence rationale for clinical decision making, refreshing communications regarding medical assessments, and updating training lesson plans to reinforce staff re-THRIVE and include the Mental Capacity Act.
Chad Allford
All Responded
2024-0585 25 Oct 2024 Derby and Derbyshire
College of Policing Derbyshire Constabulary
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.
Michael Crane
All Responded
2024-0581 25 Oct 2024 Inner North London
Metropolitan Police Prime Life Limited
Concerns summary (AI 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.
Action Taken (AI summary) The MPS runs a scenario based approach to Public and Personal Safety Training (PPST), focusing on different interactions an officer is likely to face in the course of their day to day duties. This training is mandatory for all operational police officers and Detectives within the MPS. Prime Life has reviewed its missing person policy and has provided additional training to the staff and management at Island Place in order to ensure that they have clear guidance on when and understanding in how quickly a person should be reported missing. There are a full set of policies and procedures available to all staff, which have since undergone a full review.
Martin Stubbs
All Responded
2024-0573 25 Oct 2024 West Yorkshire (Eastern)
Independent Office for Police Conduct West Yorkshire Police
Concerns summary (AI 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.
Noted (AI summary) West Yorkshire Police has implemented changes including a quarterly review by the DCI at Professional Standards, an annual review by the Head of Professional Standards, and quarterly meetings between the senior leadership team at Professional Standards and senior leaders at the IOPC. The IOPC acknowledges the concerns and highlights existing guidance and the ongoing Transformation Programme to improve timeliness, but states that primary responsibility for welfare rests with the officer's force.
John Hurst
All Responded
2024-0568 23 Oct 2024 Sunderland
Cumbria, Northumberland, Tyne and Wear … Northumbria Police
Concerns summary (AI 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.
Action Taken (AI summary) Northumbria Police has provided instruction and learning to custody staff regarding the importance of recording all relevant information and concerns related to a detainee's mental health via the Force Custody Newsletter, the Force Custody Compendium, and a direct reminder to all departmental Custody Sergeants. The NHS Trust has taken several actions, including emailing staff about the need to document concerns on the electronic custody record (ECR), updating the Local Operating Procedure, providing verbal handovers to the Custody Sergeant, and implementing a monthly clinical audit of CJLD screening documentation.
Leighton Dickens
All Responded
2024-0522 29 Sep 2024 South Wales Central
South Wales Police
Concerns summary (AI 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.
Action Planned (AI summary) South Wales Police will continue to work in partnership with NHS Wales and health boards to ensure officers can obtain medically qualified advice for people in crisis at any time.
Peter Kelly
All Responded
2025-0419 15 Dec 2023 South Yorkshire East
South Yorkshire Police
Concerns summary (AI 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.
Action Planned (AI summary) South Yorkshire Police will circulate clarification to custody sergeants and staff on involving Liaison and Diversion, provide a flowchart for completing Pre-Release Assessments, and provide further guidance on entering the "L&D" flag on the CONNECT system; they will also hold one-to-one discussions with Custody Sergeants A and B involved in the detention of PK.
Lee Brown
All Responded
2022-0360 13 Nov 2022 East London
Department for Foreign, Commonwealth an…
Concerns summary (AI 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.
Action Taken (AI summary) The FCDO highlights updated training for consular staff, including mental health awareness, and clarifies the protocol for sharing information without consent when an individual's vital interests are at risk. They emphasize that the host state is responsible for the safety and security of individuals.
Raneem Oudeh and Khaola Saleem
All Responded
2022-0352 3 Nov 2022 Birmingham and Solihull
Home Office West Midlands Police
Concerns summary (AI 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.
Noted (AI summary) West Midlands Police restructured the Public Protection Department in 2019, increasing staff allocated to DA investigation and replacing Domestic Abuse Teams with Adult Investigation and Adult Complex Investigation Teams; they have also established a scrutiny panel with the CPS to review decisions where no further action is taken. West Midlands Police restructured the Public Protection Department in 2019, increasing staff allocated to DA investigation and replacing Domestic Abuse Teams with Adult Investigation and Adult Complex Investigation Teams; they have also established a scrutiny panel with the CPS to review decisions where no further action is taken. The Home Office highlights the Domestic Abuse Act 2021 and the Tackling Domestic Abuse Plan, committing to assist in funding the rollout of Domestic Abuse Matters training and funding the College of Policing to develop a new module aimed at investigators of domestic abuse; they also mention the Police Uplift Programme and additional funding for West Midlands Police. The College of Policing has created a 'DA Matters' training package for police responders focusing on coercive control, delivered by DA charities, and has rolled out the Domestic Abuse Risk Assessment tool (DARA) to every force in England and Wales. West Midlands Police is publishing a revised Domestic Abuse policy with an initial response action checklist and will launch it with a tailored communication and briefing package; they have also created an improvement plan to increase the number of Domestic Violence Protection Notices and Orders. The Police and Crime Commissioner acknowledges the coroner's report and highlights ongoing efforts by West Midlands Police to address domestic abuse, while also noting resource constraints and the impact of cuts to public services.
Dominic Noble
All Responded
2022-0204 West Yorkshire (Eastern)
Practice Plus Group Health and Rehabili…
Concerns summary (AI summary) HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with severe mental health issues, a persistent concern.
Action Taken (AI summary) Practice Plus Group has introduced a 'Rapid Assessment & Treatment Clinic' at HMP Leeds to improve assessment times. They are also submitting a business case to NHS England to increase psychiatrist provision and are developing the role of pharmacists with mental health expertise.
Louise Bailey
All Responded
2022-0200 Inner South London
Metropolitan Police Service, The Colleg…
Concerns summary (AI summary) Police drivers lack critical information and training regarding closer units, preventing them from completing full risk assessments before responding to emergency calls.
Disputed (AI summary) The National Police Chiefs' Council and College of Policing acknowledge concerns regarding risk assessment and radio communication but clarify that 'Roadcraft' is a driver training reference, not official policy. They assert that officers and dispatchers are responsible for dynamic risk assessment. The Metropolitan Police Service is amending the Airwave manual to clarify procedures around self-assignment to incidents. They are also procuring a replacement Command and Control System designed to assign vehicles based on distance and skill set.
Luke Flynn
All Responded
2022-0191 Inner North London
Metropolitan Police
Concerns summary (AI summary) The Metropolitan Police lack a policy on handcuff use when requested by medical staff for hospital patients with medical conditions, not mental health issues.
Disputed (AI summary) The Metropolitan Police Service has reviewed its new Handcuff Policy (published November 2021) and concluded that it is sufficiently robust. They do not believe a further policy change addressing the specific scenario of handcuff use in a healthcare setting for medical treatment is appropriate.
Ian Taylor
All Responded
2022-0173 8 Jun 2022 Inner South London
Independent Office for Police Conduct Metropolitan Police Service The Royal College of Emergency Medicine +1 more
Concerns summary (AI 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.
Noted (AI summary) The Royal College of Emergency Medicine states that provision of medical cover to police custodial units does not fall within its remit. The IOPC will not be undertaking an investigation but is satisfied that the reflective practice review process can be used effectively to prompt reflection and insight into this incident. The Metropolitan Police Service will implement the Reflective Practice Review Process (RPRP) for the officer in question, which will include an opportunity to reflect on the missed opportunity to offer an apology to Mr. Taylor's family; the officer's line manager will also identify any additional training needs. The Department of Health and Social Care outlines the process and considerations involved in allowing police officers to carry salbutamol inhalers, noting it would require a change in legislation, and would need to be initiated by the Home Office, after consulting the Commission on Human Medicines (CHM) and undertaking public consultation; it also highlights NHS England's focus on preventer inhalers and monitoring by GPs.
Hannah Beardshaw
All Responded
2022-0111 13 Apr 2022 Manchester West
Greater Manchester Police Independent Office for Police Conduct
Concerns summary (AI 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.
Noted (AI summary) GMP has revisited its Graded Response Policy (GRP), implementing a new GRP on 1 February 2022 using the THRIVE framework for risk assessment. They are also implementing a new IT system called 'Sherlock' by August 2022 to improve information storage and access in the FCC. The IOPC acknowledges the report and highlights its power to make organisational learning recommendations to relevant bodies. They state that GMP has a legal obligation to respond to the recommendations in writing by 20 July 2022.
Andrew Kitson
All Responded
2022-0066 3 Mar 2022 West Yorkshire (East)
Regional Major for West Yorkshire West Yorkshire Police
Concerns summary (AI 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.
Noted (AI summary) The Mayor acknowledges the concerns regarding police pursuits but states that operational policing is under the Chief Constable's control. The Mayor highlights existing governance structures and oversight of ethical considerations around police pursuits. West Yorkshire Police details actions taken in response to concerns about police pursuits, including re-evaluating local arrangements, liaising with national leads, updating training, and revising risk assessment processes. They also describe post-incident procedures and national efforts to standardize driver training.
Jack Taylor
All Responded
2022-0029 28 Jan 2022 West Sussex
Sussex Partnership NHS Foundation Trust Sussex Police
Concerns summary (AI 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.
Action Planned (AI summary) Sussex Partnership NHS Foundation Trust, working with Sussex Police, established a working group to improve the joint response to patients absent without leave, proposing solutions including a Missing Persons Template and updated risk assessment processes. An improved escalation process has been implemented and added to the AWOL Policy and the AWOL reduction project is being rolled out across the Trust. Sussex Police is co-developing a Missing Persons Template with SPFT to improve information sharing and is reviewing existing training for Sergeants on missing person investigations, with potential enhancements. The force also plans to review the structure of the Missing Persons Team to enhance support to colleagues.
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor
All Responded
2022-0017 21 Jan 2022 East London
Metropolitan Police Service, National P…
Concerns summary (AI 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.
Action Planned (AI summary) The NPCC and College of Policing outline actions taken, including updating the Death Investigation Manual and associated training to emphasize treating deaths as suspicious until proven otherwise. They have also highlighted existing guidance on handling personal effects and assessing handwritten notes, and initiated a review of the Forensic Submissions Good Practice Guide. DCMS states that the Online Safety Bill will place new requirements on companies in relation to illegal content and anonymity online and services will have to identify, mitigate and effectively manage the risk of anonymous profiles. Ofcom will set out the types of verification methods a company could use in guidance. The Metropolitan Police Service has updated its Death Investigation Policy to emphasize treating deaths as suspicious until proven otherwise and is providing refresher training to detectives. The CONNECT Investigation platform, which is replacing CRIS, will have improved functionality to track the completion of investigative actions.
Neil Parkes
All Responded
2022-0019 20 Jan 2022 Warwickshire
Warwickshire Police
Concerns summary (AI summary) Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical history was inaccessible, hindering treatment.
Action Taken (AI summary) Warwickshire Police reviewed their response to the incident and provided words of advice to control room staff, organizational learning was circulated, and changes were implemented to improve responses in similar situations; this included reviewing the necessity to take fingerprints and ensuring incidents are resulted with actions taken and rational for closing.
Gary Williams
All Responded
2021-0401 26 Nov 2021 Liverpool and Wirral
National Police Chiefs’ Council
Concerns summary (AI 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.
Action Taken (AI summary) The NPCC states that following a previous similar case, the Self Defence Arrest and Restraint (SDAR) working group has already reviewed and updated training materials to include guidance on Acute Behavioural Disorder (ABD), and the updated package was circulated to forces in March 2021.
Trevor Smith
All Responded
2021-0387 17 Nov 2021 Birmingham and Solihull
College of Policing West Midlands Police
Concerns summary (AI 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.
Action Planned (AI summary) The NPCC First Aid Forum will formally raise the issue of establishing a first aid (CPR) coordinator at its next meeting. The College of Policing will send out a national circular to raise awareness of the Coroner's concerns so that forces can consider a coordinator role in appropriate circumstances while the associated national guidance and training is considered. West Midlands Police have updated team briefing sheets to include reference to the CPR coordinator role and updated the Medical Plan to include direction regarding the coordination of care. All Strategic and Tactical Firearms Commanders (S&TFCs), Operational Firearms Commanders (OFCs), Firearms Tactical Advisers (FTAs) and all Authorised Firearms Officers (AFOs) are aware of this recommendation.
Katrina Makunova
All Responded
2021-0388 5 Nov 2021 London Inner South
University of Gloucestershire, Universi…
Concerns summary (AI summary) Knife possession and gang affiliation were not consistently recognized as risk factors in contextual abuse assessments by police or social services. Additionally, police Child Safety Units face significant workload pressures impacting safeguarding effectiveness.
Action Planned (AI summary) The MPS will share the report with relevant departments and review training programmes to include expert evidence-based advice on knife carrying and gang membership in domestic abuse risk assessments. A review of CSU resourcing is underway, with findings to be presented to the MPS Management Board in January 2022.
Fishmongers’ Hall Inquests
All Responded
2021-0362 3 Nov 2021 London City
College of Policing Department for Education Home Office +7 more
Concerns summary (AI summary) This document is a questionnaire for the jury, intended to determine the means and circumstances by which Jack Merritt and Saskia Jones died, focusing on identifying any errors, omissions, or circumstances that may have caused or contributed to their deaths.
Noted (AI summary) CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders. The Learning Together Network CIC states it cannot take steps on the recommendations as it did not employ staff or run partnerships, and will be dissolved in January 2022. The Office for Students will write to all registered higher education providers in England, making them aware of the report and asking them to consider changes to their approach to risk assessment of events, programmes, and information sharing. The College of Policing acknowledges the concerns raised and states its commitment to supporting other bodies in achieving improvements in terrorist offender management. They provide broader offender management training products and guidance and will work with partners to ensure they are updated. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders and now feed this into the MAPPA panel. The Secretary of State will engage with the higher education sector to encourage action to implement the recommendations and officials have spoken to the Office for Students to encourage them to take action. Officials have also engaged with HMPPS to design a new framework to define roles and responsibilities of prisons and higher education providers. The University of Cambridge has created a new policy and guidance for staff and students working with people who have offended, and the Institute of Criminology has developed a Risk Assessment Form for all activities. The University has also stopped delivering the Learning Together programme. The government is legislating a new power of personal search through the Police, Crime, Sentencing and Courts Bill, allowing police to stop and search terrorist offenders on license under certain circumstances. MoJ accepted recommendations relating to the Fishmongers' Hall attack. A new framework is being designed for Learning Together activity in prisons. Statutory guidance on MAPPA meetings will be strengthened, and the Police, Crime, Sentencing and Courts Bill includes a power for police to search terrorist offenders on licence.
Donna Constantine
All Responded
2021-0350 19 Oct 2021 Greater Manchester South
National Police Chiefs’ Council, Home O…
Concerns summary (AI summary) Police encouraging vulnerable individuals to use unmonitored work mobile phones creates risks due to a lack of off-duty response, clear escalation procedures, and proper audit trails for communication.
Noted (AI summary) The Home Office acknowledges the concerns and states that police forces are operationally independent and it is for Greater Manchester Police, the NPCC and the College of Policing to address the issues raised. The NPCC and College of Policing note the concerns and explain that the Victims Code was updated in April 2021. They state that forces are not encouraged to give out mobile phone numbers and provide guidance for officers receiving emergency calls.
Alexandra Tolley
All Responded
2021-0344 14 Oct 2021 West Yorkshire (East)
Leeds and York Partnership NHS Foundati…
Concerns summary (AI summary) The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground leave lacked criteria and proper risk assessment.
Action Planned (AI summary) The Trust will update its procedure for patients who go missing, including external feedback, aiming for ratification by January 2022; it will also communicate clear timescales to external organizations for procedure input.