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
152 results
Felicity Clough
Partially Responded
2021-0402 26 Nov 2021 Dorset
Department of Health and Social Care, H… National Police Chiefs’ Council NHS England +1 more
Concerns summary (AI 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.
Action Taken (AI summary) The Secretary of State for Health and Social Care reports that Yeovil District Hospital has implemented measures to ensure staff can access pre-hospital information, including converting information from other systems into PDF documents and saving it within their existing system (Trakcare) in the Emergency Department from January 6 2022.
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.
Joseph Martin
Historic (No Identified Response)
2021-0389 16 Nov 2021 Inner North London
Police Service of Northern Ireland Belf…
Concerns summary (AI summary) Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing person's psychotic relapse were not recorded or relayed to other officers or agencies.
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) 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. 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 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.
Leon Briggs
All Responded
2021-0330 4 Oct 2021 Bedfordshire and Luton
Association of Ambulance Chief Executiv… Bedfordshire Police EEAST +1 more
Concerns summary (AI summary) The local S136 Multi-Agency Policy is unclear and lacks streamlining. There is insufficient training for first responders on recognizing medical emergencies, the effects of restraint, and monitoring detainees.
Noted (AI summary) EEAST has approved (November 2021) the National Ambulance s.136 Guidance, is developing and implementing a new mental health care service model, and has developed a specific training session in relation to Acute Behavioural Disorder, including positional asphyxia for frontline staff. Bedfordshire Police is updating its local section 136 multi-agency policy, with a revised version due to be signed off this year and is incorporating guidance from a national ABD policy review into existing guidance for relevant policing areas. AACE confirms that the national S136 guidance has recently been revised, updated, and issued nationally and that on 1st February 21 they updated the acute behavioural disturbance guidance with wording to emphasise the need for close monitoring of a patient when restraint is used.
Richard Boateng
All Responded
2021-0335 28 Sep 2021 South London
College of Policing London Ambulance Service NHS England
Concerns summary (AI summary) Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, and police lack practical guidance for safely conveying patients in emergencies.
Noted (AI summary) The College of Policing acknowledges the concerns and refers to existing APP guidance on dynamic risk assessment. The NPCC will discuss ambulance availability with colleagues and the NPCC First Aid Forum will consider practical advice to forces. The London Ambulance Service has issued staff bulletins for frontline and control room staff detailing actions for 'no trace' calls, and is updating policies OP14 and OP23 to include a step-by-step process. Policy OP14 is expected to be finalised by the end of 2021, and OP23 in early 2022. NHS England details existing guidance, clinical safety officer forums, and hazard logs for digital triage. They also highlight that practices should not rely on online access for all clinical triage.
Hamish Howitt
All Responded
2021-0320 23 Sep 2021 West Sussex
Avon and Somerset Police College for Policing Home Office +1 more
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) 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. 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 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.
Anthony Preston
Historic (No Identified Response)
2021-0319 23 Sep 2021 Essex
Essex Police National Police Chiefs’ Council
Concerns summary (AI summary) The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.
Frankie Macritchie
Partially Responded
2021-0315 17 Sep 2021 Cornwall and Isles of Scilly
Devon and Cornwall Police Constabulary Dog Legislation Office
Concerns summary (AI summary) Dog attacks require thorough investigation and, where appropriate, euthanasia of the dangerous animal to mitigate risks of future serious incidents.
Noted (AI summary) Devon and Cornwall Police are assured that they are dealing with reports appropriately where a dog poses a risk of serious harm, and will explore with the Police and Crime Commissioner the opportunities for enhanced public communication, potentially with our farming community and Local Authority partners in respect of dangerous dogs.
Emma Day
Partially Responded
2021-0263 3 Aug 2021 London Inner South
Department for Work and Pensions HM Courts and Tribunals Service Home Office +2 more
Concerns summary (AI summary) The Gaia Centre did not record the details of protective orders, Lambeth Children’s Social Care lacked knowledge of the orders, and the Metropolitan Police Service's Merlin Report did not mention the Non-Molestation Order, highlighting a potential system failure regarding protective orders and information sharing; the Child Maintenance Service of Department of Work and Pensions also exhibited a system failure in handling reports of domestic violence.
Action Taken (AI summary) The Metropolitan Police Service now records non-molestation orders on both the Police National Computer (PNC) and Criminal Intelligence System (CRIMINT), ensuring they are identified during background checks in safeguarding incidents; also, a review of the Multi-Agency Safeguarding Hubs (MASH) was commenced in June 2021, to improve risk identification.
Amanda Dunn
All Responded
2021-0261 30 Jul 2021 Staffordshire South
Staffordshire Police
Concerns summary (AI summary) Police repeatedly failed to act on reports of neighbour harassment, suggesting incidents are not taken seriously enough and leading to missed opportunities to intervene and potentially prevent future deaths.
Noted (AI summary) Staffordshire Police has commenced a criminal investigation into potential offences committed against Mrs. Dunn and is reviewing repeat cases of anti-social behaviour involving vulnerable people. They have also written to the Staffordshire and Stoke on Trent Adult Safeguarding Partnership Board to understand if further information was known by partner agencies. Staffordshire Police provides an update that the case has been referred to the Independent Office for Police Conduct (IOPC) for an independent investigation.
Levi Petitt
All Responded
2021-0231 6 Jul 2021 Lincolnshire
Lincolnshire Police
Concerns summary (AI summary) Police officers demonstrated a lack of awareness and adherence to the Concern for Welfare Policy, failing to complete required reports or inform other officers. There is a need for improved training on mental welfare procedures.
Action Taken (AI summary) Lincolnshire Police provides officers with access to a 24/7 phone line with a mental health professional, guides on mental health via mobile data terminals, regular briefings, and trained mental health workers in the FCR for immediate advice and triage.
Katie Locke
Historic (No Identified Response)
2021-0222 29 Jun 2021 Hertfordshire
Hertfordshire Constabulary Hertfordshire Partnership University NH… National Probation Service
Concerns summary (AI summary) Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.
David Ormesher
All Responded
2021-0192 4 Jun 2021 City of Brighton and Hove
National Police Chiefs’ Council Sussex Police
Concerns summary (AI summary) Police protocols regarding the constant use of in-car radios and timely siren deployment were not followed, raising concerns about emergency response safety.
Noted (AI summary) The National Police Chiefs' Council acknowledges receipt of the letter and notes its contents. Sussex Police reviewed policies and procedures on radio use and found policy 594/2021 sufficiently robust. They have a Driver Behaviour Working Group reviewing trends and a point system for interventions. A training package is in development to remind staff of radio responsibilities.
Samantha Gould and Christine Gould
All Responded
2021-0184 Cambridgeshire and Peterborough
Cambridgeshire and Peterborough Foundat… Cambridgeshire County Council (CCC) The National Police Chiefs' Council
Concerns summary (AI summary) Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance for police on communicating with such vulnerable minors.
Action Planned (AI summary) The NPCC has implemented an immediate addition to the Authorised Professional Practice (APP) guidance for all UK Police Forces, focusing on police engagement with reluctant victims/witnesses and ongoing support strategies. The NPCC Lead is also communicating this change to Local Safeguarding Children Partnerships. The Trust is reviewing its AWOL policy (completion by Oct 2021), undertaking a full policy review over six months, reminding doctors of ICD 11 changes, and developing a new joint protocol for overnight assistance for high-need adolescent mental health patients. Cambridgeshire County Council has launched the 'Strong Families Strong Communities' strategy (March 2021) and the YOUnited partnership (July 2021) to enhance emotional health and wellbeing services for children and young people, focusing on clear referral pathways and multi-agency support.
Christine Gould
All Responded
2021-0185 28 May 2021 Cambridgeshire and Peterborough
British Transport Police Network Rail
Concerns summary (AI summary) Investigations into railway suicides by BTP and Network Rail risk missing vital mitigating measures by too readily assuming a single point of access, rather than keeping an open mind about alternative routes.
Action Taken (AI summary) Network Rail is upgrading the fencing between Cherry Hinton and Teversham level crossings to 1.8m palisade fencing and has completed a significant portion of the upgrade. They are also reviewing their post-incident fence check process. The British Transport Police has created a single Fatality Investigation Team, trained frontline staff, and implemented procedures for Post Incident Site Visit (PISV) reports. They are working with Network Rail to establish regular meetings to discuss PISV reports and improvement considerations.
Kevin Fitton
All Responded
2021-0169 28 May 2021 City of Brighton and Hove
Brighton and Hove Clinical Commissionin… Brighton and Hove Council Brighton and Hove Health and Adult Soci… +1 more
Concerns summary (AI summary) There was an over-reliance on assumed capacity, failure to assess for Acquired Brain Injury (ABI) and its impact on substance use, alongside poor inter-team communication and lack of coordination, all compounded by inadequate staff training.
Action Planned (AI summary) Sussex NHS Commissioners have shared the report with commissioners to consider how long term service delivery can be improved for people with acquired brain injuries. Brighton & Hove City Council has designed and implemented a non-engagement policy, will develop a training course on mental capacity assessments and will continue to provide training courses on Acquired Brain Injury and self-neglect.
Zeyna Partington
All Responded
2021-0181 27 May 2021 Manchester North
Greater Manchester Police National Police Chiefs Council
Concerns summary (AI summary) GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR system for vehicle tracking is not fully implemented, leading to missed alerts.
Action Planned (AI summary) Greater Manchester Police acknowledges concerns about the use of PNC markers and ANPR data. They are reviewing the use of high priority markers for vulnerable missing persons and are working to connect to the new National ANPR Service.
Matthew Mackell
Partially Responded
2021-0177 25 May 2021 North West Kent
Independent Office for Police Conduct Kent Police
Concerns summary (AI summary) Kent Police failed to train staff on new phone location software, leading to a critical delay in locating the deceased. Systemic gaps exist in staff knowledge, training, and record-keeping regarding suicide policy and call management.
Action Taken (AI summary) Kent Police provides continuous professional development training packages on a 5-week rotation to FCR teams and uses a database to track attendance. The default settings on the Northgate XC mapping system have been configured to ensure that the latest functionality is utilised, and briefings were delivered highlighting the enhanced functionality.
Paul Reynolds
All Responded
2021-0151 Suffolk
Brittania Jinky Jersey Limited Brittania Hotels Group Limited
Concerns summary (AI summary) Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to ensure proper monitoring for positional asphyxia.
Action Planned (AI summary) The company is planning to remove ground restraint references from its Physical Intervention Policy and re-emphasise that non-badged staff are not permitted to participate in restraint. It is also investigating engaging external providers for annual refresher security training. Suffolk Constabulary has enhanced its training delivery and supporting guidance on officer assessments and use of force, and invested in a new skills management system to track training records. It is also reviewing training schedules and designing new scenarios for scene management.
Shane Gilmer
Historic (No Identified Response)
2021-0140 5 May 2021 County of the East Riding of Yorkshire and City of Kingston-Upon-Hull
Home Office
Concerns summary (AI summary) Crossbows lack essential regulation, including ownership records or licensing, unlike firearms. This absence of control over their circulation and storage, despite their lethal capabilities, poses a significant public safety risk.