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
Rohan Singh
All Responded
2021-0134 30 Apr 2021 East London
Dept. of Health and Social Care, Camden…
Concerns summary (AI summary) A mental health ward failed to prevent a patient from retaining dangerous contraband despite searches. Staff made false observation records due to a culture of impunity, and critical monitoring protocols after rapid tranquilisation were not followed.
Noted (AI summary) The Metropolitan Police Service will develop additional training on recording property, especially regarding risk, and implement it in the "Street Duties" course for probationer constables. The officer involved in the incident has been spoken to and advised on recording property and circumstances for seizure. The Trust has discussed the concerns with Borough Lead Nurses and sent letters to nursing staff, highlighting expectations for patient searches, observations, and rapid tranquilisation monitoring. The Trust now requires formal training and competency assessment for staff conducting searches and observations, with Registered Nurses exclusively performing RT monitoring within eyesight for the first hour post-administration. The Department acknowledges the concerns and outlines actions taken by the East London NHS Foundation Trust (ELFT), NHS England and NHS Improvement (NHSE & NHSI), and the Care Quality Commission (CQC). It highlights ongoing monitoring and planned inspections of ELFT.
Jade Rayner
All Responded
2021-0128 30 Apr 2021 Greater Manchester South
Greater Manchester Health and Social Ca… Greater Manchester Police
Concerns summary (AI summary) Police failed to record and investigate a sexual offence allegation against a vulnerable patient, denying her victim support. There was also a lack of clear multi-agency strategy for complex cases involving trauma and alcohol misuse.
Action Planned (AI summary) Two task and finish groups will review Section 42 and Multi Agency Adults at Risk System processes, with learning to be shared with the Greater Manchester Quality Board and commissioners of services. GMP has implemented the vulnerability assessment framework to identify and assess risk factors, and officers now record care plans after safe and well interviews with vulnerable adults.
Lee Marsden
All Responded
2021-0084 26 Mar 2021 Manchester North
Highways England North West Motorway Police Group
Concerns summary (AI summary) A significant delay in activating motorway warning signals and communication failure between agencies, combined with the lack of an internal review, indicate a missed opportunity for learning.
Action Planned (AI summary) Highways England will brief North West Highways England Regional Operations Centre staff and police officers on using 'free text' entries in incident logs, shared with all Regional Control Centres as best practice nationally. They maintain their existing policy for activating warning signals is robust and appropriate, and will not take further action on it. Highways England and the NWMPG have agreed to add a free text description to the log to clearly identify the source of information. Police operators and supervisors within NWMPG will be briefed to add this plain language to logs, with a briefing note circulated to staff.
Joe Robinson
Partially Responded
2021-0074 15 Mar 2021 Greater Manchester South
Home Office National Police Chiefs Council
Concerns summary (AI summary) Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether lessons learned regarding policing such events have been effectively shared.
Noted (AI summary) The Home Office acknowledges the concerns and outlines the police powers to deal with illegal raves, but states that decisions about deployment are operational matters for the police. They highlight funding to tackle drug supply, treatment services, and Project ADDER.
Joseph Agnew
All Responded
2021-0055 26 Feb 2021 London Inner South
City of London Police, Metropolitan Pol…
Concerns summary (AI summary) Police training was inadequate for assessing intoxicated individuals, monitoring breathing, and there is no suitable facility for acutely intoxicated homeless people found on buses.
Action Planned (AI summary) Since Mr. Agnew's death, City of London Police officers receive further training on assessing intoxicated persons. First aid training of City of London Police officers now includes training to recognise that snoring in a person with a reduced level of consciousness is a sign of airway obstruction and to perform the "jaw thrust" manoeuvre. The College of Policing will use the coroner's concerns to inform a review of the learning outcomes for the FALP (roads policing) programme, which will take place this year. The College has developed a vulnerability learning programme which supports the PCDA programme. Since 2016, the Mayor of London has established a night transport outreach team that assists rough sleepers on the transport network, helping over 1,020 clients. The team enables drivers and others to refer those of concern to this service.
David Blinman
All Responded
2021-0054 24 Feb 2021 South Wales Central
DHL Supply Chain UKI
Concerns summary (AI summary) Deficient risk assessments failed to incorporate local knowledge, inadequately addressed vehicle blind spots during reversing, and did not mandate crucial mitigating measures like cameras or banksmen.
Action Taken (AI summary) DHL has standardised a base vehicle safety specification which is updated following incident reviews and technology developments, including fitting 4-camera systems to all rigid vehicles procured directly by them since 2015. They will also ensure risk assessors are aware of the need to use clear terminology when describing delivery control measures in the revised Nisa DPRA process.
Kevin Clarke
All Responded
2021-0046 18 Feb 2021 London Inner South
London Ambulance Service Metropolitan Police Service
Concerns summary (AI summary) Police training inadequately addresses detainee health in non-emergency situations, with officers lacking vital sign measurement skills. There was ineffective safety officer monitoring, poor leadership and risk assessment during restraint, and insufficient paramedic input.
Action Planned (AI summary) The LAS has implemented leadership training and Acute Behavioural Disturbance (ABD) refresher training. They collaborated on national guidance for ABD for ambulance staff and are sharing updated clinical guidelines via tablet devices. Learning from the death has been presented to the JRCALC guidelines group. The MPS will include information in officer safety and emergency life support training on Acute Behavioural Disturbance (ABD) and de-escalation techniques, the impact of stress on behaviour, and reflection on actions. Supervisors will be trained to identify themselves and liaise with the Safety Officer upon arrival at a scene.
Robert Hardy
All Responded
2021-0039 11 Feb 2021 Greater Manchester South
Greater Manchester Police
Concerns summary (AI summary) Police failed to record an assault as a crime, preventing the provision of appropriate victim support and signposting for a vulnerable individual with known vulnerabilities.
Action Taken (AI summary) Greater Manchester Police has established a central Crime Recording and Resolution Unit (CRRU) to improve crime recording accuracy, in response to concerns raised. They are also implementing the national THRIVE model and the 'Making a Difference System' to improve identification of and response to vulnerabilities and to improve victim support.
Cheralyn Clulow
All Responded
2021-0009 12 Jan 2021 Dorset
Dorset Police
Concerns summary (AI summary) Police lacked appropriate fire drop keys and training for emergency access to communal properties, causing delays in attending a deceased person's address.
Action Planned (AI summary) Dorset Police officers will soon be issued with keys and fobs to allow for quick access to communal properties, with a system in place to compensate for properties where this is not achievable. A reminder on police powers of entry will be circulated to all frontline officers.
Alfie Gildea
All Responded
2020-0242 18 Nov 2020 Greater Manchester South
Greater Manchester Police, Trafford Met…
Concerns summary (AI summary) Suspects in domestic abuse cases were not placed on bail with conditions to protect alleged victims and there was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs policy.
Noted (AI summary) Greater Manchester Police has conducted a review into the triage process of district safeguarding teams, is developing a triage training course including guidance on information sharing, and has recruited a Domestic Abuse Coordinator to ensure a consistent approach to MARACs across the force. Greater Manchester Health and Social Care Partnership will present learning from the Serious Case Review to the Greater Manchester Quality Board and share it with commissioners of services for consideration. Trafford Council states it has already made significant improvements to policies and procedures since 2018 and believes the coroner's concerns are directed to central government. The CPS acknowledges differences in the definitions of a serial domestic abuser and explains the role of the prosecutor in relation to reasonable lines of enquiry. The Dept. of Health and Social Care notes the concerns raised, mentions a Serious Case Review and review of its action plan, and states that local authorities are responsible for commissioning health visitor services based on local needs. The Home Office describes national actions to manage perpetrators of abuse including College of Policing guidance, a review of the Domestic Violence Disclosure Scheme (Clare's Law), and the introduction of new Domestic Abuse Protection Orders (DAPOs) with associated training for police.
Imane Bouasbia
Partially Responded
2020-0234 12 Nov 2020 East London
Home Office Metropolitan Police Service
Concerns summary (AI summary) Police failures included inadequate communication of suicidal ideation during handover, absence of a risk assessment for self-harm, and a limited, non-expedited response to a direct suicidal text message.
Action Taken (AI summary) The MPS emailed all SOIT officers and Public Protection Department managers with the instruction that SOIT and investigating officers must inform a supervising officer if they receive any contact from a victim that causes them concern. Continuous Professional Development events for SOIT officers will include suicide awareness and a contribution from Hostage and Crisis negotiator regarding how to more effectively engage with a person in a mental health crisis.
Chelsie Greatorex
All Responded
2021-0018 11 Nov 2020 East London
Home Office Metropolitan Police Service
Concerns summary (AI summary) The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.
Action Planned (AI summary) The Home Office is conducting a review of the criminal justice response to rape, consulting on a new Victims’ Law, and investing in rape support centers and Independent Sexual Violence Advisers (ISVAs). The MPS is developing a Suicide Prevention Policy Document and Toolkit, including information on suicide prevention, support services, risk indicators, contacts and best practice, with a draft expected by the end of December 2020; they are also improving training and guidance for officers and staff, including an investigative standards document and meeting with other forces to share good practice.
Ewan Brown
Historic (No Identified Response)
2020-0235 10 Nov 2020 Newcastle upon Tyne and North Tyneside
Northumbria Police, Newcastle City Coun…
Concerns summary (AI summary) A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health training, and poor information sharing protocols hindered effective risk assessment and search efforts.
Emily Greene
All Responded
2020-0288 6 Oct 2020 South Yorkshire West
South Yorkshire Police HQ
Concerns summary (AI summary) Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and inadequate facilities, compounded by mishandling a missing person's report.
Action Taken (AI summary) South Yorkshire Police have taken action in respect of the findings, including ensuring all staff are fully trained on the new incident management system. They are implementing a new 'missing from home' IT system called 'Compact' in April 2021 and refurbishing Achieving Best Evidence rooms.
Thomas Reilly
Historic (No Identified Response)
2020-0043 25 Feb 2020 Brighton and Hove
Sussex Police
Concerns summary (AI summary) The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.
Jon James
All Responded
2020-0042 20 Feb 2020 South Wales Central
National Institute for Health and Care …
Concerns summary (AI summary) There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, contributing to a rising number of related deaths.
Action Planned (AI summary) NICE acknowledges concerns about the need for guidance on acute behavioral disturbance (ABD) and will consider this in a future update to its guideline on violence and aggression (NG10).
Mark Mallinson
Historic (No Identified Response)
2020-0137 7 Feb 2020 West Sussex
Sussex Police
Concerns summary (AI summary) Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving many officers untrained in critical situations.
Marc Cole
All Responded
2020-0087 6 Feb 2020 Cornwall and the Isle of Scilly
College of Policing Home Office
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.
Thiago Araujo
Partially Responded
2021-0132 29 Jan 2020 East London
AMHP London Borough of Camden Camden and Islington NHS Foundation Tru… +4 more
Concerns summary (AI summary) The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Noted (AI summary) The Trust has implemented an additional recommendation that discharge of Crisis Team service users due to non-engagement must be discussed in a multidisciplinary meeting with senior overview, and clearly communicated to relevant parties. Legal advice has been sought and guidance circulated to staff regarding potentially dangerous packages. Royal Mail asserts that their processes for handling restricted and prohibited items are adequate and appropriate, given the legal restrictions on interfering with postal packets. They state that they do not intend to take any action in response to the report. The MPS is developing a Suicide Prevention Policy Document and Toolkit. An investigative standards document is also under development as guidance for police first responders. The Department of Health and Social Care describes actions taken to limit the availability of chemicals used in suicides, including working with a chemical supplier to identify suppliers on online retail platforms and noting eBay's global prohibition of the sale of the chemical. It also notes work with the media to improve suicide reporting and the publication of an Online Harms White Paper. The Home Office is aiming to establish a consultation this summer on possible amendments to the Poisons Act, which will include more obligations on online marketplaces including reporting suspicious transactions within 24 hours.
Adam Harris
All Responded
2019-0247 23 Jul 2019 Manchester (South)
Greater Manchester Police
Concerns summary (AI summary) Lack of formal risk assessment for prisoners in van docks, failure to search suspects, poor handover between officers, inadequate custody record keeping, and conflicting guidance on prisoner positioning for aspiration risk were critical concerns.
Noted (AI summary) Greater Manchester Police explained their procedures for allocating detainee cell space and the role of the cell allocation team and Custody Inspector. They also detailed officer training and procedures for handling detainees who may be confused or intoxicated, as well as explaining when a full custody record may not be completed immediately.
Leroy Medford
Partially Responded
2019-0233 9 Jul 2019 Berkside
College of Policing National Police Chiefs’ Council Thames Valley Police
Concerns summary (AI summary) The coroner expresses concern that officers were unaware of a requirement in the Drugs SOP for an officer to be within the cell with a detained person, and recommends a national review of how training is delivered and monitored within the police service.
Action Planned (AI summary) Thames Valley Police have initiated a quarterly Drug Concealment Working Group and are refreshing guidance for superintendents on managing drugs concealment cases (target Nov 2019). They are developing healthcare pathways and simpler guidance, accessible on officer's mobile phones. Special Points of Contact (SPOCs) have been introduced to improve communication of new guidance. The NPCC is closely involved in the College of Policing’s work on a national strategy for police learning, which may address concerns around training. The NPCC has shared the coroner's report with chief constables, encouraging them to review training delivery within their own forces.
Edir DA Costa
All Responded
2019-0211 27 Jun 2019 London (East)
Metropolitan Police
Concerns summary (AI summary) Many police officers are not up-to-date with mandatory Emergency Life Support training, and monitoring compliance is difficult, leading to critical delays in commencing CPR.
Action Taken (AI summary) The Metropolitan Police have reduced the number of officers who need mandatory Emergency Life Support training. They have also circulated a reminder to all staff via a weekly MetCC Operational Update bulletin regarding policy compliance and will emphasise this policy in MetCC initial call handler training and Personal Development Days in October 2019.
David Bird
Historic (No Identified Response)
2019-0188 3 Jun 2019 Bedfordshire & Luton
Bedfordshire Police
Concerns summary (AI summary) Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures to ensure vulnerable detainees saw a Health Care Practitioner before release, despite identified risks.
Joshua Blackham
All Responded
2019-0182 31 May 2019 Berkshire
Surrey Police
Concerns summary (AI summary) Surrey Police lacked written policies for Welfare Officers, particularly regarding specialized training, effective communication with professional standards, and appropriate arrest locations for serving officers.
Action Taken (AI summary) Surrey Police will provide training and refreshed guidance for Welfare Officers and those who supervise them. Revised guidance has been created to include contacting the family of an officer suspended from duty, a secondary (back up) WO, and consideration about the location of the arrest of a serving officer.
Tyereece Johnson
All Responded
2019-0166 23 May 2019 London Inner (West)
Metropolitan Police
Concerns summary (AI summary) The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.
Action Planned (AI summary) The MPS will review the roles and responsibilities of the police pursuits pod to ensure they are maximising information/intelligence opportunities. They will consider a mandatory checklist of indices at the start of a pursuit and ensure Pan London courses and refresher training include an input on information and intelligence gathering. This review will be completed by 31st October 2019.