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 resultsEdir 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.
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.
David Dooley
All Responded
2019-0127A
10 Apr 2019
Brighton and Hove
Sussex Police
Concerns summary (AI summary)
Police officers' lack of knowledge regarding seafront lifeline locations caused critical delays, and public awareness of sea dangers, particularly under the influence, is insufficient.
Action Taken
(AI summary)
Police CCTV operators will now scan for water safety equipment as part of the initial response where someone has entered the water. Sussex Police will be supporting the summer 'Keeping safe campaign' which includes water safety advice, highlighting the dangers of entering the sea when under the influence of drink/drugs or in adverse weather conditions.
Aidan Ridley
All Responded
2019-0173
9 Apr 2019
Wiltshire and Swindon
Wiltshire Police
Concerns summary (AI summary)
Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve ambulance services, compounded by underutilization of a new 3-way call system.
Action Taken
(AI summary)
Wiltshire Police states that staff briefings have been sent out reminding 999 call handlers to use the three-way call process when needed. They also state that further revisions of the relevant Force procedure on managing calls have now taken place.
Lesley Armstrong
All Responded
2019-0136
4 Apr 2019
North Northumberland
Northumbria Police
Concerns summary (AI summary)
Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee and the Safeguarding Board from progressing their duties.
Disputed
(AI summary)
Northumbria Police argues that it already has a system for reminding officers to inform suspects of the outcome of police investigations, that decisions to disclose information to employers can only be made on a case-by-case basis, and that providing information to employers as a 'fail safe' mechanism would be unlawful without the employee's consent, therefore no further action is deemed necessary.
Simon Robinson
All Responded
2019-0176
7 Mar 2019
Oxfordshire
Thames Valley Police
Concerns summary (AI summary)
The current partnership agreement inadequately addresses mental health crises in private places, creating a gap in effective agency response where police powers are limited despite their primary responsibility.
Action Planned
(AI summary)
Thames Valley Police reviewed their Interagency Partnership Agreement and proposed amendments to clarify police response to mental health crises, with a consultation of amendments expected by April 30, 2019. The police intend to immediately instigate amendments 1, 2, 4, and 7 relating to operational guidance.
Charles Rashan
All Responded
2018-0210
29 Jun 2018
London Inner (North)
Metropolitan Police Service
Concerns summary (AI summary)
Police training should emphasize recognizing that struggling to resist arrest can be a struggle to breathe or silent choking, and highlight the need to manage public intervention.
Action Taken
(AI summary)
The MPS has recommended changes to the Personal Safety Manual, Module 12 'Management of Persons Suspected of Concealing Items in Mouth', now requiring that where possible the subjects head should be tilted forward; the MPS continues to review and refine existing first aid techniques.
Stephen Tidey
All Responded
2018-0140
8 May 2018
Surrey
Surrey & Borders Partnership NHS Trust
Surrey County Council
Surrey Police
Concerns summary (AI summary)
Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on high-risk MASH referrals following a critical trigger event.
Noted
(AI summary)
Surrey Police explains how Multi Agency Safeguarding Hub (MASH) reports are processed upon receipt and graded for risk. They state that they do not monitor partner agency responses and suggest forwarding one question to SABP and Adult Social Care. The Trust has already implemented a standardised log for Single Combined Assessment of Risk Forms (SCARF) across Community Mental Health Recovery Service (CMHRS) teams. They have also devised a new checking system between the MASH and the CMHRS teams and set up an automated email reply from the Mental Health/Drug & Alcohol inbox within the MASH.
Joshua Hamill
All Responded
2017-0351
5 Dec 2017
North Wales (East & Central)
North Wales Police
Concerns summary (AI summary)
Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring the individual's welfare.
Action Taken
(AI summary)
North Wales Police provide a list of mental health resources including webinars, powerpoints, business cards, posters, and modules that are delivered to officers as part of training.
Michaela Haines
All Responded
2017-0415
23 Nov 2017
Carmarthenshire & Pembrokeshire
Dyfed-Powys Police
Concerns summary (AI summary)
The police STORM report was not consistently updated, leading to uncertainty about completed actions, potential loss of evidence, and duplicated work, highlighting a need for better training.
Action Planned
(AI summary)
Following a review, the police force will implement eight recommendations including reviewing and amending the Sudden Death Policy, preventing closure of the STORM log until investigation completion, and recording all raised actions numerically.
Mark Banks
All Responded
2017-0271
14 Aug 2017
Exeter and Great Devon District
Devon and Cornwall Police Headquarters
Concerns summary (AI summary)
Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and insufficient efforts to search for and check on the deceased's wellbeing.
Action Taken
(AI summary)
Devon and Cornwall Police have reviewed their grading and deployment policy and operational practices regarding call grading and incident creation. They have also put in place training packages for staff, quality assurance checks, and processes to assess THRIVE compliance, as well as reviewing their command and control policy.
Terence Pimm
All Responded
2017-0217
14 Aug 2017
Essex
Essex Partnership University NHS Founda…
Essex Community Rehabilitation Company
Essex Police
Concerns summary (AI summary)
Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health issues. Insufficient training also affected police in identifying immediate risk and mental health assessors.
Action Taken
(AI summary)
The Trust has directed all health-based place of safety calls through a new call centre where calls are recorded and documented. They have also reinforced to staff the importance of family involvement, reinforced the information-sharing concordat, launched a new street-triage team, and put a new flowchart in place for staff detailing actions to take when people are subject to a warrant, with training underway. Essex Police have instructed switchboard operators to refer public calls not concerning a person in custody to the Force Control Room, and advised custody suite staff on handling detainee-related calls. FCR staff receive training on threat, harm, and risk assessment. The police are implementing a process to notify Essex Police when staff meet with wanted persons and are developing Information Sharing Agreements with health partners.
Ozeivo Akerele
All Responded
2017-0337
19 Jul 2017
Coventry
West Midlands Police
Concerns summary (AI summary)
Police failed to locate the deceased during an intensive search due to a critical oversight in searching a nearby disused graveyard, and subsequent efforts were inadequate.
Action Planned
(AI summary)
The case will be referred to the National Missing Persons Operational Group to consider amending guidance around how a search is co-ordinated in similar cases. This will provide clarity around the tasking of the search, what is being searched for, and the accurate recording of the search.
Olaseni Lewis
All Responded
2017-0205
28 Jun 2017
London (South)
Metropolitan Police
South London and Maudsley NHS Trust
Concerns summary (AI summary)
Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged restraint." Additionally, there was a critical lack of clarity and training on inter-agency roles and responsibilities between police and healthcare staff.
Action Planned
(AI summary)
The Metropolitan Police Service describes updated training for officers regarding restraint techniques, Acute Behavioural Disturbance (ABD), and mental health, including de-escalation techniques and communication skills. It also notes the implementation of a national MOU about when police can be asked to attend mental health settings. The South London and Maudsley NHS Trust outlined actions to address training compliance, including immediate action requests and potential service suspension if training levels fall below minimum safety standards.
James Fox
All Responded
2017-0014
2 Feb 2017
London (North)
Metropolitan Police Service
Concerns summary (AI summary)
Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for officers.
Disputed
(AI summary)
The Metropolitan Police defends its officers' actions and states that there is no indication of misconduct. The IPCC investigation reported no matters of organisational learning other than a positive comment with regard to the use of body worn video.
Thomas Gallagher
All Responded
2016-wp25354
11 Aug 2016
Greater Manchester (North)
Greater Manchester Police
Concerns summary (AI summary)
Staff lacked formal training in risk assessment and child mental health, and there was intentional disregard of force policies; also, decisions not to allocate additional cover or resources lacked documented rationale, and a 'Golden Hour' was missed due to delays.
Action Taken
(AI summary)
GMP has implemented a programme of staff training emphasizing vulnerability, safeguarding, and risk mitigation. Locally, Bury has introduced a demand/triage desk and intelligence support to conduct Golden Hour tasks, including service calls to informants. The escalation policy has been amended to require recall to the informant within 40 minutes.
Henry Hicks
All Responded
2016-0244
4 Jul 2016
London Inner (North)
Metropolitan Police
Concerns summary (AI summary)
Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, implying non-compliance with the Metropolitan Police Service's standard operating procedure.
Noted
(AI summary)
The Metropolitan Police states that the existing pursuit policy remains unchanged but will be fully explored in the context of a formal disciplinary process for the officers involved, and notes that their guidance is kept under constant review and revision.
Luisa Mendes
All Responded
2016-0243
30 Jun 2016
Warwickshire
Chief Constable of Warwickshire Police
Concerns summary (AI summary)
Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift changes. The STORM computer system also lacked alerts for unauthorised deferrals.
Action Taken
(AI summary)
Warwickshire Police have trained staff on threat, harm, risk, and vulnerability using the National Decision Making model and are seeking to introduce a system change to alert priority incidents out of time. They are also in the advanced stages of procuring a new Command and Control system to include changes required as a result of the inquest.
Christopher Fields
All Responded
2016-0194
18 May 2016
Manchester South
Department of Health and Social Care
Greater Manchester Police
NHS England
+1 more
Concerns summary (AI summary)
Police left a vulnerable, injured person in an unsafe situation without awaiting an ambulance, leading to further assault. Ambulance dispatch algorithms are inaccurate, causing critical delays in response times for seriously injured patients.
Disputed
(AI summary)
North West Ambulance Service is exploring ways to minimise lengthy waits during high demand periods and has secured funding for additional frontline staff and new vehicles. It defends its coding system and response, citing pressures and circumstances at the time. The Department of Health disagrees with the coroner's concern, stating the call was correctly coded based on the information available at the time and the algorithm used is appropriate. They suggest the coroner contact the Priority Dispatch Corporation directly with concerns about the algorithm's design. Greater Manchester Police gave management action to an officer for lack of documentation, and addressed errors in recording inaccurate information. They propose to report back on wider work around vulnerability in October 2016. NHS England is conducting a review of ambulance coding systems and trialling a new system, taking into account previous similar calls and coroner's reports. Recommendations are expected in autumn 2016.
Adele Blakeman
All Responded
2016-0145-wp25219
15 Apr 2016
Manchester South
Greater Manchester Police
Concerns summary (AI summary)
The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed to consistently record pertinent intelligence on individual profiles.
Action Planned
(AI summary)
• GMP is investing significantly in the replacement of technology through the IS Transformation Programme to replace existing separate command and control, custody, intelligence, work allocation, and property systems with one user experience and more intelligence information management process that enables partner agency information sharing (iOPS).
• Mobile technology is distributed to operational staff which is already demonstrating through pilot site a significant forwards steps in information access, input, and decision-making.
• GMP is undertaking comprehensive procurement, design and testing process before implementation which is currently scheduled for late 2017.
Stewart Akins
All Responded
2016-0091
3 Mar 2016
Worcestershire
West Mercia Constabulary
Concerns summary (AI summary)
Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' Court, leading to bail being granted without full awareness of the high self-harm risk.
Action Taken
(AI summary)
West Mercia Police revised its practice so all Prisoner Escort Forms are signed as accurate by the custody sergeant, who has overall responsibility for ensuring risks are correctly documented and communicated. Mandatory training for custody sergeants includes highlighting known risks to the OIC upon consideration for MG7 remand application.
Darren Wakefield
All Responded
2016-0020
22 Jan 2016
Plymouth, Torbay and South Devon
National Police Chiefs’ Council
Concerns summary (AI summary)
The report highlights a national safety issue and requests confirmation that IPCC recommendations have been followed, implying a potential gap in implementing or verifying crucial safety improvements.
Action Taken
(AI summary)
The Department for Transport has reviewed legislation regarding derelict vessels and concluded that the existing legal framework is sufficient. They have provided further guidance in the revised Port Marine Safety Code and associated Guide to Good Practice, which are to be published shortly.
Dean Joseph
All Responded
2015-0319
12 Aug 2015
London Inner (North)
Metropolitan Police Service
Concerns summary (AI summary)
Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public confidence.
Action Taken
(AI summary)
The MPS has directed the post incident manager (PIM) to consult with the DPS and the IPCC to decide on what reference materials are proposed to be used by officers when giving their accounts, and the PIM is trained to record his or her decision and reasoning.
Wiktoria Was
All Responded
2015-0271
13 Jul 2015
London (Inner South)
Metropolitan Police
Concerns summary (AI summary)
Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately learned or disseminated. Officers lacked sufficient and rigorous refresher training.
Action Taken
(AI summary)
The Metropolitan Police Service has rolled out an RT Operators Course since 2011 to selected elements of the uniformed workforce and since July 2014 to all new recruits. They are also planning to implement enhanced driver training, pending release of funds, and are working to ensure officers serving prior to the course introduction may have an opportunity to take the course in the near future, most likely re-worked as a computer-delivered package.