Police related deaths

Concerns 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.

Concerns summary The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review of procedures for managing such medical emergencies.

Concerns summary Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner of mental health concerns or family-reported history.

Concerns 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.

Concerns summary Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays in handling a missing person report.

Concerns 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.

Concerns summary Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring the individual's welfare.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a clear bullet mass retention specification.

Concerns 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.

Concerns 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.

Concerns summary Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further complicated by a lack of multi-language support for safety information.

Concerns summary Inconsistent police training and guidance regarding PAVA spray use and forcible mouth searches for detained persons with objects in their mouths, conflicting with FFLM recommendations, indicates a systemic failure to implement past lessons.

Concerns 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.

Concerns summary Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to inadequate Health Care Professional involvement.

Concerns summary There is a critical lack of protocol and training for monitoring non-detained individuals in police stations, including guidance on interpreting snoring, the impact of intoxication, and effective information sharing.

Concerns 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.

Concerns 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.

Concerns summary Delays in emergency service attendance and patient transfer, coupled with inadequate 999 call triage and police notification, led to an unmanaged incident scene and increased risk of death.

Concerns summary Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in similar future circumstances.

Concerns 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.

Concerns 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.