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 resultsLuisa 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.
Beverley Devanney
Historic (No Identified Response)
2016-0485
24 Jun 2016
West Yorkshire (West)
West Yorkshire Police
Concerns summary (AI summary)
Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in similar future circumstances.
William Nute
Partially Responded
2016-0229
24 Jun 2016
Cornwall
Devon and Cornwall Police
South Western Ambulance Service
Concerns summary (AI 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.
Noted
(AI summary)
South Western Ambulance Service NHS Trust provides context on the ambulance delay and describes the NHS England Ambulance Response Programme (ARP), a clinically led review of call coding systems being trialled in two sites.
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.
Philmore Mills
Partially Responded
2016-0110
17 Mar 2016
Berkshire
College of Policing
National Police Chiefs’ Council
Concerns summary (AI summary)
Police training for subjects with suspected excited delirium lacks instruction on containment tactics and fails to inform officers that restraint take-down procedures can carry a risk of death, only focusing on minor injuries.
Action Planned
(AI summary)
The College of Policing will add specific reference to 'containment' to the ABD/PA chapter of the National Personal Safety Manual and clarify that, in certain circumstances, prone restraint carries a risk of death, within the next scheduled update.
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.
Adam Rice
Partially Responded
2016-0085
3 Mar 2016
West Yorkshire (East)
St James’s University Hospital
West Yorkshire Police
Concerns summary (AI summary)
There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, and a lack of understanding of welfare check protocols.
Action Taken
(AI summary)
West Yorkshire Police has implemented measures to ensure vulnerable persons who come into contact with the Police receive the best possible care, including a full training programme for Custody Staff on PACE and relevant provisions of the College of Policing APP. They have also implemented daily briefings for custody staff and reviewing risk assessment processes.
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.
Jan McLean
Historic (No Identified Response)
2015-0237
22 Jun 2015
Surrey
Surrey Police
Concerns summary (AI summary)
Police officers require full and adequate training to thoroughly interrogate all details relating to warning markers held on the PNC to prevent future deaths.
Darren Neville
All Responded
2015-0220
10 Jun 2015
London Inner (North)
Metropolitan Police Service
Concerns summary (AI summary)
Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing acute behavioural disturbance.
Noted
(AI summary)
The Metropolitan Police acknowledge the concerns and detail the challenges of responding to Acute Behavioural Disorder (ABD) incidents, highlighting existing training and the need for officers to act decisively. They assert that measures have been introduced since 2013 and in response to the death to refine training and equip officers.
Alice McMeekin
Historic (No Identified Response)
2015-0211
4 Jun 2015
Cumbria
Cumbria Constabulary
Cumbria Partnership NHS Foundation Trust
Concerns summary (AI summary)
Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and early discharge of a high-risk individual with significant mental health issues.
Nicholas Rowley
Partially Responded
2015-0138
15 Apr 2015
Stoke-on-Trent & North Staffordshire
Department of Health and Social Care
G4S
National Police Chiefs’ Council
+2 more
Concerns summary (AI summary)
Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks in detainees.
Noted
(AI summary)
The College of Policing will incorporate guidance on verbal consultation between medical practitioners and custody sergeants and will make additions to the Detention and Custody Authorised Professional Practice providing advice on observation levels; updated guidance will be published circa summer 2015. Guidance has been issued to custody staff and the medical services provider to ensure verbal updates are given by medical practitioners to the Custody Sergeant. A Custody Training sub-group has been created and further guidance issued regarding levels of observation, and training secured regarding drug and alcohol abuse. G4S no longer provides Detention Officer Services to Staffordshire Police as of June 2015. They state they always have and continue to provide mandatory training regarding setting levels of observation and first aid, and will write to contracting police forces to recommend joint ventures as best practice.
Neil Budziszewski
All Responded
2015-0109
23 Mar 2015
South Yorkshire (West)
South Yorkshire Police
Concerns summary (AI summary)
Multiple failures in police custody included incomplete and unreviewed risk assessments, lack of 30-minute rousing checks for an alcoholic detainee, and inadequate staff training on managing risks associated with alcohol withdrawal.
Action Planned
(AI summary)
South Yorkshire Police will highlight the importance of opening a custody record and completing a risk assessment, even when a detainee is uncooperative, in training and through a briefing document and rotational training. They will also incorporate information about acute alcohol withdrawal syndrome into first aid training for custody staff.
Jason Palmer
All Responded
2014-0534
12 Dec 2014
Exeter and Greater Devon
Devon and Cornwall Constabulary
Concerns summary (AI summary)
A breakdown in information sharing between police units meant domestic incident details were not available to the Firearms Unit, impacting suitability assessment for a shotgun licence renewal.
Action Taken
(AI summary)
The police force has introduced an electronic system which sweeps all police incident logs every ten minutes and sends an immediate alert to the Firearms Licensing Unit if any log relates to an existing certificate holder. Written working practice is also being developed to formally capture the existing process for reviewing restricted logs.
Amanda Hawkins
Partially Responded
2014-0516
26 Nov 2014
Staffordshire (South)
Walsall and Dudley Mental Health NHS Tr…
West Midlands Police
Concerns summary (AI summary)
Patient vulnerability was exacerbated by service changes and failures in coordinating care, including sending critical appointment letters directly to a patient unable to understand them, and a lack of follow-up on missed appointments.
Action Planned
(AI summary)
The Trust will ensure outpatient letters from CRS North medical teams are copied to the care coordinator. A working group led by the Head of Recovery Services is looking at long-term solutions.
Kirk Williams
Partially Responded
2014-0499
14 Nov 2014
Teesside
Cleveland Constabulary
IPCC
JCUH
+2 more
Concerns summary (AI summary)
A significant mismatch exists between police and A&E staff perceptions regarding the treatment of aggressive patients, including those with Excited Delirium, compounded by a lack of dialogue and clear guidelines.
Action Planned
(AI summary)
Multiple CCGs and Trusts report that if a detainee has a known past mental health history, they should be taken to the 136 unit at Roseberry Park; if serious concerns regarding physical health exist, detainees should be presented to A&E. Senior A&E staff and the police will jointly decide where best to provide treatment if a detainee is violent and aggressive. The Trusts, CCGs, Ambulance Service and Tees, Esk and Wear Valleys NHS Trust have signed up to the Crisis Care Concordat. The lead Security Officer for the Trust has held discussions with Durham Constabulary lead officers to ensure that all police officers know that patients should be taken to the Emergency Department; The process is kept under review by the Trust. All agencies involved in treating or looking after patients in crises meet monthly to share learning, discuss difficult cases and monitor patients detained under a section 136 in the emergency department. Cleveland Police provides annual Personal Safety Training to all front-line officers, including training on "excited delirium." The police, along with medical directors and A&E consultants, established new guidelines for aggressive detainees in custody being taken to A&E, and are briefing staff on these new guidelines. NHS England will consider the case further with the Northern Regional Medical Director to determine whether changes need to be made to relevant policies and guidance, including liaison with Public Health England regarding substance misuse services. They also acknowledge that various local healthcare organizations have signed up to the Crisis Care Concordat.
Arsema Dawit
All Responded
2014-0442
13 Oct 2014
London (Inner South)
Metropolitan Police Service
Concerns summary (AI summary)
Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting for non-adults and a reluctance to use interpreting services.
Action Taken
(AI summary)
The Metropolitan Police Service has made improvements in training and reference materials for staff, investigator accreditation & quality assurance, supervision, and provision of support resources; it has broadened the function of the civilian Station Reception Officer to 'PAO' -Public Access Officer, developed a supervisor training package, updated the MPS 'Supervision Toolkit', increased the number of accredited PIP level 2 investigators, and invested heavily in providing translation services.
Suzanne Cammell
Partially Responded
2014-0579
28 Jul 2014
Oxfordshire
Thames Valley Police
Gloucestershire Constabulary
Concerns summary (AI summary)
Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between police forces or to frontline officers. This hindered proper risk assessment and the implementation of a Mental Health Act assessment.
Noted
(AI summary)
Thames Valley Police reviewed the communication between their control room and Gloucestershire Police regarding the deceased. They clarified the information that was shared and noted that Gloucestershire Police had previous knowledge of the deceased's mental health issues. They have also put measures in place to address information sharing between the Professional Standards Department and the officer who prepared the report.
Hywel Hughes
Partially Responded
2014-0311
2 Jul 2014
North West Wales
Home Office
North Wales Constabulary
Security Industry Authority
Concerns summary (AI summary)
Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by door supervisors.
Action Taken
(AI summary)
North Wales Police amended their training materials on positional asphyxia to include snoring as a symptom and added an exercise to demonstrate the dangers of medical emergencies. They also designed and are testing a single cell compartment bubble car and considering auditory improvements.
Ryan Boyle
All Responded
2014-0263
9 Jun 2014
Surrey
Surrey Police
Concerns summary (AI summary)
Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' to manage incidents effectively.
Action Taken
(AI summary)
Surrey Police updated its pursuit management guidance to align with ACPO guidance, installed a 'Call Supervisor' button in the Force Control Room, and briefed staff that two people must monitor the Force Channel at all times; staff were also instructed to shout to alert supervisors to incidents.
Mark Duggan
All Responded
2014-0182
29 May 2014
London (North)
Association of Chief Police Officers
Coroner's Society
Crown Prosecution Service
+4 more
Concerns summary (AI summary)
Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.
Noted
(AI summary)
The IPCC acknowledges the coroner's concerns, particularly regarding access to intelligence materials, and states it is best placed to determine who within the IPCC investigation should have access. The IPCC considers that there should be a clear legal right of access by IPCC investigations to all relevant intelligence material. The Home Office acknowledges the concerns raised, particularly regarding the IPCC's resources at the scene and access to intelligence. The response explains the existing legal framework for investigations and information disclosure, highlighting the need to balance transparency with national security. The National Armed Policing Portfolio has commenced work to determine whether the introduction of body worn video (BWV), might be included in armed policing operations. The National Policing portfolios will ensure liaison with the College of Policing to incorporate, reiterate and reflect issues relating to cordon management and evidence preservation in its post incident management and operational training. The National Crime Agency notes the concerns raised and states it has undertaken a thorough internal review of its operating procedures regarding intelligence gathering, development, and dissemination. Following this review, the Agency believes that no more could have realistically been done to avoid the incident. The MPS will adopt a procedure for all future police shootings whereby a Garage Sergeant or Collision Investigator is called by the DPS to download the IDR at the scene, which will then be available to police; the IPCC and any subsequent legal proceedings
Vincent Gibson
Historic (No Identified Response)
2014-0148
1 Apr 2014
Gateshead & South Tyneside
Independent Police Complaints Commission
Northumbria Police
Concerns summary (AI summary)
Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising response safety and efficiency.