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 results
Katherine Wright
All Responded
2025-0624 11 Dec 2025 Oxfordshire
Thames Valley Police
Concerns summary (AI summary) Police lack structured training and clear guidance for conducting adequate searches in missing person cases, and there are no protocols for officers to escalate safety concerns during searches.
Action Taken (AI summary) Thames Valley Police has reviewed their Missing Persons Operational Guidance and included a new section dedicated to the searching of premises for missing persons which includes sections on the extent of the search; equipment and resources and potential hazards. The new Premises Search Guidance sets out options for officers when encountering hazards and specifying supervisory escalation requirements.
Andrew McCleary
All Responded
2025-0599 25 Nov 2025 Bedfordshire and Luton
Bedfordshire Police
Concerns summary (AI summary) Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff or monitor the detainee adequately.
Action Taken (AI summary) Bedfordshire Police has reviewed policies and procedures, provided mandatory MCA training to frontline officers, delivered refresher training, updated the Mental Health Training package, and worked with partners to introduce the Right Care, Right Person (RCRP) programme.
Brian Ringrose
All Responded
2025-0399 1 Aug 2025 Milton Keynes
Central North West London NHS Foundatio… Milton Keynes University Hospital Thames Valley Police
Concerns summary (AI summary) Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also did not apply the National Decision Model or challenge inappropriate techniques, contributing to the death.
Action Taken (AI summary) The trust has implemented a joint entry protocol for documentation, mandating verbal handovers post-assessment and reinforcing the principle that discharge from ED should not proceed with unresolved safety concerns. Refresher and Human Factors training are also taking place. The hospital has updated its Police Custody SOP, incorporated Emergency Department-specific guidelines, is reviewing training on restraint and restrictive practices, and has reiterated Toxbase guidelines to clinicians. Breakaway and conflict resolution training remains mandated. Thames Valley Police has reviewed training material on handcuffing, implemented additional Personal Safety Training, provided training to officers on medical issues that can arise with prolonged restraint, rolled out the College of Policing's 'Upstander' E-Learning, and included communication and handover protocols in training scenarios.
Kaine Fletcher
All Responded
2025-0383 25 Jul 2025 Nottinghamshire
College of Policing Custodial Services Department of Health and Social Care +6 more
Concerns summary (AI summary) Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite rejection by psychiatric bodies.
Action Planned (AI summary) The Trust is providing training for all acute facing mental health staff on ABD in August and October 2025 and signs and symptoms, clinical assessment and escalation processes are now included within the Trust Fundamentals of Care training for mental health staff. The Trust has updated Internal Working Instructions and established a strategy group and works across the system to strategically plan access and treatment for people with dual diagnosis needs. The NPCC clinical panel is reviewing existing guidance developed by the Faculty of Legal and Forensic Medicine regarding Acute Behavioural Disturbance. The College of Policing provides the Mental Health Approved Professional Practice (APP) to assist forces in developing their policies and responses to incidents relating to people with mental ill health. The Department and NHS England are finalising the Co-occurring Mental Health and Substance Use Delivery framework to improve delivery of integrated, person-centred care across drug and alcohol treatment and mental health services.
Marie Theobald
All Responded
2025-0366 18 Jul 2025 East London
London Metropolitan Police
Concerns summary (AI summary) Delays in a criminal investigation mean a suspect in a fatal road incident is unrestricted, posing a risk of further harm due to the absence of bail conditions or driving disqualification.
Action Taken (AI summary) The Metropolitan Police have reviewed options to limit further offences by the suspect, including Operation Revoke and bail conditions. The Serious Collision Investigation Unit has recruited new detectives to increase capacity and is implementing new processes to ensure efficient functioning, and the case is undergoing a full review.
Kaine Fletcher
All Responded
2025-0363 17 Jul 2025 Nottinghamshire
East Midlands Ambulance Service Nottingham and Nottinghamshire Police
Concerns summary (AI summary) A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for Section 136 detentions creates significant risks for vulnerable individuals.
Action Taken (AI summary) • Nottinghamshire Police has implemented the Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency, sections 135 and 136 Mental Health Act 1983 Procedure since its inception. • Nottinghamshire Police has consulted with colleagues from EMAS to address the issue of differing positions on the application of the document and suggested several potential remedies. • EMAS Head of Mental Health advised that their Chief Executive directed that they will not be seeking to implement or refine the existing multi-agency policy. • East Midlands Ambulance Service (EMAS) acknowledged the concerns raised regarding the lack of clarity and shared understanding between agencies on the applicable local policy and working standards for s.136 Mental Health Act detentions. • EMAS has been operating under a Regional Mental Health conveyance policy since May 2021, developed in consultation with regional Police Forces, Mental Health Trusts, and other stakeholders.
Elaine Tarbuck
All Responded
2025-0342 7 Jul 2025 Manchester West
College Of Policing Greater Manchester Police
Concerns summary (AI summary) The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting in inappropriate first responder attendance.
Action Planned (AI summary) GMP are implementing measures to mitigate risks around the evaluation and assessment of concern for welfare calls, including mandatory briefings, enhanced training, revision of risk assessment tools, and a review of the escalation process, overseen by the FCCO Senior Leadership Team. NWAS and GMP have implemented collaborative measures including targeted training, review of incident logs, visits by GMP supervisors to the NWAS control room, and ongoing meetings between leadership teams, to address the issue of calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare. The College of Policing will highlight the issue of forced entry at the next meeting of the National RCRP Tactical Delivery Board to ensure national learning is shared; the College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews.
Barry Spooner
All Responded
2025-0331 1 Jul 2025 Nottingham and Nottinghamshire
Nottinghamshire Police
Concerns summary (AI summary) Inadequate information sharing by police with Adult Social Care means prior public protection notices are not consistently provided, hindering full risk assessment and decision-making for vulnerable individuals.
Action Planned (AI summary) Nottinghamshire Police will be amending their information sharing processes so that PPNs considered suitable for referral to adult social care will be accompanied by PPNs from the previous 12 months that were not previously deemed suitable for sharing, commencing 1st October 2025.
Muhammad Qasim
All Responded
2025-0446 25 Jun 2025 Birmingham and Solihull
IOPC College of Policing
Concerns summary (AI summary) Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led to the absence of a crucial forensic collision report.
Action Planned (AI summary) The IOPC will update internal guidance to investigators about securing full Forensic Collision Investigation Reports, including early contact with the Coroner, and will update internal written guidance within six weeks. The College of Policing will amend the Police Pursuit APP to replace 'spontaneous pursuit' with clearer guidance aligned with the National Decision Model, aiming to publish revised guidance by December 2025.
Amy Levy
All Responded
2025-0289 10 Jun 2025 Avon
Avon and Somerset Police College of Policing Surrey Police
Concerns summary (AI summary) Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying location and aid for a critically ill individual.
Action Planned (AI summary) The College of Policing will support national sharing of best practice on voicemail protocols, update the national Contact Management Curriculum to address voicemail guidance in emergencies, and ensure forces align training programs by March 2026. Surrey Police has updated its procedure to include guidance on leaving voicemails, is incorporating this guidance into training for new recruits and detectives, and will evaluate the effectiveness of the training. Avon and Somerset Constabulary will introduce a dedicated force policy and procedure for 'suicidal' cases, update the Concern for Welfare policy to mandate leaving voicemails or text messages, and provide training to all communications staff on the updated policies.
Dean Bradley
All Responded
2025-0248 28 May 2025 Teesside and Hartlepool
Department of Health and Social Care Hartlepool Council Integrated Care Board (NHS North East a… +4 more
Concerns summary (AI summary) Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, leaving vulnerable people at risk.
Noted (AI summary) Redcar and Cleveland Borough Council will recirculate the Section 136 Policy to relevant staff within Adult Social Care and make them aware of the concerns identified through Mr Bradley’s inquest. They reiterate the use of the Crisis Assessment Suite at Roseberry Park as the appropriate place of safety. Stockton on Tees Council will bring TEWV's Section 136 policy to the Mental Health Legislation Operational Group to consider further education for Cleveland Police. They will also recirculate the Section 136 Policy to relevant staff within Adult Social Care. Middlesbrough Council will ensure their mental health service receives refreshed communication regarding section 136 guidance, and the circumstances relating to the Regulation 28 report. This will be flagged within the Multi-Agency Mental Health Legislation Operational Group to determine the need for further awareness and training among wider partners. Hartlepool Council will give consideration to further education and awareness raising within Cleveland Police regarding the use of Section 136 powers. They will also recirculate the Section 136 Policy to relevant staff within Adult Social Care and make them aware of the inquest's concerns. The ICB acknowledges the concerns regarding mental health safeguarding for intoxicated individuals, explains existing crisis services, and states they have no plans for a specific holding facility. They note that the crisis team was not contacted in this specific case, so they can't comment on the potential outcome. Tees, Esk and Wear Valley NHS shared learning with the police via the Multi-Agency Mental Health Legislation Operational Group on the 11 July 2025 to ensure awareness of the Report and best practice. This report has also been shared with Crisis Teams. The Department of Health and Social Care liaised with the NHS North East and Cumbria Integrated Care Board (NENC ICB) who will be responding directly. They also mentioned Cleveland Police began to implement the Right Care Right Person approach in 2024, and committed £26 million in capital investment to support people in mental health crisis.
Sophie Cotton
All Responded
2025-0246 27 May 2025 Durham and Darlington
Durham Constabulary Officer of the College of Policing
Concerns summary (AI summary) Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter locked premises, and leading to dangerous delays in supervisor reviews.
Noted (AI summary) Durham Constabulary's Deputy Chief Constable states that a full review of the case and police actions was undertaken, with the outcome and actions attached to the response. The Police and Crime Commissioner expressed condolences and noted that a review by Durham Constabulary didn't highlight significant failings but resulted in two points of organisational learning and recommendations. The commissioner will monitor the 'Right Care Right Person' model. The College of Policing has contacted Durham Constabulary, who have reviewed their policies and procedures in line with the College of Policing toolkit and Approved Professional Practice. The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. Durham Constabulary will implement recommendations aligned with the National Toolkit for Right Care, Right Person (RCRP), aiming for full implementation by mid-July 2025. These include a review of police systems for further intelligence, supervisor review, and immediate escalation to the Supervisor on a second call about the same person within a 12 hour period.
Paul Alexander
All Responded
2025-0244 27 May 2025 West Yorkshire West
West Yorkshire Police
Concerns summary (AI summary) Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare concerns, a known recurring issue.
Action Taken (AI summary) West Yorkshire Police has worked with partners to develop an escalation process for RCRP, including briefings, training, and revised policies to improve identification and mitigation of risks related to mental health. The force continues to work with partners to share learning, address gaps, and improve service delivery.
Lewis Johnson
All Responded
2025-0242 23 May 2025 Inner North London
Independent Office for Police Conduct
Concerns summary (AI summary) The IOPC's investigation terms of reference failed to include measuring vehicle distances during police pursuits, impacting the inquest by lacking objective evidence crucial for future learning and policy development.
Action Planned (AI summary) The IOPC is updating its internal guidance for investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report, including distance calculation, and will consult with the Coroner about their approach. Internal technical leads will also liaise with investigators in the early stages of relevant investigations.
Lewis Johnson
All Responded
2025-0241 23 May 2025 Inner North London
Metropolitan Police Service
Concerns summary (AI summary) The MPS failed to effectively implement and train staff on police pursuit policies, leading to inconsistent expectations among officers regarding the time required for pursuit authorization decisions.
Action Taken (AI summary) The Metropolitan Police Service has implemented a new Pan London Pursuit Training (PLPT) course for pursuit supervisors and operators, focusing on policy implementation, decision-making, and communication, with stringent testing and assessment criteria.
Nicholas Gedge
All Responded
2025-0148 11 Mar 2025 West Yorkshire East
Leeds Community Healthcare NHS Trust West Yorkshire Police
Concerns summary (AI summary) A significant delay in commencing CPR occurred due to a lack of shared understanding of its urgency and an uncoordinated response among detention officers and a nurse. No clear protocols define emergency roles.
Noted (AI summary) Leeds Community Healthcare NHS Trust outlines actions taken, including a working group to review the Death in Custody procedure, reflective conversations with staff, and inclusion of 'coordination of response' in the investigation process. They are enhancing CPR training and clarifying the contents of the emergency bag. They clarified that the intervention was an intramuscular injection of Naloxone, not an intraosseous needle. West Yorkshire Police clarifies the roles and training of Detention Officers in medical emergencies, emphasizing their responsibility to provide basic life support until a Healthcare Professional arrives and to follow the Healthcare Professional's directions. However, the Chief Constable intends to review contracts, policies and procedures between the Force and Leeds Community Healthcare to ensure clarity on roles in emergencies.
Robert Evans
All Responded
2025-0120 4 Mar 2025 Liverpool and Wirral
College of Policing National Police Chiefs’ Council
Concerns summary (AI summary) A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing drugs during a street search if not arrested, creating a critical gap in care compared to those in custody.
Noted (AI summary) The NPCC Stop & Search portfolio will review the Regulation 28 document and work to ensure officers are equipped to resolve incidents such as these; they will work with other portfolios and stakeholders to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them. The College of Policing asserts that its Authorised Professional Practice (APP) on Detention and Custody adequately addresses concerns about medical attention for individuals suspected of swallowing drugs, pointing to existing guidance on immediate medical response, arrest procedures, risk assessment, and information sharing.
Alfie Lawless
All Responded
2025-0118 4 Mar 2025 Manchester South
Greater Manchester Police
Concerns summary (AI summary) Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about the quality of their internal review and learning from incidents.
Action Taken (AI summary) Greater Manchester Police PSD has designed a new form for assessing incidents relating to Death or Serious Injury (DSI), including rationale and learning opportunities; the PSD's Organisational Learning team will monitor the forms and escalate any risks to the Tactical Organisational Learning Board. The PSD will ensure mandatory referrals are made without delay, ensure AA's attend formal training and will undertake a period of monthly dip sampling to ensure that this process is embedded.
Lachlan Campbell
All Responded
2025-0115 28 Feb 2025 Cornwall and the Isles of Scilly
Department of Health and Social Care
Concerns summary (AI summary) Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented their death.
Action Planned (AI summary) The government acknowledges concerns around emergency service pressures and is working with NHS England to address them, with a focus on ambulance response times and handover delays; the upcoming 10-Year Health Plan will set out radical reforms for the NHS and address these issues.
Lachlan Campbell
All Responded
2025-0114 28 Feb 2025 Cornwall and the Isles of Scilly
Devon and Cornwall Constabulary South Western Ambulance Service NHS Fou…
Concerns summary (AI summary) Poor information sharing between ambulance service and police, including incorrect call status and police not being given ETAs or asked about scene presence, led to significant delays in patient care. The lack of police-to-hospital conveyance options for urgent cases is also a concern.
Action Planned (AI summary) Police officers are being trained to dial 999 from the scene for medical support, and SWAST has implemented a new communication pathway to improve inter-agency information sharing. SWAST is implementing a Timely Handover Process at RCHT to instigate rapid handover if not undertaken within 90 minutes of arrival. Devon & Cornwall Police is participating in a multi-agency group to promote closer working arrangements between emergency services, with meetings scheduled to identify and address specific areas for improvement. The Assistant Chief Constable has reiterated the expectation that sergeants can redeploy police resources in liaison with an inspector and/or the Force Incident Manager.
Ronald Bainborough
All Responded
2025-0099 18 Feb 2025 Inner North London
Metropolitan Police Ministry of Justice
Concerns summary (AI summary) Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police delays, expose individuals to significant harm before assessment.
Action Planned (AI summary) The MPS is reviewing its corporate process for s.135 warrants and will incorporate the matters raised in the PFD report and learning identified into this review. HMCTS has reiterated arrangements for applications to magistrates’ courts in London and held a meeting with NHS colleagues to explore concerns, committing to continued communication and partnership working.
Zahra Mohamed
All Responded
2025-0098 18 Feb 2025 Inner North London
Metropolitan Police Ministry of Justice
Concerns summary (AI summary) Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling issues, increasing the risk of harm to vulnerable patients.
Action Planned (AI summary) The MPS corporate process for s.135 warrants is being reviewed, and the PFD report's matters and learning will be incorporated into this review. HMCTS has reiterated the arrangements for applications to be made to magistrates’ courts in London whether routine, urgent or out of hours. They also arranged a meeting with NHS professionals to explore concerns.
Liam Allan
All Responded
2025-0132 30 Jan 2025 West London
Kingston Council Lambeth Council Lewisham Council +15 more
Concerns summary (AI summary) Inadequate visibility of riverside buoyancy aids and slow, telephone-based police-to-fire service communication create critical delays in emergency response, increasing drowning risks.
Noted (AI summary) The London Fire Brigade has made significant changes to its radio system following the Grenfell Tower Inquiry, improving communication interoperability. They have also installed throwline boards, provided throwline training to businesses and parks patrols, opened a water safety training room, and strengthened operational working with Surrey Fire and Rescue Service. The National Fire Chiefs Council highlights the Fire Control Fire Standard and Guidance, the Multi-Agency Information Transfer (MAIT) system, and ongoing liaison with London Fire Brigade to ensure learning is captured and shared. They support fire and rescue services to improve the effectiveness and maximize the use of digital systems and this is a key priority for them in the Fit for the Future strategic plan. The London Borough of Barking and Dagenham will undertake a survey and asset mapping of waterbodies and riverside locations, assess sites using risk assessment criteria, standardise safety equipment, and implement a structured inspection and maintenance programme. They will advocate for enhanced inter-agency communication. The London Borough of Havering will give further consideration to the lighting of life buoys at inland bodies of water, ensure new buoyancy aids meet British Standards and require white stripes, and consider including a policy for developers to provide and maintain lifesaving equipment. They consider communication between emergency services to be a matter for the emergency services to address. The City of London acknowledges the concerns raised. The text describes various procedures and resources in place for managing incidents and ensuring safety, without stating a change in policy.
Anugrah Abraham
All Responded
2025-0024 14 Jan 2025 Manchester North
College of Policing National Police Chiefs’ Council West Yorkshire Police
Concerns summary (AI summary) Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers disclosing suicidal thoughts, and student officer training causes stress without adequate progress tracking.
Action Planned (AI summary) West Yorkshire Police has reflected on the events, and has already taken or is planning to take the following actions: The OH answerphone message should include advice for the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, Discussions between the clinical team regarding risk should be documented, Frequency of suicidal ideation should be recorded, Protective factors should be recorded, the OH page should include the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, contact Force Legal Services to provide inquest feedback, the service level agreement target is to be abandoned as unrealistic, Introduction of 90mins appointments, and Escalation to Force Medical Advisor for student officers referred due to their mental health. The College of Policing will review APP on suicide prevention to incorporate Anugrah Abraham's case and will also create a central repository of information on suicide prevention. They will also ensure the sharing of information about concerns with performance and any associated processes that are commenced will be referenced.
Matthew Brierley
All Responded
2025-0008 8 Jan 2025 Cumbria
College of Policing Ministry of Justice National Police Chiefs’ Council
Concerns summary (AI summary) Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support fail to address their elevated risk.
Noted (AI summary) The College of Policing outlines existing guidance and practitioner advice for officers and staff regarding suspects of child sexual exploitation and risk assessment processes following release from custody, noting Mr. Brierley declined support offered. The Home Office acknowledges the report and expresses condolences, notes the relevant guidance provided by the College of Policing, and states that a review concluded appropriate support was provided to Mr. Brierley by Border Force. The NPCC is undertaking research to identify commonalities in post-custody suicides to establish a post-release risk assessment process and mandatory referral to support agencies, and has shared the PFD report with all UK custody leads with recommendations for investigative strategies. The Ministry of Justice believes the report should have been directed to the Home Secretary, as it relates to police investigative procedures, bail conditions, and Border Force (Home Office) matters.