Using PFD Reports

We’ve started the new year with some familiar messages – more preventing future death reports (PFDs) from UK coroners after someone tragically lost their life in circumstances which gave rise to fears that aspects could be repeated and lead to future tragedy. PFDs are statutory notices, something the Coroner issues to an agency who may control aspects of what went wrong or contributed to the outcome. This could be anything from training of staff, to policies and procedures within or across agencies to anything else thought relevant. The organisation in receipt of such a notice has 56days to respond outlining their reaction to the recommendation(s) and these things are usually uploaded to the Office of the Chief Coroner’s website, where the notices are categorised by theme.

I’ve regularly browsed this website for a number of years and this post comes after another recent session – you may find these links useful, if you wish to do the same. These things are tagged in the way that a social media blog would be, so you may find the same report featuring across the searches and the other categories, where there are multiply relevant –

There is a lot of learning in there – that’s the very idea behind issuing notices and publishing them online. I’ve also heard it argued for years that some of this learning is not assimilated in to practice, which is a terrible shame. Deborah Coles, the CEO of the charity Inquest, once stated at a conference that organisations are not just guilty of failing to learn lessons (as promised in most press releases after adverse incidents leading to a death), but they are actually repeatedly guilty of failing to learn repeated lessons.

The lessons are often contained in these reports.


So here are just a few examples of PFDs issued and uploaded on the Chief Coroner’s website where a local tragedy has learning which is potentially relevant for ALL police forces and mental health trusts. As an operational cop, I can say with absolute certainty that some of the learning in these reports has not been learned and we continue to see assumptions or requests about what the police will or won’t do, which either appears to be literally ignorant of the learning or which is wilfully disregarding it (for a range of complex reasons).

  • The death of David Stacey. << Learning includes: the ability to admit patients urgently to hospital under the MHA, compliance by CCGs with s140 of the Mental Health Act to provide clear routes for this.

NB: I can’t find a link to this particular PFD, but I highlight the case as I’ve long argued its general importance and the link provided here is the blog I wrote at the end of 2018 which summarises the relevant issues.

  • The death of Sasha Forster. << Learning includes: not over-relying upon the police to return patients to hopsital. The importance of hospitals knowing by what means they secure NHS resources to return patients in circumstances where paragraph 28.14 of the Mental Health Act Code of Practice applies.
  • The death of Nimo Younis. << Learning includes: unclear procedures and communication about AWOL patients; decision making by NHS trusts and police forces with sub-optimal information leading to under-responses to risk; the need for good-quality, effective local protocols and clarity about the police role.
  • The death of Dr Deborah Lamont.  << Learning includes: confusion over locations where s136 MHA be applied by police officers and in particular the importance of interpreting the word ‘living’ in s136(1A) for hotel rooms.

NB: This case is recent and the PFD not yet published – this is a link to my blog post on the incident and I will update this post once the PFD is published by the Coroner.

What is also an unfortunate feature of this landscape, one which has often caused me some frustration, are the errors one sees creeping in to the Coroner’s reports. I’m not going to highlight specific examples of this, but even in just scanning some PFDs I’d not previously read, there are errors to be seen so it would take some careful navigation to learn from them.  Examples include errors in referring to sections of the Mental Health Act, incorrect use of statutory terms and titles and I also think in some cases, the PFDs miss a trick in failing to take on certain challenges to push for change that could be legitimately sought.  But don’t let that put anyone off the realisation there is a wealth of learning in these things, if they’re absorbed.

The above cases are just four examples of such potential learning – plenty more if you use the links nearer the top of this post to search the Chief Coroner’s website.


The big accusation against us all, including from charities who campaign on this and support families, is that there are repeated themes across geographies.  So police force X may be connected to a tragedy and an inquest occurs, leading to learning and a PFD, but does police force Y learn from that? – do they ‘stress test’ their own processes and policies against what went wrong, to ensure it can’t happen there, or is reduced in its likelihood?  The evidence  seems to be – in policing, in mental health trusts and in ambulance services – that they don’t always learn from that and could do better because we know there are similarities in separate events which Coroners have painstakingly untangled. I’ve long had a frustration, for example, about deaths in police custody where we hear of police officers arresting people (or detaining them under s136 MHA) and then not calling an ambulance, but removing them by police vehicle to police custody because they are ‘violent’.

This is the story behind a number of tragedies, like Michael Powell, Sean Rigg, James Herbert, Toni Speck, Terry Smith and Leon Briggs as well as others. What is noticeable about them is that each happened in a different police force. When investigations and inquests took place, we saw repeated problems with joint policies and procedures, themes around the expectations officers and non-police staff had about how the police would manage members of the public believed to have mental health problems and exhibiting challenging or disruptive behaviours. Over the years, professional guidance in policing and in healthcare has reinforced what a dangerous idea it is to think that such patients under restraint should be taken by police car to custody and nothing at all prevents all forces learning from those tragedies without needing to wait until their own responses and policies are tested.

My own view on this particular problems is that we see much less of it now: since returning to operational policing last year, I’ve been the duty inspector a few times where officers have encountered vulnerable but challenging patients believed to be suffering from acute mental health problems or so-called acute behavioural disturbance, sometimes (but not always) exacerbated by drugs. They have consistently called ambulances and removed people to Emergency Departments for medical assessment, before thinking about detention for Mental Health Act assessment.  It only took twenty years, but we seem to have got there. The problem remains, though, in the PFDs on other aspects of this interface.


In more recent times, we’ve seen PFDs for cases which touch upon other similar issues. There have been PFDs from Nottingham and from Birmingham about deaths which gave rise to questions about Mental Health Act assessments and s135 protocols. The Nimo Younis case, above and the Sasha Forster case, both give rise to questions about processes relating to AWOL patients. The David Stacey case and the Nigel Abbott case raise questions about the availability of inpatient mental health beds and there are many more cases besides on those particular matters.

So if I were a force mental health lead or still at the College of Policing(!), I’d be reading the website for the Office of the Chief Coroner reasonably regularly – looking at the new cases coming up and asking whether aspects of those cases could be repeated somewhere else yet the learn the acute lesson.  But there are only a few really big messages within all this, and they are remarkably easy to summarise (even if some may claim they’re difficult to implement) —

  • Do police forces have effective joint protocols? – local agreements with partners in MH and acute trusts, as well as ambulance and AMHP services on the major MHA topics: these include –
  • s136 & Places of Safety;
  • Mental Health Act Assessments including s135(1);
  • AWOL patients, including s135(2); and
  • Conveyance of Patients under the MHA.
  • And by ‘good’ and ‘effective’, I mean, policies which do accurately reflect the law, the Codes, the professional guidance and the case law, as well as synthesising the lessons from these cases?
  • And(!), crucially – are they LEGALLY CHECKED?! You’d be amazed how many aren’t when you ask the question!

There is still loads to do – and whilst it’s being done, there are frontline staff from all organisations operating in the vacuum created by not having comprehensive structures in place which take account of the above learning.

Given that learning usually came at grave cost to real people, it seems such a shame.  To say the very least.

Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown OBE, 2020

I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current.  Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.

Government legislation website –