Preventing Future Deaths

For a couple of years, I’ve been regularly reading the website of the Chief Coroner, in particular the section on Preventing Future Deaths and I’ve blogged about this before.  I had a discussion with an academic last year about the potential of me undertaking PhD research on PFD issues affecting policing and mental health, not least because of the obvious potential to argue that lessons from these notices are not always fully learned.  To the extent that they are, usually by the organisations directly affected, they are not necessarily learned more widely across agencies and across the country.  In my recent reading, I kept a list of cases with at least some bearing on policing and mental health issues and thought it may be useful to provide links and summary comments about those which stick out, at least for me.

You’re not just guilty of failing to learn lessons, you’re repeatedly guilty of failing to learn repeated lessons.” — Deborah Coles, Executive Director of Inquest, 2017.


  • Olaseni Lewis, died-2010; verdict-2017 – speaks to issues around ABD and restraint; as well as the medical oversight of police responses in medical settings during police attendance at a disturbance in a mental health setting.
  • Kingsley Burrell d-2011, v-2015 – speaks to issues on ABD / restraint; as well as the street triage as a generic solution when it’s unlikely to have affected this type of incident.  Of note on triage, is the response from the Metropolitan Police Commander who was NPCC lead at the time.
  • Terry Smith, d-2013, v-2018 – speaks to issues around ABD and restraint; as well as the ambulance service interface with the police during MH crisis.
  • Greg Hutchings, d-2017, v-2018 – speaks to the need for unambiguous communication between cooperating agencies and to a clear, joint understand of what ‘street triage’ actually is, inc what telephone triage between nurse and patient can amount to.
  • Eugeniusz Niedziolko, d-2017, v-2018 – speaks to issues on ambulance service responses to police-led healthcare incidents; to consideration of A&E care for drunk people and to the non-use of section 136 MHA in such cases.
  • David Stacey, d-2017, v-2018 – speaks to NHS legal duties and institutional compliance with the Mental Health Act itself (specifically s140 MHA) and the planning for predictable events to which that section gives rise.
  • Darren Cumberbatch, d-2017, v-2019 – speask to issues around ABD, restraint and the use of force, as well as the Probation Service’s awareness of ABD.
  • Sasha Forster, d-2017, v-2019 – speaks to issues of assumptions sometimes found within the health system about what is a police responsibility.  The Coroner’s concern about resources to return patients follow remarks in court by a senior doctor that despite the Code of Practice MHA highlighting the NHS trust’s responsibilities, they preferred the police to do it because they lacked resources.  Also speaks to indifference about the impact of policing on patients known to be fearful of them, as Sasha was.
  • Douglas Oak, d-2017, v-2019 – speaks to issues around ABD and restraint; as well as the ambulance service interface with the police during MH crisis.
  • Nigel Abbott, d-2018, v-2019 – speaks to issues around joint s135 policies, agencies’ perception of others’ policies and responsibilities and urgently required MHA assessment and / or admission / no beds.
  • Kevin Clarke, d-2018, v-2020 – speaks to issues around ABD and restraint; as well as the ambulance service interface with the police during MH crisis, including inadequate clinical assessment and inherent medical risks.
  • Ewan Brown, d-2019, v-2020 – speaks to the need for officers not only to have up to date training, but also refresher training on policing & mental health.
  • Deborah Lamont, d-2019, v-2020 – speaks to issues officers’ understanding MH legislation.  This case involved, amongst other things, non-use of s136 where it may have been considered lawful; also involved risk-taking advice from MH services to police that officers found uncomfortable but where they deferred to perceived expertise even through the MH professionals were not present to assess things in person.
  • Nimo Younis, d-2019, v-2020 – speaks the need for clarity of communication between agencies, to the need for agreements in protocols or at least clear agency procedures where there are no agreements, to ensure police are provided with relevant information when patient’s reported missing.
  • Valeria Biggs, d-2019, v-2021 – speaks to issues culture and risk taking in NHS mental health services.
  • Thiago Araujo, d-2020, v-2021 – speaks to agencies’ perceptions of each others policies and responsibilities and two-week delays to convene a Mental Health Act assessment for someone at ‘acute risk of suicide’.
  • Katie Locke, d-2015, v-2021 – speaks to information sharing across police services, mental health trusts and probation around the risk posed by offenders under the PDP programme who have threatened to kill whilst mentally ill.
  • Leon Briggs, d-2013, v-2021 – speaks to the need for clear, effective protocols (s136) as well as training for police officers and greater awareness of post-restraint monitoring of those subject to a use of force.
  • Anthony Prestond-2020, v-2021 – speaks to issues around voluntary attendance at ED, police not accompanying on the basis of someone not being (able to be) detained MHA and of welfare checks v missing.
  • Jack Taylor, d-2021, v-2021 – speaks to issues around MH trusts responsibilities to return patients, AWOL protocols and consistency with force missing persons’ policies.
  • Angeline Phillips, d-2021, v-2021 – this relates to the downgrading of a log about a concern for the welfare of a vulnerable person, received from a friend and to a subsequent decision that it was “a medical matter” which was transferred to the ambulance service.

Update: some more recent PFD notices are included in another post
I’ll update this page in due course.

Remember what these are: notices from a Coroner to say that unless certain things are changed by organisations with the responsibility to make those changes, then other people may die. 

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, 2023

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 –