The Association of Police and Crime Commissioners (APCC) has recently published updated guidance – their second edition – on the topic of “Preventing Deaths in Police Custody and Suicides Following Release from Custody“.
Rather wordy, isn’t it? – many reading this will be aware I’ve started researching this topic for mental health related incidents and I’m spending a lot of time this spring / summer writing short, informal papers which I call “briefing notes”. They are ideas for my own future reference or for my PhD supervisors and one of them in progress right now is just about the terminology of what I’m now researching.
Police Contact Death(s) – PCD(s).
I’ve settled (at least for now) on this term precisely because it’s not wordy and means I can use a handy three letter acronym – PCD. As you start reading materials from organisations like APCC or indeed from the Independent Advisory Panel on Deaths in Custody, which advises the Ministerial Board on Deaths in Custody and which publishes their own guidance on this topic, there’s a whole host of reasons (now running to c3,000 words on my laptop) why I believe my terminology is preferrable for me – but it’s mainly preferrable because it’s short and actually usable.
“Suicides Following Release from Police Custody” are still police contact deaths; “deaths in police custody” includes deaths after arrest and before arrival in a police custody facility, as well as deaths which occur in a cell block, once detained in such a facility – but it’s all “police contact death” so why not just use that term until there is specific reason to be more detailed? … you’ll notice this guidance from the APCC as well as other guidance, wrestles with language by using fuller, apparently more descriptive terminology in titles and introductions before then dropping that language because it’s not really useable, especially when terminology is repeatedly necessary.
I digress!
SECOND EDITION
I was surprised to see a second APCC edition in April 2025 because their first edition was only published in June 2024 (now withdrawn from the internet). So unless you downloaded the first effort, we can’t see precisely what’s changed. As the document is not specific to mental health, I’m not about to attempt a full summary or critique of it, I only have a few observations to make about mental health issues but it’s in a context where the IAPCD state there were “24 deaths in or following police custody and 68 apparent suicides within 48 hours of release from custody” during 2023/24. That will immediately confuse some by making us wonder what the precise difference is between a death “following police custody” and a “suicide within 48 hours of release from custody”? I can only refer you to my post about the last Independent Office for Police Contact (IOPC) report on that topic which breaks down some of the interminable terminology employed.
We know mental health matters play a part in a significant number of police contact deaths – sometimes, mental health is coincidental to the outcome but in others, it’s directly contributory. We don’t know precisely how many mental health related deaths there are because the data published by the IOPC is partial. They only make reference to deaths which are independently investigated by them and we are left to guess how relevant mental health is to some of these and other deaths. By way of example, I was an operational officer involved in two mental health police contact deaths and neither of them would have made it to the IOPC’s published data because neither were independently investigated. In those particular cases it was because initial assessment indicated neither death was contributed to by negligent police actions and in one case, the officers involved were treated only as witnesses to the events. In the other, we were served misconduct notices and after an interview by Professional Standards, fully cleared of any wrongdoing at all – about which they presented no evidence anyway. They simply asked us to explain what happened and that was that.
My main point is this: why, when we see guidance on mental health police contact deaths (MH-PCD), do we see little reference to the requirement for joint protocols between partner agencies, explicitly required by statutory guidance. I can find no reference to them in the APCC’s guidance, despite five different paragraphs of the Mental Health Act Codes of Practice (England and Wales) requiring Chief Constables to have such protocols agreed with their partners and we know some of the most high-profile police contact deaths have been mental health related where joint protocols became relevant in the Coroners’ courts to untangling the events which preceded tragedy. A previous post deals with those five specific issues.
JOINT PROTOCOLS
The relevance of these things is about the kind of attention to detail which we often find missing from political and strategic leaders. Some MH-PCDs occur, for example, amidst constables and sergeants not accurately understanding the law. Others include assumptions being made about which agency is responsible for something. Some include straight-forward failures to train frontline staff on what senior leaders require of them – often because those leaders haven’t specified it in a joint protocol, perhaps because they don’t actually know? – knowledge is often poor.
A lot of this is very detailed stuff, requiring a close attention to legal, guidance and other policy requirements, all moulded in to a joint protocol which needs to pass the quality test and my work as an expert witness in Coroners courts has often led to me calling in to question how something got through a force or mental health trust goverannce process when stuff is obviously missing or wrong. Nevertheless, local leaders have a duty to bring this all together in their local context to explain how it will work in practice and how the compromises and overlapping obligations will be managed at 9pm on a Tuesday night.
One example (of dozens I could give):
We’re hearing a lot at the moment about the “one hour handover” after use of s136. This is phrase four of the “Right Care, Right Person” programme and in the National Partnership Agreement, it sets out an ambition officers who have removed someone to a Place of Safety under s136 MHA will be able to handover and leave within an hour. (Interestingly, the APCCs own guidance on RCRP goes further than that: extending the expectation to Emergency Departments as well as mental health unit Places of Safety – I’m not sure if they asked ED what they think of that mission creep). But the one hour handover is an example of something which needs managing in a protocol so we don’t end up with the police sitting around for hours unnecessarily, but we don’t end up with NHS unable to manage someone who poses a threat to them or is capable of walking out in to difficult circumstances where they may be at risk and definitely so we don’t end up with a serious untoward outcome as we saw in the Webley case. I’ve also just finished writing a blog for publication later, about a real incident where officers walked out without NHS staff agreement and the patient proceeded to smash the place up and threaten NHS staff with broken glass, only for the police to refuse to return.
INATTENTION TO DETAIL
So the attention to detail stuff is really important and protocols should cover the handover process amongst many other things which are often inadequately covered or simply missing – how does it all work, how are disagreements handled, how does escalation occur and of course, what happens if there really is not agreement once managers look at things: do the police have the right to walk out or do the NHS have the right to insist they remain?
Well, as the law stands, nothing in law actually obliges the police to remain there but if they walk away they probably remain liable in negligence for any untoward consequences which occur. Imagine if a PoS nurse had been stabbed with a piece of glass?! … it doesn’t bear thinking about so joint protocols are important, training on their content is important – attention to detail on day-to-day matters which really does mitigate against police contact deaths is vitally important.
And that’s why the APCC’s complete failure to even mention this is important and disappointing. They aim, they claim, to ensure lessons are learned (a phrase I’m tired of hearing) and given the repeated occasions where His Majesty’s Coroners have drawn attention to the kinds of strategic, operational and tactical omissions I’m referring to here, including where they have amounted to negligence or contributed to unlawful killing, it’s something which probably needs mentioning in any third edition they may produce and it’s certainly something PCCs should be looking at in their overt political mission “to hold Chief Constables to account”.
This would be an easy win that makes a difference – “Chief Constable, have you got five protocols agreed across police, NHS and local authority around this MHA stuff and are they checked off as actually comprehensive? Get it sorted – including training for staff.”
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, 2025
I am not a police officer.
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 – www.legislation.gov.uk
Mental Health Cop 