A Preventing Future Death report is not always issued in an inquest where something went wrong and we’ve seen this recently with some inquests related to Right Care, Right Person. Christian Parker died in Worcestershire in early 2025 and his inquest was held in October. The record of inquest shows that West Mercia Police admitted getting the deployment decision wrong in court (albeit they later denied getting it wrong to the Times newspaper) and as a result of the acceptance of error in the inquest and assurance to make good that error through refreshed training to call handlers, the Senior Coroner did not issue a PFD notice.
Quite arguably, he could have done so by raising a matter of concern to the College of Policing or National Police Chiefs Council to ensure such errors were corrected or not repeated in other parts of the country, as indeed they have been. But the local admission by the force involved was enough to mean no PFD was issued.
We saw this also in the case of Martin Waite in Huddersfield where West Yorkshire Police admitted their contribution to what the Coroner described as “lamentable”, saying the police and ambulance services were engaged in “hokey-cokey” giving rise to a 12hr delay before entry was forced to Mr Waite’s home. Media coverage showed the force admitted their staff’s understanding of “immediate risk to life” was not good enough, so they’d given refreshers or reminders. Whether that simply repeated the errors which were inherent in the RCRP training originally used, we don’t know but these reassurances appear to be the basis of the Senior Coroner not issuing a PFD.
SO HOW MANY?
I have a list for my ongoing research of mental health related police contact deaths – currently stands at 327 cases since the turn of the century and 174 of those cases involved the issuing of a Preventing Future Deaths notice. I have started the process of thematically grouping the issues which are flagged by the coroner, things like –
- Fatal police shootings
- Restraint related deaths
- Missing people / patients
- Mental Health Act related
- Mental Capacity Act related
- Section 136
- Section 135(1)
- No beds
- Acute Behavioural Disturbance
- Training
- Joint protocols
- Leadership
- Findings of neglect
- Findings of “more than minimal” contributions
- Right Care, Right Person.
- Ambulance contribution
- Mental health provider contribution
- … to name just a few.
It’s early days on that analysis and it will continue throughout 2026/7 as it’s a slow-process, part-time PhD I’m doing! So far, I have 26 “RCRP” flagged inquests – crucially, that’s not to say deaths were caused by the RCRP programme because we know they weren’t. It’s just to say the inquest, the PFD or the responses to the PFD tell us something worth noting about the programme and the extent to which it remediates the lessons learned from the wider MH-PCDs this century.
And it all invites us to ask the question:
HOW MANY NON-PFD INQUESTS?
It was recently drawn to my attention by more than one source, a force who have had a number of RCRP PFDs so far, have in fact had three times as many inquests related to RCRP decision-making where errors were made?
Now of course, it’s the worst idea in the world to then think the inquests we’re hearing about with PFDs might represent just 1/3rd of the total inquests, but it does make me wonder how many non-PFD inquests like Christian Parker and Martin Waite have there been where errors were made but a PFD avoided because the force concerned had admitted the errors and promised remedy during the hearing?
We simply don’t know – because the inquests are not collated, the PFDs aren’t even collated and there has still been no meaningful and credible evaluation of this programme since it was conceived in 2020 and rolled out nationally in 2023. Another way to say the same thing is, there could be loads of inquests happening we know nothing about where errors were been made, commitments given to ensure remedial action and no sense of whether that actually happens.
But I find the numbers I’m hearing to be quite alarming, especially because they’re buried and because we know from hearings like Christian Parker and others due to take place in 2026 and 2027 that we now need to worry about integrity of post-mortem processes.
Awarded the President’s Medal, by
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, 2026
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
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