Independent Commission on Mental Health and Policing Report Published

News item posted: 19 June 2017

An independent report has found that the Metropolitan Police Service (MPS) must improve its response to mental health to reduce the likelihood of deaths or serious injury occurring in the future.

The Independent Commission on Mental Health and Policing reviewed 55 cases, involving people with mental health issues, over the past five years. Five cases were deaths in police custody, and 45 deaths were either prior to or following contact with the police. The other five cases resulted in serious injury.

Mental health is a core part of day-to-day MPS business. People with mental health issues interact with the police in many different ways; as witnesses, victims of crime and as suspects. Frontline police officers are the public face of policing and encounter difficult challenges every day. They should be supported in any work that relates to mental health issues through thorough training and guidance.

The Commission has also concluded that the MPS must respect all members of the public, in particular the most vulnerable. It also needs leadership that recognises public safety.

Key findings include:

  • The events that informed this inquiry are far less likely to happen in the future if the recommendations in the report are implemented.
  • In most cases, there were failures in systems, mis-judgments or errors by individuals, resource limitations, poor co-ordination with other services or discriminatory attitudes towards people with mental illness that led eventually to these deaths.
  • People with mental health issues complained they were treated like criminals by the police. They also felt individuals with mental health issues were handled with too much force, that the police should engage more with the families, and that police and NHS staff should have more mental health training.
  • Many families said they could not understand why there was not better liaison between agencies. Some professionals made similar points in evidence.
  • The Commission did have access to MPS files. However paper files and records were incomplete. This is clearly unacceptable for a 21st Century, customer-focused police service.
  • Care pathways must be recognised and developed and there needs to be greater operational working together, such as inter-agency working within the NHS, clinical commissioning groups and local government.
  • The London Ambulance Service (LAS) needs to respond to someone experiencing a clear mental health crisis as an emergency even if the police are present.


Lord Victor Adebowale, speaking at the launch of the report, said:

"I would like to offer my sincere thanks to the families of those who have died for their contribution to this report.

Whilst a report like this cannot take away their suffering, I hope that those who receive this report, ensure that the recommendations are implemented in the name of the families as citizens who have lost loved ones in terrible circumstances. They deserve the reassurance that other families will not suffer the same loss.

The Commission has sought to provide actionable recommendations, so that there is a real opportunity for the MPS to change their approach significantly to those with mental health issues in their everyday policing.

The report acknowledges that the MPS cannot do all of this on its own. The inter-relationships between health and social care mean that many agencies must work together to provide a clear and effective system.

This report is grounded in evidence through: an expert panel of Commissioners; interviews and surveys with people who have mental health issues, the wider public and serving police officers; and through numerous meetings within the NHS and social services. It includes the judgement of coroners, IPCC reports and the views of families. I have been out on shifts with the police and the London Ambulance Service, so have seen at first hand that things can change and can change for the better."

Read the full report