“3 1”

The coroner’s concerns

3 1. Police: Person Escort Record (PER) At my request, Hampshire police assisted the jury in understanding the purpose and procedures involved in both the custody process and the process by which information about a person’s risk of self-harm is transferred and used as they move between police custody, court and prison. greatly assisted the court by drawing on his extensive expertise as a former custody sergeant and now an accredited trainer on all aspects of the custody process. After a short opportunity to familiarise himself with the statements provided by key police personnel as well as the documentation including the police copy of the PER he confirmed: a) The current PER form uses carbonated paper and is a pilot system adopted by only two police forces in the UK. It has been in use for 2.5 to 3 years and a national working group has suggested moving towards an electronic system but this has not been implemented. b) Mr Folley was assessed as NCTS (no current thoughts of self-harm or suicide) and thus placed on the lowest observation rate of 60 minutes. However, access to previous data held on police (both internal and external) and other agency systems was not available to officers completing the PER and thus they could rely on current observations only. Despite this, it was essential to consider the risk of self-harm or suicide demonstrated and recorded over the previous months (July – September) not simply since detention on this occasion. c) Detention Officer PER training may not have been completed if a DO had many years of experience in the police force which would give what he referred to as “grandfather rights”. d) A custody officer can delegate the preparation of the PER but the custody officer should specify the risks to the detention officer and either personally speak to him or telephone. It was not known if that occurred in this case. e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry. This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded. f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers. g) The detention officer in this case would not have access to local police Information Systems in Kent or Thames Valley nor the incident on the railway line at Cosham and possibly Southampton as this may have involved British transport police. h) The suicide/self harm warning alert (SASH) at page 9 of the PER was meant to be completed if there was a risk of self-harm or suicide since arrest or within the last month. In other words, it was felt the relevant period to be considered was not just the current period of detention but also anything relevant within a month before arrest. In this case the SASH form was never completed. i) A heavy responsibility is placed on a custody sergeant takeaway detainees freedom and to keep a person in custody until they can be brought before a criminal court. In this case, the reasons given included that it was in Mr Folley’s own interest in the sense of his own protection given his indication that if he was not remanded in custody, he would harm himself or someone else. That in itself, could be a reason to start the SASH form. 4 There are a number of issues that need to be addressed: i. Ensuring key information is included in the PER and ensuring procedures are adequately followed; See 1c) to 1f) and 1h) to 1i) above ii. Linking intelligence held on other systems; See 1b) and 1g) above. iii. Progressing the pilot to reform the PER nationally See 1a) above. This is the second prison death inquest I have handled where this issue was raised (Hargrave April 2017). A reply from in June 2017 confirmed that the ownership and management of both the PER form and the pilot rests with NOMS who confirmed that they are currently working towards a digital version of the PER as a long term solution. Whilst I accept this may be complex as it involves a range of partners and IT difficulties, no progress seems to have been made to adopt an interim solution and pilot this in Hampshire and some other forces despite a further two years since my last PFD. 2. GeoAmey – Person Escort Record During the inquest I heard from a mental health practitioner employed by Solent NHS Trust who confirmed that when Mr Folley was remanded in custody by the magistrates at approximately 4 PM the same day she telephoned the Geo Amy staff to discuss the associated risks contained within the two HDLS reports. She was explicit that the written reports would need to be placed in the PER and raised with the booking in team at the prison. This was because she was concerned regarding the potentially escalating risk if Mr Folley’s needs were perceived by him as not being met and she wanted that information to be passed to the prison staff. She specifically asked the staff to send the two court reports with the PER and her recollection was that she was assured this would happen. I also heard from , the Head of Compliance for GEOAmey who confirmed that although officers receive initial training including the completion and handling of PER and SASH forms, the overwhelming perception created was that the police are primarily responsible for the PER and that the court custody officers merely as a courier to transport any paperwork they are given to the prison. I am concerned that the impression created was that GEOAmey staff do not actively engage in and contribute to the contents of the PER to highlight any information relevant to risk assessment irrespective of what source it comes from. In addition, there was apparently no log of call to the court cells. The electronic PER

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2019-0230

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0