Police fail to convey critical health information to ambulance crew
Metropolitan Police received 2 coroners' reports about this hazard between 27 Jun 2019 and 26 Nov 2020.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Evidence was heard at the Inquest that errors were made in communicating information to the LAS.”
Original on judiciary.uk ↗ Metropolitan Police responded, stating 4 specific actions.Response (PDF) ↗
“request that the working group, driven by Met training, review the attendance of officers at mandatory ELS training and review the systems in place for supervisors to monitor attendance”
Stated timescale: April 2020
“The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise)”
Stated timescale: October 2019
2 more stated actions in the Promises tab.
- 1 year 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms [name redacted] to hospital, nor to any of the doctors or nurses at the hospital.”
Original on judiciary.uk ↗ Metropolitan Police responded, stating 1 specific action.Response (PDF) ↗
“The MPS will shortly be introducing a Merlin Toolkit, which will provide advice and guidance on the circumstances in which reports should be completed. This also references the Vulnerability Assessment Framework (VAF) which should be used as the basis for assessment for all officers.”
Stated timescale: shortly
- All reports to Metropolitan Police
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2019 → 2020Agnès Marchessou1 year 5 months after Edir DA Costa · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures by police to convey critical health‑related information to medical responders. The earlier report cites communication breakdowns with the London Ambulance Service due to noise and procedural lapses; the later report describes police not passing on vital patient statements and observations to ambulance crews and hospital staff.
Edir DA Costa · 27 Jun 2019
“Evidence was heard at the Inquest that errors were made in communicating information to the LAS.”
Original on judiciary.uk ↗ Agnès Marchessou · 26 Nov 2020
“The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms [name redacted] to hospital, nor to any of the doctors or nurses at the hospital.”
Original on judiciary.uk ↗
Stated action · timescale: April 2020
“request that the working group, driven by Met training, review the attendance of officers at mandatory ELS training and review the systems in place for supervisors to monitor attendance”
Stated action · timescale: October 2019
“The MPS are requested to review the training provided to staff in relation to the role of the safety officer in a street setting and to consider whether a reminder of the importance of the safety officer role, in the street setting, should be issued to staff (by way of bulletin or otherwise)”
Stated action · timescale: October 2019
“Future restraint lessons will reference the revised Module 12 of the National Personal Safety Manual (NPSM) which was presented by Inspector Collett during the Inquest as the final draft”
Stated action
“The MPS is requested to review the guidance and procedures in place for officers, in relation to the use of CS spray where a person is believed to be holding items in their mouth”
Stated action · timescale: shortly
“The MPS will shortly be introducing a Merlin Toolkit, which will provide advice and guidance on the circumstances in which reports should be completed. This also references the Vulnerability Assessment Framework (VAF) which should be used as the basis for assessment for all officers.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Metropolitan Police at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2019 → 2020 | 0.72 | 0.04 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.