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recurance

Oladeji Omishore

25 Mar 2025 · Coroner Fiona J Wilcox · Inner West London

This report repeats 2 earlier warnings. See the linked reports.

The coroner's concerns

  1. 1. inconsistent recording of mental health information by call handlers

    “inconsistency of approach between call handlers/first responders in the recording of information passed to them by members of the public that may represent a training issue; in this case the mental health matters reported to them”
  2. 2. lack of training on recording for dispatch transmission

    “call handlers/ first responders may have a training issue in relation to the importance of recording this information in manner which is likely to be passed on to responding officers by dispatchers, for example in the NICL codes and/ or "golden line"”
  3. 3. inadequate mental health data transmission increases taser risk

    “the above concern of potential training need is highlighted by the increased use of taser in black men and those suffering mental health issues and so the real need for this information to be recorded and passed on in the most effective form”
  4. 4. insufficient NICL code capacity for mental health tagging

    “the limitation of 3 NICL codes makes it difficult to record mental health as a qualifier in incidents such as this where the main risk factor is the weapon”
  5. 5. uncertain recording location for mental health data

    “call handlers/first responders may need training as to where to record such information i.e. in the "golden line" or NCIL code, as long as of course it is reported to them before the "golden line" and NICL code has gone out”
  6. 6. time pressure prevents mental health data capture

    “use of THRIVE usually requires time that is not available in I grade calls and does not mitigate the need to circulate promptly information as to mental health issues, in the format most likely to digested and passed on by dispatchers that is "golden line" or NICL codes”
  7. 7. absence of mental health NICL code

    “the lack of NICL code "mental health believed" compounds this”
  8. 8. dispatchers lack training on mental health communication

    “dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health”
  9. 9. dispatchers unclear on unit assignment communication

    “dispatchers may require training in relation to what to pass out more generally given the confusion in the evidence about other units being assigned by CAD, which dispatchers themselves did not seem to appreciate and understand let alone pass such information out to responding officers”
  10. 10. systemic dispatcher failures omit critical mental health data

    “apparent system failure issues in dispatcher pods if due to pressure of work, important issues such as mental health concerns for the subject are being missed and the number of units on the way are not being passed over the airwaves, given the potential importance of these matters to responding officers when applying their NDMs, and the reliance of responding officers on the information that they receive over the radio on their way to an I grade call”
  11. 11. inadequate de-escalation training for taser use

    “training for response officers may require review in relation to tactical options used to de-escalate prior to taser deployment, in appropriate circumstances, given the increased use of taser in black men with mental health issues; and in particular, training in relation to deploying with taser drawn and pointed with accompanying commanding language where the subject may be suffering with mental ill-health”

Linked reports

Repeats an earlier warningAnne Wilson21 Jul 2015 · 9 years 8 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“(b) an example of how to manage a request for a welfare check concerning the mental health of an individual”
Original on judiciary.uk ↗

This report

“dispatchers may require training in relation to the importance of passing on possible mental health concerns for the subject over the airwaves given the increased use of taser in black men and those suffering with mental ill health”
Full chain: Inadequate mental health communication during welfare checks
Repeats an earlier warningAnna Hedman25 Sept 2019 · 5 years 6 months earlier
Closely relatedConfidence 0.80 · moderate

Earlier report

“That the training offered to police officers becoming part-time call handlers is too short and rushed, especially in relation to call coding.”
Original on judiciary.uk ↗

This report

“That the call handlers/ first responders may have a training issue in relation to the importance of recording this information in manner which is likely to”
Full chain: Insufficient training on recording dispatch transmissions

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error