Sean Williams

I

METROPOLITAN
POLICE

Ms Mary Hassell
HM Senior Coroner
Inner North London
St Pancras Coroner's Court
London
N1C 4PP

Deputy Assistant Commissioner
Metropolitan Police Service
New Scotland Yard
Victoria Embankment
London
SW1A 2JL

Email:

23/04/2026

Correspondence By Email

Dear Ms Hassell

Prevention of Future Deaths - Mr Sean Williams

We acknowledge receipt of your Regulation 28 report dated 20 February 2026 concerning
the inquest into the death of Mr Sean Williams. We extend our sincere condolences to the
family and all those affected by this tragic event.

In response to the matters of concern you have raised,
the Healthcare Director for the
Metropolitan Police Service (MPS) Custody has outlined the governance and procedures in
place to manage the care of detainees.

'

Summary of Concern 1

"The MPS had already recognised before inquest that, following Mr Williams' detention,
he was not seen by a custody nurse for 23 hours."

MPS Response - Action Taken

MPS Custody Teams (Police Sergeant Custody Officer and Designated Detention Officers)
complete a risk assessment and identify detainees who require medical assessment. They
inform the Healthcare Practitioner (HCP) on duty (Nurse, Doctor or Paramedic). The
communication takes the form of a 'medical request' on the MPS CONNECT' system,
in
addition, a verbal handover is sometimes included direct to the HCP.

In this case, there was a delay in referring the individual to the Custody HCP; consequently,
operational reminders have been issued reminding Custody Officers to ensure such requests
are made.

1 CONNECT captures MPS data and detainee records into a single, integrated platform.

 A new protocol for 'case finding' was implemented in November 2025, where the HCP on duty
runs through the custody whiteboard with the Grip Sergeant2 at around 05:30hrs and checks
if there are any detainees who may have unmet medical needs (i.e. they do not have a medical
request on CONNECT).

ì

The Custody HCP will prioritise cases waiting to be seen and check the CONNECT entry, risk .
assessment and reason for medical referral.

·

Detainees are seen in the medical room or cell depending on their level of cooperation or risk
of violence. The HCP will complete an initial assessment and devise a plan of care, which may
include medication and regular reviews.

Detainees who present with medical conditions or potential to withdraw from alcohol and/or
drugs, are seen as a minimum every six hours whilst in, custody. Some are seen more often
depending on their condition and medication needs.

Outcome/Impact

The MPS are monitoring compliance with protocols regarding 'case finding' and withdrawal
management Individual detainee cases are reviewed monthly, and feedback provided to
HCPs who are not following clinical practice guidelines and actively completing the discussion
with the Grip Sergeant.

Summary of Concern 2

"The custody nurse who reviewed Mr Williams on two separate occasions in the twelve
hours immediate/y before he attended court, did not on the second occasion take any
observations of Mr Williams' vital signs before (or after) prescribing dihydrocodeine,
and did not record any part 'of Mr Williams' clinical picture".

•

MPS Response - Action Taken

lt is a requirement that the HCP records a full set of vital signs and other observations (e.g.
COWS - Clinical Opiate Withdrawal Scale) prior to medication administration.
In April 2024,
the new SYSTMOne? templates were created which mandate a set of vital signs (unless the
patient refuses) to be recorded at the initial clinical assessment and when reviews take place.

The importance of detainee reassessment (including vital signs) each time there is a clinical
review cannot be underestimated, and this is communicated to all HCPs during the induction
and annual
refresher programme (Immediate Life Support and Professional Development
Days).

Detainees may not have fully disclosed / be aware of or understand all their medical needs -
their physical or psychological condition can change during their stay in custody.

Grip Sergeants lead the team on duty and manage the effective and safe management of a custody suite.
3 SYSTMOne is the healthcare electronic medical records system.

 Regular checks (minimum hourly) by Designated Detention Officers are also part of the
'recognition of deterioration' system in place for all detainees in custody.

The Clinical Practice Guidelines followed by HCP in custody highlight this approach to safe
care and assessment for detainees. Compliance with guidelines and quality of care delivered
is monitored through HCP audits led by the Senior HCPs in each area. Feedback and
guidance are provided where the documentation falls below standards or there are learning
needs to provide the standard of care expected from all HCPs working in MPS Custody Suites.

HCPs enter medical records in the NHS SYSTMOne system, which is separate from the Police
CONNECT system, this maintains medical confidentiality. The system is template driven and
requires HCPs to complete mandatory fields (unless the patient refuses to cooperate with
observations/ questions). This promotes consistency in practice and record keeping. The HCP
is prompted to record a reason in the case that mandatory fields are not completed.

Outcome/Impact

Regular monitoring of HCP practice is undertaken by a Senior HCP for each area, who reviews
the clinical documentation. The new template has improved the recording of vital signs at each
review and decision point for medication administration.

Summary of Concern 3

"Despite having prescribed dihydrocodeine for drug withdrawal, when giving evidence
in court the nurse was unable to describe the signs and symptoms of withdrawal".

MPS Response -Action Taken

Annual refresher training is in place for· all custody HCPs. This includes assessment and
recognition of drug (and alcohol) dependency and withdrawal.

The template for opiate dependency / withdrawal uses the COWS score and the list of signs
and symptoms are on the screen. Clinical practice guidelines have been updated to ensure
that detainees who are likely to withdraw can be medicated earlier to prevent this.

HCPs can follow the Patient Group Direction to provide medication when the detainee is
showing signs of withdrawal,
if a prescription is required earlier there are non-medical
prescribers on duty 24 hours every day.

Qutcome/Impact

Review of clinical notes as part of the ongoing audit programme has resulted in feedback and
additional training for HCPs. This focusses on recognising drug and alcohol withdrawal
in the
custody setting, medication protocols and recognising when medication is not working or
requires review.

 Clinical Governance

Oversight for monitoring clinical standards of care is managed by the Clinical Governance
Committee (CGC) which is chaired by the Healthcare Director. Attendance and scrutiny are
provided by an external Senior Medical Advisor and Consultant Pharmacist. The CGC review
investigations, and inquests. The Clinical Standards Group informs
learning from incidents,
the CGC of national
reviews, changes to guidance and supports local dissemination of
learning.

We are committed to ensuring that lessons are learned and that robust measures are in place
to prevent similar incidents in the future. We will continue to monitor the effectiveness of these
changes and make further improvements where necessary.

If you require any additional
hesitate to contact us.

Yours sincerely

information or evidence of the actions taken, please do not

Deputy Assistant Commissioner

•

!

Ms Mary Hassall 
HM Senior Coroner for Inner North London 
St Pancras Coroner’s Court, 
Camley Street 
London, 
N1C 4PP 

17th April 2026 

Dear Ms Hassall, 

Thank  you  for  your  Prevention  of  Future  Death  Report  (‘PFDR’)  dated  20  February  2026  following  the 
conclusion of the Inquest into the death of Sean Perry Williams who sadly died in March 2024. 

As the Managing Director of Serco’s Justice and Immigration business, I am responding on behalf of Serco 
, Serco’s Group Chief Executive Officer to matters of concern that you have raised in the 
and 
PFDR, in so far as they relate to Serco under the Prisoner Escort and Custody Services (PECS) contract. I am 
aware that you will share a copy of this response with Mr Williams’ family and I would like to express my 
sincere condolences for their loss. Every death in custody is a tragedy, and the safety of those detained and 
transported by Serco is our absolute priority. 

I  am  grateful  to  you  for  bringing  the  matters  of  concern  to  Serco’s  attention.  Thankfully  medical 
emergencies on our vehicles whilst they are in transit are fairly unusual, when you bear in mind that Serco 
PECS complete over 250,000 journeys per annum. Mr Williams’ death was the first of only three deaths on 
a Serco PECS vehicle in the last 10 years. I can provide some assurance that in the vast majority of cases 
involving a medical emergency on a vehicle staff have acted promptly, professionally, and have followed 
the correct procedure to keep the prisoner safe and have provided the appropriate care pending the arrival 
of the emergency services. Serco recognises that any death in custody or during transport is a matter of the 
utmost seriousness, regardless of how infrequently such events occur. The circumstances of Mr Williams’ 
death have prompted detailed reflection on our policies, training, and operational guidance, with the aim 
of reducing the risk of any recurrence. Indeed, our health and safety management is always under review 
as we seek to continuously improve. Following an incident, we review the risk factors involved and whether 
we have sufficient and effective controls in place to ensure compliance with our obligations to keep the 
often-vulnerable  individuals  in  our  custody  safe  and  well.  Serco  does  not  hesitate  to  implement 
enhancements to its processes where these are appropriate. As with existing procedures any changes are 
subject to approval by the MOJ before implementation  

Since the death of Mr Williams we have revised Standard Operating Procedure (SOP) 038 Prisoner Welfare 
on  a  Vehicle,  SOP  009  Duties  of  a  Vehicle  Escort  Officer  and  SOP  047  Death  or  attempted  suicide  of  a 
prisoner in custody, to improve the clarity of the steps to be taken where a medical emergency is suspected 
and I understand copies of the updated SOPs have been provided to you. The changes have also been 
reflected in other SOPs and training documents to ensure consistency.  

However, I note the jury’s findings and your concerns in relation to the apparent lack of urgency on the part 
of the  staff involved with  Mr  Williams, their  competencies,  and the contents  of the relevant training  and 
guidance provided to staff in relation to first aid and dealing with a medical emergency on a vehicle. 

Serco Justice & Immigration  
Serco House, 16 Bartley Wood Business Park, Bartley Way,  
Hook, Hampshire, RG27 9UY United Kingdom 
T: +44 (0)1256 745 900  |  F: +44 (0)1256 744 112  |  www.serco.com  

Serco Group Plc, a company registered in England and Wales No. 2048608 
Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Adequacy of training – First Aid issues 

As you will be aware from the evidence at the Inquest, all Serco escort staff undergo an extensive five and 
a half week initial training course (ITC), the contents of which are regularly reviewed and updated in order 
that  improvements  can  be  implemented.  The  ITC  is  followed  by  a  comprehensive  assessment  of  staff 
competencies before any member of staff is passed on the course and  are permitted to work within the 
PECS contract. 

I believe that you have been provided with the slides which form the basis of the two modules of the ITC 
most  relevant  to  Mr  Williams’  death,  being  vehicle  emergencies  and  First  Aid,  and  that  the  slides  were 
included in the Inquest bundle. However, the contents of the slides are merely the basis of the training, with 
each slide being expanded upon by the trainer responsible for delivering the training, in accordance with 
policy and procedures set out in our Standard Operating Procedures. The resulting qualification meets the 
Health  and  Safety  Executive  (HSE)  requirements.  In  addition,  the  Highfield  Level  3  Award  in  First  Aid  at 
Work is regulated by Ofqual. 

In light of the concerns raised, we have undertaken  additional steps to review our ITC provision and our 
annual training programme to ensure that any further opportunities to strengthen our approach are given 
full and proper consideration 

I note the jury’s findings and that one particular concern related to seizures. As you will note the First Aid 
slides  include  a  whole  section  on  seizures  (slides  118-122).  Nevertheless,  while  seizure  recognition  and 
response  forms  part  of  existing  first‑aid  training,  this  finding  has  prompted  Serco  to  consider  whether 
additional measures are required to strengthen staff confidence and recognition with respect to this issue 
in practice. Similarly, the findings relating to use of the recovery position have informed a focused review 
of how this aspect of training is emphasised and reinforced. That said, once again, you will have noted that 
there is a whole section on the recovery position within the training slides (slides 49-57). I can also confirm 
that aspects of both of these sections are included in the assessment of staff when the training is concluded. 

The Use of Force training provided annually to all staff also references training on the recovery position. 

The jury’s findings indicate that further consideration needs to be given to strengthening recall, urgency 
and confidence when staff are required to respond to medical emergencies under operational pressure. 
This issue is likely to be compounded by the fact that  it is fairly rare for staff to  be faced with a medical 
emergency  let  alone  a  seizure,  or  an  occasion  when  it  would  be  appropriate  to  place  a  casualty  in  the 
recovery position.  That said, Serco accepts that training must continue to evolve to address this risk. 

However,  the  difficulty  faced  by  staff  in  recalling  their  medical  emergency  training  in  an  emergency 
(referred  to  by 
  in  his  evidence  as  fright,  flight  or  freeze)  is  covered  during  the  use  of  force 
training and during the medical emergencies on a cellular vehicle training during the ITC. It is also covered 
in the annual staff refresher to assist staff. 

To  further  improve  retention  of  the  instruction  provided  during  training,  as  confirmed  by  our  Training 
Partner  during his evidence at the Inquest,  since March 2026 the training on medical emergencies on a 
cellular  vehicle  and  first  aid  principles  have  been  included  in  the  PECS  internal  annual  refresher  within 
Serco’s internal Learning Management System (LMS). 

Serco Justice & Immigration  
Serco House, 16 Bartley Wood Business Park, Bartley Way,  
Hook, Hampshire, RG27 9UY United Kingdom 
T: +44 (0)1256 745 900  |  F: +44 (0)1256 744 112  |  www.serco.com  

Serco Group Plc, a company registered in England and Wales No. 2048608 
Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom 

 
 
 
 We are also in the process of reviewing the training provided with the awarding organisation, Highfield, to 
explore the possibility of including a video of a seizure in the training, to assist staff in identifying a seizure, 
and in retaining the instruction provided on how to deal with a seizure should they encounter one. A review 
of the adequacy of the training on the recovery position is also being undertaken to ensure that any possible 
improvements  are  implemented.  We  are  also  reviewing  whether  it  would  be  appropriate  to  include 
additional and new training on the recovery position within the training module on vehicle emergencies, 
to emphasise its importance, and to assist in retention of this very importance aspect of the training. 

Adequacy of training – process issues 

I note the jury’s findings and the particular concerns in relation to guidance provided to staff on the use of 
the emergency buttons installed on all Serco vehicles for  use in emergency situations, and the potential 
conflicting information provided in relation to who to contact and where to take the prisoner to, in order to 
provide prompt and efficient assistance to a prisoner during a medical emergency. 

As you are aware the process to be followed if staff encounter a medical emergency on a vehicle is covered 
in the ITC, and I can confirm that it is also included in the annual refreshers that all operational staff in PECS 
undertake.  

In  addition,  in  order  to  remind  staff  of  the  required  process  and  aid  their  retention  of  the  information 
provided  during  the  training,  in  March  2025  we  created  a  new  online  course  on  Serco’s  LMS.  This  is  a 
mandatory course for all staff members and includes what to do in an emergency medical incident, basic 
life support, self-harm incidents, vehicle breakdown, fire and anything deemed a vehicle emergency. The 
content  provides  a  refresher  of  the  training  covered  in  the  ITC  course,  to  reinforce  learning  and  gives 
additional prominence by being a separate module and links together the concepts that staff have learned 
during their Highfield First Aid training. This new medical emergency on a cellular vehicle training course 
also reinforces that staff must conduct CPR if a prisoner is unresponsive and summon medical attention, 
and  that  CPR  must  continue  until  the  prisoner  is  breathing,  a  medical  professional  arrives,  or  they  are 
otherwise directed to stop by a medical professional or emergency call-handler. There is an exam at the 
end of the course with a pass rate of 80%. If they fail this test employees must take it again until they have 
achieved the required pass mark. 

The action that staff should take in the event of a medical emergency will inevitably be fact specific.In such 
circumstances the staff on scene must carry out a dynamic risk assessment specific to the case in hand, to 
identify what steps must be taken to keep the prisoner safe and to provide prompt assistance. 

Following the death of Mr Williams, Serco has taken steps to assist staff to recall their training on who to 
contact and where to take the casualty to, to ensure they receive prompt medical attention.  Having said 
that, there does need to be some degree of flexibility in the process, so that if part of the process cannot 
be  followed,  for  whatever  reason,  the  staff  feel  confident  to  take  further  appropriate  steps  to  keep  the 
prisoner safe. 

I am aware that in Mr Williams’ case, the staff on the vehicle contacted the emergency services promptly to 
request  an  ambulance,  but  that  there  were  considerable  difficulties  in  communicating  their  location  to 
ensure  that  the  ambulance  attended  at  the  correct  location.  Although  the  particular  communication 
difficulties encountered by staff in this case were not anticipated, it is in part for this reason that the process 
requires  staff  to  press  the  emergency  button  on  the  vehicle  and  to  call  the  Operational  Control  Centre 
(OCC) to seek assistance. 

Serco Justice & Immigration  
Serco House, 16 Bartley Wood Business Park, Bartley Way,  
Hook, Hampshire, RG27 9UY United Kingdom 
T: +44 (0)1256 745 900  |  F: +44 (0)1256 744 112  |  www.serco.com  

Serco Group Plc, a company registered in England and Wales No. 2048608 
Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom 

 
 
 
 
 
 
 
 
 As was confirmed by the evidence at the Inquest, all Serco PECS vehicles are tracked by the OCC. Activation 
of the emergency button enables the OCC to prioritise the call from that vehicle and to communicate the 
vehicle’s location directly to the emergency services, thereby reducing the risk of location‑related delay. 

Not only are the resources available to staff at the OCC more readily available, but the staff member at the 
OCC is able to assist the staff on scene in assessing the situation and ensuring that appropriate assistance 
is provided promptly. 

As outlined by Serco’s Head of Professional Standards and Security in his evidence, and to support staff on 
scene in following the correct process, Serco has developed a flowchart for escort officers following the 
death of Mr Williams. A copy appears in the Inquest bundle. This has since been incorporated into training, 
and laminated copies are now displayed within all escort vehicles in a position visible from the escort seat. 
The intention is that this readily accessible guide will reinforce existing training, clarify the required steps, 
and  support  escort  officers  in  responding  with  confidence  and  consistency  during  suspected  medical 
emergencies. 

Serco has also developed a corresponding flowchart for the OCC to reflect that provided to PCOs, together 
with structured prompt questions to assist OCC controllers in identifying the nature of an emergency and 
providing  appropriate  support  and  direction  to  PCOs  when  an  incident  occurs.  A  copy  of  the  OCC 
flowchart has also been provided. 

A laminated version of this flowchart is now attached to each controller’s desk within the OCC with several 
copies  of  the  list  of  questions  being  available  on  each  desk  for  completion  during  each  incident.  It  is 
intended  that  the  standardised  response  protocol  for  alarm  activations,  supported  by  structured 
questioning, will help gather sufficient information to ensure an appropriate response. However, we have 
also reiterated to staff that PCOs should feel confident to take the decision, having activated the alarm, not 
to wait for direction if life-threatening circumstances exist, including opening the cell door and contacting 
the emergency services directly.  

More generally I also note the concern in relation to  the adequacy of Serco’s  assessment of the first aid 
knowledge and competence of its staff. Staff competence is assessed through formal testing and practical 
assessments as part of the Level 3 First Aid at Work qualification, together with instructor-led observation 
and scenario-based assessment during the Initial Training Course, with staff being required to demonstrate 
competence before being signed off as operational. In relation to the formal testing, learners must achieve 
at least 70%. Further oral questioning can be undertaken if learners do not achieve the required pass mark. 
Practical assessment is completed throughout the course delivery, and requires learners to demonstrate 
practical first aid skills to an acceptable and competent standard. 

Finally, since the conclusion of the Inquest a review of the jury’s findings has taken place internally in order 
to  attempt  to  put  additional  safety  measures  in  place,  to  avoid  a  similar  incident  in  the  future.  This  has 
resulted in a full review of relevant SOPs, updates to training materials to ensure full consistency with those 
procedures, and the introduction of clearer, more accessible guidance to support staff during suspected 
medical  emergencies.  This  work  has  been  supported  by  a  structured  internal  review,  with  time-bound 
actions and supporting analysis to ensure that any changes are evidence-led, proportionate and effectively 
implemented.  

Serco Justice & Immigration  
Serco House, 16 Bartley Wood Business Park, Bartley Way,  
Hook, Hampshire, RG27 9UY United Kingdom 
T: +44 (0)1256 745 900  |  F: +44 (0)1256 744 112  |  www.serco.com  

Serco Group Plc, a company registered in England and Wales No. 2048608 
Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom 

 
 
 
 
 
 
 
 
 Thank you again for bringing your concerns to our attention. I hope you are reassured by the response to 
the issues raised. If I can be of any further assistance, please do not hesitate to contact me. 

Yours sincerely, 

Managing Director, Justice & Immigration 
Serco UK & Europe 

Serco Justice & Immigration  
Serco House, 16 Bartley Wood Business Park, Bartley Way,  
Hook, Hampshire, RG27 9UY United Kingdom 
T: +44 (0)1256 745 900  |  F: +44 (0)1256 744 112  |  www.serco.com  

Serco Group Plc, a company registered in England and Wales No. 2048608 
Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom