Thomas Mayhew

Dear Mrs Bradford, The following is a response from the Department for Science, Innovation and Technology (DSIT) to your Regulation 28 Prevention of Future Deaths report issued following the inquest into the death of Thomas Alexander Ferdinand Mayhew (known as Ned), concluded on 21 April 2026. We were very saddened to hear of the case involving Ned, and we wanted to thank you for raising this important matter so that it can be considered by the relevant authorities accordingly. We recognise the seriousness of the issues raised and welcome the opportunity to respond. While we are not responsible for the operational delivery of emergency services, including police and ambulance response or control room decision-making, we maintain the Public Emergency Call Service (PECS) Code of Practice on behalf of the 999/11 2 Liaison Committee. The Liaison Committee is the primary governing body responsible for the technical and operational oversight of the UK's Public Emergency Call Service. The Code of Practice is not a formal policy statement, but provides guidance to organisations on the handling of 999/112 public emergency telephone calls between the Call Handling Agents and the Emergency Authorities in the UK. The detailed operational policies and processes set out within the Code are developed and implemented by BT, as the call handling agent, and the emergency services, drawing on their operational expertise. We work with these partners to bring forward agreed updates to the PECS and ensure that changes are formally reflected and applied consistently across the emergency call system. We coordinate closely with emergency service organisations and BT, as the 999 call handling agent, to ensure that the Code of Practice reflects agreed operational practice and supports the prioritisation of life-saving interventions. Following receipt of your report, we have engaged with the relevant operational partners who can advise on the proposal (BT, ambulance services, and policing, including through the 999 Liaison Committee and consultation with the National Police Chief Council (NPCC)) to consider the issues raised and decide whether the proposed change

should be adopted into standard practice. Upon confirmation from these operational partners of their conclusions on your proposal and the appropriate procedures for this kind of scenario, any changes, if applicable, can then be reflected in the PECS Code of Practice. We understand that the NPCC is responding separately on the operational action being taken by policing. Any changes to the PECS would be intended to strengthen arrangements for call routing and interagency coordination in time-critical situations, particularly where there is uncertainty as to whether the person has died, ensuring access to an appropriate clinical response. Thank you again for bringing this matter to our attention. We hope this response provides assurance that the issues you have identified are being considered with the seriousness they deserve, and that DSIT will continue to work with operational partners to ensure any agreed improvements are reflected appropriately in the PECS Code of Practice.

Dear Mrs Bradford,

I write on behalf of UK policing, through the National Police Chiefs’ Council (NPCC), in response to your Regulation 28 Prevention of Future Deaths report issued following the inquest into the death of Thomas Alexander Ferdinand Mayhew, concluded on 21 April 2026.

UK policing is grateful to you for setting out the concerns arising from this inquest and, in particular, for the clarity with which the clinical evidence regarding the very limited window for life-saving intervention following ligature was presented. We fully recognise the seriousness of the issues raised and the importance of ensuring that emergency systems operate in a way that best protects life.

We note your concern that, where a member of the public reports the discovery of an apparently deceased person, current arrangements under the Public Emergency Call Service Code of Practice (PECS) may result in the initial routing of the call to the police. You expressed the view that this process carries a risk of delay before ambulance attendance in circumstances where medical evidence demonstrates that life-saving intervention may still be possible and where every second is critical.

UK policing accepts the central clinical principle underpinning this concern: life should be presumed unless and until death is confirmed by an appropriately trained medical professional. We agree that the preservation of life must take precedence and that non-medical professionals, including police officers and police call handlers, should not be expected to make clinical judgements regarding life extinction.

Following receipt of your report, senior policing leads met with representatives from BT 999 Call Handlers, to review both the specific circumstances of this case and the wider operation of PECS. That review confirmed that, in this instance, the caller Essex Police Headquarters, Springfield Rd Chelmsford, Essex. CM2 6DA

15th June 2026

made a clear and explicit request for police assistance and that BT acted correctly and lawfully in routing the call in accordance with nationally agreed arrangements. It was also recognised that BT call handlers are not empowered to challenge or reinterpret an explicit service request, as doing so risks role confusion and may introduce delay in other circumstances.

While acknowledging that the call handling in this case complied with existing national arrangements, UK policing recognises that your report highlights an opportunity to strengthen system-level safeguards in time-critical scenarios. As a result, a number of actions are now underway or proposed.

Policing has asked BT to engage formally with ambulance services and the 999 Liaison Committee to consider whether, in cases where a caller describes the discovery of a body or an apparently deceased person and is unsure which service is required, calls should default to routing to the ambulance service, which ambulance colleagues have agreed too and the appropriate PECS governance process and training will be updated. This proposal reflects the principle that clinical need should take primacy where there is any possibility that life remains.

In addition, UK policing will reinforce national expectations that, where there is any uncertainty as to whether life is extinct, police control rooms must immediately notify ambulance services and not await on-scene confirmation. While this expectation already exists in operational practice, it will be re-emphasised through guidance and assurance activity in light of the issues highlighted by this case.

Policing also supports the continued development of technical solutions, such as onward call connect or rapid call transfer functionality, which would enable emergency calls to be transferred swiftly between police and ambulance services when initial mis-routing is identified, without requiring the caller to re-dial. Although responsibility for such functionality does not sit with policing, we are actively supporting its development and adoption where available.

We also recognise that public understanding of how to respond in these circumstances forms part of the wider system context. The way in which online search engines and digital assistants present guidance to the public may influence which emergency service is requested in moments of acute distress. While this is a complex, multi-agency issue beyond the scope of this specific response, UK policing will explore with policing digital leads and partners whether there are opportunities to work collectively with health services and digital platforms to promote clearer public messaging that reinforces the primacy of seeking urgent medical assistance where life may still be present.

For completeness, it may be helpful to note that changes to BT call handler practice or default routing rules require multi-agency agreement and formal amendment to PECS, and cannot be directed unilaterally by policing. Similarly, UK policing does not consider it safe or appropriate for police or BT call handlers to undertake enhanced clinical triage, as this risks further delay and unintended harm.

In conclusion, UK policing acknowledges your concern that avoidable delay in life-threatening circumstances is unacceptable and agrees that the emergency system should do all it reasonably can to ensure that clinical need is prioritised where life may still be present. While the call handling in this case complied with existing national arrangements, your Regulation 28 report has prompted appropriate national scrutiny and proportionate action to improve inter-agency safeguards, reduce reliance on public judgement, and strengthen coordination in time-critical incidents.

We trust this letter provides assurance that the matters you have raised are being taken seriously and addressed constructively at a national level. Should you require any further information or clarification, we would of course be happy to assist.