Recurring concern

Failure to make and document informed prosecution decisions in vulnerable cases

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First reported 18 Nov 2020•Latest report 31 Aug 2022

Definition

What this concern includes

Includes failures in prosecution decision-making processes to obtain and assess material evidence, consider relevant victim or defendant vulnerability and public-interest factors, set necessary actions, and document the reasoning and outcome, including decisions involving absent direct victim evidence or complex mental-health vulnerability.

Not included

  • Excludes general police investigation, victim contact or court-process failures where the prosecution decision-making process is not itself deficient.
  • Excludes failures to record routine administrative information when no prosecution assessment, rationale or action plan is affected.
  • Excludes clinical, safeguarding or social-care decisions that are not part of a prosecution decision.
  • Excludes failures to implement a prosecution decision after it was adequately assessed and documented.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2020–2022

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2
Crown Prosecution Service1
Greater Manchester Health and Social Care Partnership1
Greater Manchester Mental Health NHS Foundation Trust1
Greater Manchester Police1
Home Office1
Lincolnshire Police1
Ministry of Justice1
Office of the Chief Coroner1
Pennine Care NHS Foundation Trust1
Trafford Borough Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Lincolnshire

    AI-generated summary

    Dainton Harley Hill Cressell GITTOS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dainton Harley Hill, an 11-year-old vulnerable child with cerebral palsy who could not speak, bear his own weight, or call for help, was left unsupervised in a bath on 22 January 2021 and was later found unresponsive. The inquest concluded that parental neglect in failing to supervise him contributed directly to his death, which was consistent with drowning. Concerns were raised about the lack of supervision, failure to use a non-slip bath mattress, prior social services records concerning neglect and emotional harm, and the decision not to bring charges.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to adequately test evidence and reconsider charging criteria in suspected child neglect cases

    Wider context from the report

    “I refer to all the evidence heard at the Inquest particularly, that of DC ████████ and the Police’s own expert Dr. ████████, (recited above) and do not accept why any charges have not been brought against either or both parents focusing on s1(1) Children and Young Persons Act 1933 The police are asked to review their file again in view of the many concessions made by CPS and the findings as to cause of death now made in the Coroner’s Court (admittedly on a different standard of proof but they are still findings after hearing evidence). Neglect runs right through this case and irrespective of the parent’s allegations against each other in the Coroner’s Court the belief is that the evidence needs to be tested and if agreed charging criteria reconsidered as there are 3 other siblings. A vulnerable child aged 11 is dead. ”

    Source location

    Dainton Harley Hill Cressell GITTOS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Michelle Louise Jennings · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michelle Louise Jennings had a history of suicidal thoughts and contact with mental health services. She died after delays in accessing therapy, prosecution following a railway incident, and problems with communication and case ownership between mental health teams. The report identified concerns about therapy waiting lists, referral and discharge arrangements, and how prosecuting authorities account for mental health vulnerability.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to assess the public interest and mental health vulnerability when making prosecution decisions

    Wider context from the report

    “3. The evidence before the inquest was that there needed to be a clear understanding by all prosecuting authorities of the impact of a prosecution on someone with a complex mental health background such as Michelle. In Michelle’s case the BTP file reviewer (the nature of the offence Michelle faced meant that it was not a CPS lawyer who made the charging decision) had not correctly applied the public interest test and had not considered the mental health/vulnerability of Michelle Jennings as required to. As a consequence a decision was taken to prosecute her without an assessment of the impact on Michelle and her case was dealt with by the Magistrates Court without them being given the full background in relation to her deteriorating mental health. BTP are as a consequence of Michelle’s death taking steps to address how their prosecution teams should deal with the public interest test and gather information where mental health is an issue. However there is no clear mechanism for such learning and changes (to reduce the risk to life) in relation to vulnerable people such as Michelle to be implemented within the other 42 Police forces in England and Wales or within other agencies responsible for prosecuting criminal offences. ”

    Source location

    Michelle Louise Jennings · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Alfie Gildea · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of CPS decision makers to follow guidance and document prosecution assessments

    Wider context from the report

    “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information. ”

    Source location

    Alfie Gildea · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train all CPS Direct prosecutors on case analysis, decision rationale, evidence assessment, domestic abuse history and detailed action planning.

    Verbatim wording from the response

    “All CPS Direct prosecutors have been recently trained on ‘Case Analysis and Strategy’. This training focussed on the importance of recording the rationale for decisions and the selection of charge. It included a detailed case study on a coercive and controlling case involving a serial Domestic Abuse perpetrator. The training also involved a comprehensive analysis of available evidence and the suspect’s previous Domestic Abuse history with other partners and emphasised the importance of setting a detailed action plan to ensure early and effective case progression from the outset. This training took place from December 2019 to June 2020 and is part of the induction program for new lawyers joining CPS Direct.”

    Source location

    2020-0242-Response-from-CPS-Redacted.pdf
    Page 2 · response
    Published 24 December 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train all CPS Direct prosecutors on evidence-led domestic abuse prosecutions, including case-building without victim support and policy compliance before no-further-action decisions.

    Verbatim wording from the response

    “CPS Direct have also trained all prosecutors on ‘Domestic Abuse Evidence Led Prosecutions’. This built on the Case Analysis and Strategy training focussing on the importance of case-building DA cases from the very start, where possible strengthening the case to ensure that it could proceed without the victim. It also gave refresher guidance on the available legislation and gateways for the admission of evidence without calling the victim, stressing the need to ensure scrupulous policy compliance before an ‘NFA’ decision is reached. This training was completed between July-October 2020 and is also part of the induction program for new lawyers joining CPS Direct.”

    Source location

    2020-0242-Response-from-CPS-Redacted.pdf
    Page 2 · response
    Published 24 December 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train CPS North West prosecutors on good review structure, decision-making records and considering whether domestic abuse cases can proceed without victim support.

    Verbatim wording from the response

    “In CPS North West over the course of August and September 2020 prosecutors underwent training about the structure and content of a good review which included a specific section on the need to carefully record decision making in Domestic Abuse cases and to think about whether it is possible to proceed without the support of the victim. The Evidence Led Prosecutions course which has been delivered by CPS Direct will also be rolled out locally to Magistrates’, Crown Court and RASSO prosecutors as soon as we are able to do so. I am not able to commit to a date at the present time because of other national training commitments which are required to be delivered first.”

    Source location

    2020-0242-Response-from-CPS-Redacted.pdf
    Page 2 · response
    Published 24 December 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The CPS cannot commit to a date for rolling out Evidence Led Prosecutions training because other national training commitments must be delivered first.

    Verbatim wording from the response

    “In CPS North West over the course of August and September 2020 prosecutors underwent training about the structure and content of a good review which included a specific section on the need to carefully record decision making in Domestic Abuse cases and to think about whether it is possible to proceed without the support of the victim. The Evidence Led Prosecutions course which has been delivered by CPS Direct will also be rolled out locally to Magistrates’, Crown Court and RASSO prosecutors as soon as we are able to do so. I am not able to commit to a date at the present time because of other national training commitments which are required to be delivered first.”

    Source location

    2020-0242-Response-from-CPS-Redacted.pdf
    Page 2 · response
    Published 24 December 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.

    Verbatim wording from the response

    “I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.”

    Source location

    2020-0242-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted.pdf
    Page 1 · response
    Published 24 December 2020

    Open published response
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Data last updated 7 September 2026