Recurring concern

Failure to identify and respond to disclosed knife and offensive-weapon possession

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First reported 19 Jul 2018•Latest report 1 May 2022

Definition

What this concern includes

Includes only assertions that directly instantiate the manually reviewed condition ‘Failure to identify and respond to disclosed knife and offensive-weapon possession’ and satisfy this evidence boundary: Two distinct reports directly support failures by police, social services or social workers to record, assess or investigate known knife possession. The separate assertion about teenagers' general understanding of knife-carrying risks is a public-education control and must not be used to widen the parent. Retain the three institutional recognition/response assertions from two reports and exclude the education seed.

Not included

  • Excludes generic risk-assessment, documentation or information-sharing deficiencies where no knife or offensive-weapon risk is materially identified.
  • Excludes general violence, gang-affiliation or domestic-abuse risk concerns where knife or offensive-weapon risk is not the shared unsafe condition.
  • Excludes unlawful possession or weapon-related harm as an outcome where no continuing failure to recognise or control the associated risk is asserted.
  • Excludes broader weapon regulation, school knife access and public knife-carrying culture concerns where the deficient control is not an individual or service process for recognising and managing a person's weapon risk.
  • Excludes manifestations outside the manually reviewed boundary: Two distinct reports directly support failures by police, social services or social workers to record, assess or investigate known knife possession. The separate assertion about teenagers' general understanding of knife-carrying risks is a public-education control and must not be used to widen the parent. Retain the three institutional recognition/response assertions from two reports and exclude the education seed.
Reports
3

Distinct published reports

Individual concerns
9

A report can raise multiple concerns

Date range
2018–2022

First to latest report issue date

Stated actions
1

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.

Metropolitan Police Service2
Dorset Healthcare University NHS Foundation Trust1
Durham University1
Mayor's Office for Policing and Crime1
University of Gloucestershire1

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. Dorset

    AI-generated summary

    Ryan Albert Frederick Merna · 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

    Ryan Albert Frederick Merna died from injuries sustained in a knife attack at his home on 14 August 2016. The concerns included that information about the perpetrator possessing a knife and sleeping rough was not probed, recorded, or raised at a care programme meeting, resulting in a missed opportunity to reassess risk.

    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 document discussion of the response to offensive-weapon disclosures

    Wider context from the report

    “1. During the inquest evidence was heard that: i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping. ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker. iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records. iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure. 2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain. ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented. ”

    Source location

    Ryan Albert Frederick Merna · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 document action taken in response to offensive-weapon disclosures

    Wider context from the report

    “1. During the inquest evidence was heard that: i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping. ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker. iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records. iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure. 2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain. ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented. ”

    Source location

    Ryan Albert Frederick Merna · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 raise offensive-weapon disclosures at Care Programme Meetings

    Wider context from the report

    “1. During the inquest evidence was heard that: i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping. ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker. iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records. iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure. 2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain. ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented. ”

    Source location

    Ryan Albert Frederick Merna · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 contemporaneously document disclosures of possession of an offensive weapon

    Wider context from the report

    “1. During the inquest evidence was heard that: i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping. ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker. iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records. iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure. 2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain. ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented. ”

    Source location

    Ryan Albert Frederick Merna · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 pass offensive-weapon disclosure information to the police

    Wider context from the report

    “1. During the inquest evidence was heard that: i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping. ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker. iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records. iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure. 2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain. ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented. ”

    Source location

    Ryan Albert Frederick Merna · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 investigate disclosures of possession of an offensive weapon

    Wider context from the report

    “1. During the inquest evidence was heard that: i. The members of the Dorset Forensic Team did not probe as to where the perpetrator was sleeping. ii. The disclosure made by the perpetrator that he was in possession of a knife was not probed further by the Social Worker. iii. The disclosure made by the perpetrator that he was in possession of a knife was not recorded contemporaneously in the perpetrator’s records. iv. The disclosure made by the perpetrator that he was in possession of a knife was not raised during a Care Programme Meeting held the day following the disclosure. 2. I have concerns with regard to the following: The Trust Clinical Risk Policy should make reference to the fact that i. The Trust should use its best endeavours to identify where a service user is living by reference to information to be sourced from the individual and from that which may be in the public domain. ii. Where there is disclosure that a service user is in possession of an offensive weapon this must be documented; there must be a documented discussion as to the response; the information must be passed to the police; any action taken by the Trust and/or the police to be documented. ”

    Source location

    Ryan Albert Frederick Merna · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner South London

    AI-generated summary

    Katrina Makunova · 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

    Katrina Makunova had experienced abuse, coercive and controlling behaviour, and threats before she was fatally pushed by her ex-boyfriend on 12 July 2018. The report identified concerns about knives and gang affiliation not being consistently recognised or recorded as risk factors, and about workload pressures affecting the capacity of police Child Safety Units to carry out safeguarding effectively and safely.

    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 consistently record knife possession

    Wider context from the report

    “Concern 1: Whilst significant steps have been taken to recognize contextual abuse by all the organizations since the death, there remains a concern. Police officers knew of the perpetrator’s wearing of a knife. Possession of a knife was not recognized in risk assessments and not always recorded by police, nor social services. It was also unclear from police evidence when gang affiliation should be explored and when it would be recognized as a risk. Those around Katrina, knew of her past and present association with gang members; yet this too never seems to have been investigated and identified by police as a risk factor. Evidence was heard from her brother and another witness that her fear of what harm the might do led her not to make a full disclosure of his controlling behaviour to the police. ”

    Source location

    Katrina Makunova · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 recognise knife possession in risk assessments

    Wider context from the report

    “Concern 1: Whilst significant steps have been taken to recognize contextual abuse by all the organizations since the death, there remains a concern. Police officers knew of the perpetrator’s wearing of a knife. Possession of a knife was not recognized in risk assessments and not always recorded by police, nor social services. It was also unclear from police evidence when gang affiliation should be explored and when it would be recognized as a risk. Those around Katrina, knew of her past and present association with gang members; yet this too never seems to have been investigated and identified by police as a risk factor. Evidence was heard from her brother and another witness that her fear of what harm the might do led her not to make a full disclosure of his controlling behaviour to the police. ”

    Source location

    Katrina Makunova · Prevention of Future Deaths report
    Page 2 · 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

    Engage relevant academics and support their research into considering knife carrying and gang membership in domestic-abuse risk assessment.

    Verbatim wording from the response

    “The MPS will engage positively with the relevant experts and assist where possible in any research undertaken by the academics. The MPS’ Lead Responsible Officer for Domestic Abuse will be writing proactively to both academics offering his support. If consideration is to be given to introducing a new category to the DASH risk assessment tool, then the College of Policing will need to be closely involved in these discussions.”

    Source location

    2021-0388-Response-from-Metropolitan-Police_Published
    Page 1 · response
    Published 19 November 2021

    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

    Any new DASH risk-assessment category requires the College of Policing to be closely involved.

    Verbatim wording from the response

    “The MPS will engage positively with the relevant experts and assist where possible in any research undertaken by the academics. The MPS’ Lead Responsible Officer for Domestic Abuse will be writing proactively to both academics offering his support. If consideration is to be given to introducing a new category to the DASH risk assessment tool, then the College of Policing will need to be closely involved in these discussions.”

    Source location

    2021-0388-Response-from-Metropolitan-Police_Published
    Page 1 · response
    Published 19 November 2021

    Open published response

  3. Inner North London

    AI-generated summary

    Jeroen ENSINK · 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

    Dr Jeroen Ensink was stabbed to death in a wholly unprovoked attack on 29 December 2015. The report identified multiple concerns involving police recording and information-sharing failures, including failures to identify and communicate possible mental health problems and issues in the handling of evidence and custody records.

    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 investigate a volunteered admission of hammer possession

    Wider context from the report

    “16. The interviewing officer was surprised when ████████ denied possession of a bladed article in a public place but volunteered possession of a hammer. As a consequence of his surprise, he asked very few questions about this and did not pursue it. ”

    Source location

    Jeroen ENSINK · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
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Data last updated 7 September 2026