Recurring concern

Unreliable operation of the STORM emergency incident-management system

First to latest report 30 Jun 2016 — 28 Mar 2024

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
6

What this concern includes

Includes failures of the named STORM system and its dedicated operating controls, including staff rollout and competence, updating actions and developments, monitoring or alerting for unauthorised deferrals, and other system functions needed for reliable emergency incident command and control.

What is not included
  • Excludes generic staff training, record-keeping, management oversight or IT deficiencies where STORM is not the deficient system.
  • Excludes emergency call handling, ambulance dispatch, clinical treatment and other downstream processes unless the assertion directly concerns a STORM control.
  • Excludes failures of other incident-management or patient-safety systems without an explicit STORM connection.
  • Excludes failures to act on complete and current STORM information when the STORM system and its operating controls functioned reliably.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Suffolk

    AI-generated summary

    Ellen Ocean WOOLNOUGH · 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

    Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.

    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

    Incomplete and ineffective rollout of STORM training to staff

    Wider context from the report

    “i. STORM training continues to be rolled out, although the evidence from a number of witnesses questioned the effectiveness of the rollout in reaching all staff. ”

    Source location

    Ellen Ocean WOOLNOUGH · 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

    Review and refresh the Education Strategy, including the STORM training offer and any further Trust-wide rollout.

    Verbatim wording from the response

    “1. STORM© training continues to be rolled out, although the evidence from a number of witnesses questioned the effectiveness of the rollout in reaching all staff.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 1 · response
    Published 15 April 2024

    Open published response

  2. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Michaela Marie Haines · 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

    Michaela Marie Haines died on 23 December 2016 after police were dispatched to a report of a female hanging in the stairwell of flats at Tenby Mount, Tenby. The principal concern was that the STORM report was not updated with actions taken, creating uncertainty about whether enquiries had been completed and whether evidence had been preserved.

    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 keep the STORM report updated with actions taken and changing developments

    Wider context from the report

    “The STORM report had not been up-dated with actions taken. This caused uncertainty as to whether outstanding enquiries had been actioned or not. This may have resulted in evidence not being preserved. It could also result in work being duplicated with enquiries being made when they have already been undertaken. If the STORM report is to be used as an effective command and control document it is essential that it is updated in the light of changing developments. Training may be required to remind those using this vital work tool of the need to keep it up to date. ”

    Source location

    Michaela Marie Haines · Prevention of Future Deaths report
    Page 1 · 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

    Keep STORM logs open until investigations are complete or transfer enquiries to an alternative recording system.

    Verbatim wording from the response

    “recommendations were identified which are currently subject to implementation and include:”

    Source location

    2017-0415-Response
    Page 2 · response
    Published 27 February 2018

    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

    Record all raised actions numerically.

    Verbatim wording from the response

    “recommendations were identified which are currently subject to implementation and include:”

    Source location

    2017-0415-Response
    Page 2 · response
    Published 27 February 2018

    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 review found no suspicious circumstances or evidence of third-party involvement despite shortcomings in recording and managing the investigation.

    Verbatim wording from the response

    “Following the completion of the review I am firmly of the belief that there are no suspicious circumstances. The investigation concerning the events of the evening shows no evidence of third party involvement. However, it apparent that the recent separation from her boyfriend was causing Ms Haines some distress and I support your view that it was a cry for help which tragically resulted in her death.”

    Source location

    2017-0415-Response
    Page 1 · response
    Published 27 February 2018

    Open published response

  3. Warwickshire

    AI-generated summary

    Luisa Mendes · 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

    Luisa Mendes was pronounced deceased on 25 October 2012 after a catastrophic abdominal bleed caused by rupture of the spleen, following the deliberate application of force by a third party. The report raised concerns about incident categorisation, handover procedures between control-room staff, and the STORM computer system's handling of unauthorised deferrals. The inquest also identified errors or omissions involving the police response, handover process, deferral of the response, computer-screen configuration, and supervision of the control room.

    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

    Absence of a STORM computer system feature alerting management to unauthorised deferrals

    Wider context from the report

    “(3) The set up of the STORM computer system as it relates to deferrals. The basis for the concern is the absence of any feature on the STORM computer system which will alert management to the effect that an unauthorised deferral has been effected by a controller. ”

    Source location

    Luisa Mendes · 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

    Develop a STORM alert that automatically reactivates out-of-time priority incidents and notifies relevant staff to mitigate unauthorised deferrals.

    Verbatim wording from the response

    “There remains a difficulty with substantive technical adaptations to the STORM system as it is used by a large number of police forces and other emergency service providers. After discussions with the company who own the system, Sopra-Steria, we have identified a change to the system that we are seeking to introduce in the next few weeks that will provide some mitigation to the issue of unauthorised deferrals. This change is still under development and it is intended that it will provide an alert on all priority incidents out of time. It is recognised that this does not prevent irregular deferrals being made, however within the current restraints of the system, is considered the best change we can deliver.”

    Source location

    2016-0243-Response-by-Warwickshire-Police
    Page 3 · response
    Published 30 June 2016

    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

    Check deferred priority incidents for supervisor consent for a defined period and reinforce the prohibition on unauthorised deferrals.

    Verbatim wording from the response

    “The change will be in addition to the reinforcement of the policy in relation to deferrals and the commitment that for a given period, all deferred priority incidents should be subject to checks to ensure that they were deferred with the consent of a supervisor. This will also serve to reinforce the training that no priority incident should be deferred without the consent of a supervisor. It addresses the deferral issue because, if the incident in question has been deferred, either rightly or wrongly, the system will automatically re-activate it and then send the relevant alerts.”

    Source location

    2016-0243-Response-by-Warwickshire-Police
    Page 4 · response
    Published 30 June 2016

    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

    Build a new command-and-control platform incorporating inquest-related changes, including correct authority levels for deferring incidents.

    Verbatim wording from the response

    “Finally, Warwickshire Police and West Mercia Police are in the advanced stages of the procurement of a new Command and Control system. We are building the new platform with the suppliers, to our specifications, which will include the changes required as a result of the learning through the inquest. This will include the correct authority level around deferring incidents.”

    Source location

    2016-0243-Response-by-Warwickshire-Police
    Page 4 · response
    Published 30 June 2016

    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

    Substantive STORM adaptations are constrained by the shared system, so only the best feasible mitigation can be delivered.

    Verbatim wording from the response

    “3. The set up of the STORM computer system as it relates to deferrals. The basis for the concern is the absence of any feature on the STORM computer system which will alert management to the effect that an unauthorised deferral has been effected by a controller.”

    Source location

    2016-0243-Response-by-Warwickshire-Police
    Page 3 · response
    Published 30 June 2016

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026