Recurring concern

Unreliable sharing of safety-critical risk information between police, healthcare and probation services

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First reported 16 Apr 2015•Latest report 8 Apr 2026

Definition

What this concern includes

Includes failures in arrangements between police, healthcare and probation or closely connected custody functions to identify, record, transfer, access, clarify and acknowledge safety-critical risk information about people subject to care, supervision or public-protection arrangements.

Not included

Excludes generic communication, documentation or information-system deficiencies where no safety-critical risk-information-sharing condition is identified.
Excludes failures in clinical assessment, treatment, probation supervision or police response after relevant risk information has been reliably shared.
Excludes information sharing with families, courts or other recipients unless it directly forms part of the same police-healthcare-probation risk-information interface.
Excludes single-service risk records and named systems where cross-service sharing is not the deficient condition.

Reports: 14
Individual concerns: 14
Date range: 2015–2026
Stated actions: 34

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Justice5

HM Prison and Probation Service4

Department of Health and Social Care3

Home Office3

Metropolitan Police Service3

National Police Chiefs’ Council3

NHS England2

Probation Service2

Association of Police and Crime Commissioners1

Birmingham and Solihull Mental Health NHS Foundation Trust1

Central and North West London NHS Foundation Trust1

College of Policing1

Crown Prosecution Service1

Cumbria Constabulary1

Greater Manchester Combined Authority1

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.

17 Jun2019
South Yorkshire (Western)
Concerns raised1
1. Failure to share relevant information with the Probation Service after identifying details become available
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr John Gogarty · 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

Mr John Gogarty was unlawfully killed at his home on 13 July 2015 by two people who planned to steal money to pay a drug debt; he was stabbed 69 times. The report identified missed opportunities and inadequate monitoring by the Probation Service, including failures relating to licence breaches, drug testing and recall. It also identified a missed opportunity for information about an offender’s relationship with a female patient to be shared with the Probation Service.

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 share relevant information with the Probation Service after identifying details become available
Wider context from the report
“Your Trust was solely concerned with the care of ████████. During that care your patient was associating with who had a very considerable history and was under the supervision of the National Probation Service following a sentence for murder. Although original offers were made to contact the Probation Service to pass on information, these came to nothing because insufficient details about the male were known. However, within a relatively short time further information to identify this male became apparent but there was no further follow up with the Probation Service. No specific criticism is made of the member of staff involved at that time, it might very well be that many staff might have assumed that there was nothing to be gained. However, in reality, if the Probation Service had been aware of your patients background they would have at least had the opportunity to consider the conditions of the parole afresh, potentially putting in place further safeguards. It is respectfully suggested that the lesson here is that small pieces of information properly shared on an inter-agency basis might well add up to a bigger picture for other organisations. ”
Source location
Mr John Gogarty · Prevention of Future Deaths report
Page 3 · concerns
Open source report
12 Jun2019
Sunderland
Concerns raised1
1. Failure to share relevant police information with Probation
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Operate the MK-flag and MASH process to queue relevant offender-record changes, share information with NPS, and retain emails for audit.
  Stated by Northumbria PoliceStated completed
2. Action
  Update Category 2 Level 1 offender warning screens with instructions requiring officers to share risk-relevant information with the relevant probation area.
  Stated by Northumbria PoliceStated completed
3. Action
  Disseminate force-wide bulletins informing and reinforcing officers’ responsibility to share relevant information with NPS.
  Stated by Northumbria PoliceStated completed
1. Action
  Add newly notified Category 2 Level 1 offenders to Northumbria Police systems immediately upon notification from NPS.
  Stated by Northumbria PoliceStated planned
Respondent positions 2
1. Position
  Existing Northumbria Constabulary information-sharing steps are accepted by MAPPA and NPS representatives as a permanent solution at this time.
  Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
1. Position
  The agreed police and probation information-sharing process is considered definitive and sufficient, although it may evolve with future IT development.
  Stated by Northumbria PoliceExisting arrangements considered sufficient
AI-generated summary

Miss Nguyen Ngoc Quyen · 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

Miss Nguyen Ngoc Quyen died on 15 August 2017 at Success Road, Shiney Row, Houghton Le Spring; her death was consistent with the effects of fire. The report identified concerns about failures to act sufficiently, promptly and in a coordinated manner on known breaches of life licence conditions, including failures in information sharing between the Police and Probation Service, alongside wider organisational and supervision failings.

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 share relevant police information with Probation
Wider context from the report
“In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log. As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders. The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated, and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer. The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident. ”
Source location
Miss Nguyen Ngoc Quyen · 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
Operate the MK-flag and MASH process to queue relevant offender-record changes, share information with NPS, and retain emails for audit.

Verbatim wording from the response
“In December 2018 Northumbria Police devised a process to ensure compliance for the purpose of information/intelligence sharing on every record for a Category 2 (violent) Level 1 MAPPA offender.”

Source location
2019-0194-Response-by-Northumbria-Police
Page 2 · response
Published 15 August 2019
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
Update Category 2 Level 1 offender warning screens with instructions requiring officers to share risk-relevant information with the relevant probation area.

Verbatim wording from the response
“Included within the process implemented in December 2018 was that all Category 2 Level 1 offenders would also have an NPICCS warning marker updated with a new instruction on the IS record for that offender. This will highlight the requirement for any officer who is in possession of relevant information to inform the relevant probation area.”

Source location
2019-0194-Response-by-Northumbria-Police
Page 3 · response
Published 15 August 2019
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
Disseminate force-wide bulletins informing and reinforcing officers’ responsibility to share relevant information with NPS.

Verbatim wording from the response
“To ensure staff were aware of this change, a force wide bulletin was sent to officers and staff informing them of the process and that it was their responsibility to share any relevant information/intelligence with NPS.”

Source location
2019-0194-Response-by-Northumbria-Police
Page 3 · response
Published 15 August 2019
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
Add newly notified Category 2 Level 1 offenders to Northumbria Police systems immediately upon notification from NPS.

Verbatim wording from the response
“In relation to new Category 2 Level 1 offenders, when we receive notification from NPS to the MOSOVO Department, they will be added to Northumbria Police systems immediately.”

Source location
2019-0194-Response-by-Northumbria-Police
Page 3 · response
Published 15 August 2019
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
Existing Northumbria Constabulary information-sharing steps are accepted by MAPPA and NPS representatives as a permanent solution at this time.

Verbatim wording from the response
“The regulation 28 report acknowledges that some of the issues identified by the investigation into the death have already been addressed by Northumbria Constabulary. However, you raised concern that actions taken provided an interim rather than a permanent solution. By way of confirmation, I have set out below in an addendum to this response, the actions I am advised have been taken by Northumbria Constabulary and am able to confirm that these steps are acknowledged and accepted by the MAPPA representatives and Heads of Service in the NPS North East Division in both the North of Tyne and South of Tyne Local Delivery Units as being correct and a permanent solution at this time.”

Source location
2019-0194-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 15 August 2019
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 agreed police and probation information-sharing process is considered definitive and sufficient, although it may evolve with future IT development.

Verbatim wording from the response
“The final point in relation to the current process was your concern that the Police were of the view this was a permanent solution to this issue, whereas NPS were viewing it as an interim solution. This concern may have emerged because of the way the evidence came out at the inquest. We have contacted NPS with regards to the content of this letter and they confirm that they agree this process is definitive going forward. It may of course evolve in the future as IT systems are further developed and the two organisations co-operate to further improve the system but at present the system outlined above is agreed as the operating model going forward.”

Source location
2019-0194-Response-by-Northumbria-Police
Page 3 · response
Published 15 August 2019
Open published response
4 Jun2015
Cumbria
Concerns raised1
1. Failure to communicate significant risk information to ambulance and psychiatric staff
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Alice Anne McMeekin · 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

Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

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 communicate significant risk information to ambulance and psychiatric staff
Wider context from the report
“1.The Police The evidence revealed that on the 6th June 2013 the perpetrator made remarks to a member of the public to the effect that he “would not kill his mother”. This information was passed to the Officers who attended the area. Some 2 hours later the same officers attended a call about a man behaving strangely and covered in blood. An ambulance was called. The officers had not spoken to the original caller, who subsequently gave evidence that the remarks were that the perpetrator said he “would kill his mother”. “Common sense” told the officers that the person was one and the same and they did a welfare check on his mother. At no stage did they question the perpetrator about his originally reported remarks. Also, citing confidentiality they did not pass those remarks onto the Ambulance Team. This meant that when later seen by psychiatric nurse the latter was in ignorance of this significant statement. It is possible that had the nurse been aware this may have altered the outcome of the perpetrator’s initial assessment and how he was dealt with. ”
Source location
Alice Anne McMeekin · Prevention of Future Deaths report
Page 1 · concerns
Open source report
16 Apr2015
Manchester South
Concerns raised1
1. Failure to provide Appropriate Adults with relevant custody risk information
This report raised 27 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kesia Lena Mary Leatherbarrow · 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

Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

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 provide Appropriate Adults with relevant custody risk information
Wider context from the report
“She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS, nor that she had threatened to jump off a bridge on her release. ”
Source location
Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Page 7 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to share relevant information with the Probation Service after identifying details become available

Concerns raised1

Failure to share relevant police information with Probation

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to communicate significant risk information to ambulance and psychiatric staff

Concerns raised1

Failure to provide Appropriate Adults with relevant custody risk information

Actions described in response 4

Respondent positions 2