Recurring concern

Unreliable police investigative evidence gathering

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First reported 29 May 2014•Latest report 13 Jan 2026

Definition

What this concern includes

Includes delayed achievement of best evidence, inadequate investigative questioning and failures to pursue material admissions or evidence in police investigations.

Not included

Clinical, employment, regulatory or coronial evidence gathering
Police dispatch or emergency-response failures
Investigation-review failures that do not affect evidence gathering

Reports: 10
Individual concerns: 16
Date range: 2014–2026
Stated actions: 20

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.

Metropolitan Police Service2

Cambridgeshire Constabulary1

College of Policing1

Department for Education1

Department of Health and Social Care1

Devon & Cornwall Police1

Essex Police1

Greater Manchester Police1

Health and Safety Executive1

Home Office1

Humberside Police1

Independent Office for Police Conduct1

Mid and West Wales Fire and Rescue Service1

Ministry of Justice1

National Crime Agency1

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.

13 Jan2026
Northamptonshire
Concerns raised1
1. Failure to investigate suspected tablet-supply activity referred by another police force
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

Heidi Audrey Diana WILLIAMS · 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

Heidi Williams died at her home on 14 December 2024, and the stated cause of death was opioid and bromazolam toxicity. A review of her mobile phone indicated that she had been ordering tablets from a number linked to banking details and a suspect in Essex. Northamptonshire Police asked Essex Police to investigate, but the report states that Essex Police had refused to do so at that time; the investigation and inquest had not concluded.

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 suspected tablet-supply activity referred by another police force
Wider context from the report
“A review of her mobile phone showed that she was ordering a large number of tablets from a mobile number which also supplied banking details. These details resolved back to a suspect ████████ with two addresses linking back to him within the Essex area. This gentleman also has two addresses known on PNC within the Essex area. Northamptonshire Police have been in correspondence with Essex Police asking that Essex Police look into this matter. At the present time Essex police have refused so to do. ”
Source location
Heidi Audrey Diana WILLIAMS · Prevention of Future Deaths report
Page 1 · concerns
Open source report
25 Nov2025
Cambridgeshire and Peterborough
Concerns raised1
1. Failure to seize and retain relevant scene samples and evidence for later investigation
This report raised 7 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 3
1. Action
  Establish SOCO liaison and incorporate assessment and seizure of potentially evidential biological samples into child-death forensic strategies.
  Stated by Cambridgeshire ConstabularyStated completed
2. Action
  Amend, reissue and widely circulate procedural guidance and aide-memoires for child-death investigations, covering evidence preservation, medical liaison and anaphylaxis considerations.
  Stated by Cambridgeshire ConstabularyStated completed
3. Action
  Include revised child-death investigation processes in ongoing training cycles for frontline and investigative staff.
  Stated by Cambridgeshire ConstabularyStated completed
AI-generated summary

Benedict BLYTHE · 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

Benedict died at Peterborough City Hospital on 1 December 2021, aged 5, from fatal anaphylaxis following accidental exposure to cow’s milk protein. The report identifies concerns about the retention and testing of samples, including blood and stomach contents, and the police seizure and retention of relevant evidence such as vomitus during investigations of unexplained deaths.

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 seize and retain relevant scene samples and evidence for later investigation
Wider context from the report
“1) In relation to Pathology That Kennedy samples collected during a post-mortem examination, should be revised to include the following in cases of suspected anaphylaxis: a. blood samples for mast cell tryptase and sp IgE serology 2 suspected allergens b. stomach contents to be immediately stored (and/or frozen) by the pathologist for the analysis of the presence of the triggering allergen c. blood samples if taken at hospital should not be destroyed but retained for testing d. that an early blood sample is taken after death and stored for later analysis e. that the possibility that the death is due to anaphylaxis is raised with the senior coroner for the area where the death occurred at the earliest opportunity f. tissue samples are taken and retained. g. Consideration given to the development of a standard protocol to ensure appropriate samples are taken at the correct time to assist later investigation. 2.) The police investigation: In the circumstances where there is an unexplained death of a child or the person and where that data samples and evidence available at the scene including by way of example vomitus, that the police should include as part of their investigation, the seizure and retention of any such material for the purposes of later investigation either by the Police Pathologist or the Coroner. ”
Source location
Benedict BLYTHE · 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
Establish SOCO liaison and incorporate assessment and seizure of potentially evidential biological samples into child-death forensic strategies.

Verbatim wording from the response
“First, full liaison with Scenes of Crime Officers (SOCOs) has been established to ensure that, in all cases of unexplained child death, the potential evidential value of samples found at the scene—such as vomitus or other biological material—is actively recognised and considered. SOCOs have been formally briefed, and the need to assess and seize such samples is now incorporated into the forensic strategy in consultation with the Senior Investigating Officer. This ensures that opportunities to preserve material for the Coroner, the Pathologist, or investigators are not missed.”

Source location
Response form Cambridgeshire Constabulary
Page 1 · response
Published 2 December 2025
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
Amend, reissue and widely circulate procedural guidance and aide-memoires for child-death investigations, covering evidence preservation, medical liaison and anaphylaxis considerations.

Verbatim wording from the response
“Second, the Constabulary has amended and re-issued internal procedural guidance and aide-memoire materials relating to child death investigations. These documents have been circulated widely to all officers and staff who may attend such incidents,”

Source location
Response form Cambridgeshire Constabulary
Page 1 · response
Published 2 December 2025
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
Include revised child-death investigation processes in ongoing training cycles for frontline and investigative staff.

Verbatim wording from the response
“Finally, the revised processes are now included within ongoing training cycles for child death investigations, meaning all staff involved in frontline or investigative roles will receive regular reinforcement of expectations and good practice standards. This training emphasises the forensic, investigative, and safeguarding considerations required in early decision-making, helping ensure that opportunities to understand cause of death are preserved and that future investigations are informed by best practice.”

Source location
Response form Cambridgeshire Constabulary
Page 2 · response
Published 2 December 2025
Open published response
17 Sep2025
Swansea and Neath Port Talbot
Concerns raised2
1. Absence of a Police-HSE memorandum of understanding or protocol for domestic explosion evidence requirements
2. Lack of understanding of evidence requiring preservation during domestic explosion investigations
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.
Actions described in response 3
1. Action
  Raise the identified investigation concerns with the National Liaison Committee for consideration in the Protocol review.
  Stated by South Wales PoliceStated planned
2. Action
  Develop a proposed Suspected Gas Explosion checklist for consideration alongside the existing Carbon Monoxide checklist.
  Stated by Health and Safety ExecutiveStated in progress
3. Action
  Prepare national training material on work-related aspects of investigations, including advice for first responders.
  Stated by Health and Safety ExecutiveStated in progress
Respondent positions 3
1. Position
  The National Liaison Committee is responsible for deciding and implementing any appropriate amendments to the Protocols.
  Stated by South Wales PoliceRedirects responsibility
1. Position
  The existing Work Related Death Protocol is considered fit for purpose and addresses evidence preservation, investigation coordination and information-sharing concerns.
  Stated by Health and Safety ExecutiveExisting arrangements considered sufficient
2. Position
  The National Liaison Committee owns the protocol and must agree proposed updates, including a suspected gas explosion checklist.
  Stated by Health and Safety ExecutiveRedirects responsibility
AI-generated summary

Brian Lyn Davies · 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

Brian Lyn Davies was pronounced dead at his home on 13 March 2023 after sustaining chest and neck injuries in an explosion. The cause of the explosion could not be determined because material evidence was not preserved during the search and rescue and clean-up operations, and concerns were raised about the lack of guidance or a protocol between the Police and the HSE on preserving evidence from domestic explosions.

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 Police-HSE memorandum of understanding or protocol for domestic explosion evidence requirements
Wider context from the report
“During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion may not be secured and as such was disposed of without an exercise to determine its significance to the investigation. The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation. It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events. I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence. 1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion; 2. There was no order given to secure such evidence; 3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation ”
Source location
Brian Lyn Davies · 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
Lack of understanding of evidence requiring preservation during domestic explosion investigations
Wider context from the report
“During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion may not be secured and as such was disposed of without an exercise to determine its significance to the investigation. The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation. It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events. I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence. 1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion; 2. There was no order given to secure such evidence; 3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation ”
Source location
Brian Lyn Davies · 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
Raise the identified investigation concerns with the National Liaison Committee for consideration in the Protocol review.

Verbatim wording from the response
“In this respect, South Wales Police will take steps to raise your concerns with the National Liaison Committee in order that due regard may be had to such a possibility in the future, so that any amendments which are considered appropriate, may be made to the Protocol.”

Source location
Response from South Wales Police
Page 4 · response
Published 19 December 2025
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
Develop a proposed Suspected Gas Explosion checklist for consideration alongside the existing Carbon Monoxide checklist.

Verbatim wording from the response
“• Provide an update to the NLC on other HSE on-going work to develop a proposed ‘Suspected Gas Explosion checklist’, to sit alongside the current ‘Carbon Monoxide checklist’ within Appendix 1 of the WRDP Practical Guide – ‘Additional duties of first officer – Domestic Gas Incidents’. This would be for the NLC to agree and update the guide.”

Source location
Response from HSE
Page 3 · response
Published 19 December 2025
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
Prepare national training material on work-related aspects of investigations, including advice for first responders.

Verbatim wording from the response
“• Provide an update to the NLC regarding work HSE has been doing in preparing national training material focussing on the work related elements of such investigations for those responding to incidents including more specific advice for those first on scene. This will in due course be put to the NLC for consideration and endorsement;”

Source location
Response from HSE
Page 3 · response
Published 19 December 2025
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 National Liaison Committee is responsible for deciding and implementing any appropriate amendments to the Protocols.

Verbatim wording from the response
“As would be expected, the Protocols contains provisions and guidance which provide full or partial answers to the issues you have raised. However, it remains important that the Protocols are reviewed and refreshed as appropriate. In this regard, it is significant that Detective Superintendent ████████ ████████ from South Wales Police attended the National Work Related Death Liaison Committee on 17 November 2025 which is the national multi agency meeting that oversees the Protocol and linked matters. At that meeting the Protocols, were discussed as it was universally agreed that these documents need to be updated. The motion to give effect to the same was carried, and the National Liaison Committee has committed to undertaking a review and update as appropriate.”

Source location
Response from South Wales Police
Page 3 · response
Published 19 December 2025
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 existing Work Related Death Protocol is considered fit for purpose and addresses evidence preservation, investigation coordination and information-sharing concerns.

Verbatim wording from the response
“In relation to the specific ‘Matters of Concern’ raised in your letter, it is HSE’s opinion that the Work Related Death Protocol (WRDP) addresses your points. I have responded to each of those points individually with excerpts from the protocol below.”

Source location
Response from HSE
Page 2 · response
Published 19 December 2025
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 National Liaison Committee owns the protocol and must agree proposed updates, including a suspected gas explosion checklist.

Verbatim wording from the response
“The purpose of the protocol and supporting (practical) guide is to ensure effective joint investigation of work-related deaths in England and Wales. The WRDP National Liaison Committee (NLC), ‘owns’ the protocol and HSE sits on the committee alongside the other signatories.”

Source location
Response from HSE
Page 1 · response
Published 19 December 2025
Open published response
22 Nov2024
Swansea and Neath Port Talbot
Concerns raised1
1. Failure to preserve fire scenes until all instructed investigations are completed
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.
Respondent positions 3
1. Position
  The Welsh Government has no control over operational scene and inter-service matters and cannot take action addressing them.
  Stated by Welsh GovernmentOutside remit
1. Position
  Operational matters concerning scene items and inter-service working are for South Wales Police and Mid and West Wales Fire and Rescue Service.
  Stated by Welsh GovernmentRedirects responsibility
2. Position
  Police retain responsibility for scene management and decisions to remove or seize items in fatality or suspected-criminality fire investigations.
  Stated by Mid and West Wales Fire and Rescue ServiceRedirects responsibility
AI-generated summary

Muhammad Esmael and Naemat Esmael · 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

On 1 July 2023, a fire started in an upstairs bedroom of a Council-leased property while three-year-old Muhammad Esmael was inside; Muhammad and his father, Naemat Esmael, died in the fire. The concerns included that the two working smoke alarms were not activated by the fire because it was contained in a closed bedroom, and that bedroom items were removed before all investigations were completed, potentially preventing the cause of the fire from being determined.

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 preserve fire scenes until all instructed investigations are completed
Wider context from the report
“I heard that certain items within the bedroom where the fire started, including a console unit and electrical items, were removed before they could be fully inspected in situ by the Chartered Electrical Engineer instructed to investigate the cause of the fire. I am told that the items were removed by the Crime Scene Investigators from South Wales Police in circumstances where the Fire Service had exercised its powers under section 45 of the Fire and Rescue Services Act 2004 and had commenced an investigation which was aimed at determining the point of origin, cause and behaviour of the fire at ████████. The Chartered Electrical Engineer expert told me that he was unable to provide me with any assistance on the cause of the fire because the items had been removed from the scene and because he had only been able to view photographs. It was this Expert’s opinion that it would have been preferable if the items had remained in position at the property to enable him to inspect them in situ. I am concerned that items were removed from the scene before all inspections were completed and that this may have prevented me and indeed the Fire Service investigators from determining the cause of this fire. I am concerned either that there may not be a sufficiently robust protocol in place between South Wales Police and the Fire Service on preserving a scene to ensure a full investigation takes place and / or that if there is such a protocol it may not have been followed in this instance. If coroners and investigators are unable to determine the cause of a fire because the scene has not been preserved for as long as required to ensure a full in situ investigation by all instructed investigators, then this prevents lessons from being learnt about the cause of a fire which in turn means there is a continuing risk to life. ”
Source location
Muhammad Esmael and Naemat Esmael · Prevention of Future Deaths report
Page 4 · concerns
Open source report
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 Welsh Government has no control over operational scene and inter-service matters and cannot take action addressing them.

Verbatim wording from the response
“I am responding in relation to the first Matter of Concern raised in your Report, regarding the provision of smoke alarms within rented accommodation. The second Matter of Concern relates to the possible removal by South Wales Police (SWP) of relevant items from the scene of the fire, and to the working relationship between SWP and Mid and West Wales Fire and Rescue Service (MWWFRS). Those are operational matters for SWP and MWWFRS over which the Welsh Government has no control; as such there is no action we can take which would address this concern. However, I note your Report has also been issued to the Head of Mid and West Wales Fire and Rescue Service and I understand that he will respond on that Matter.”

Source location
Response from Welsh Government
Page 1 · response
Published 26 November 2024
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
Operational matters concerning scene items and inter-service working are for South Wales Police and Mid and West Wales Fire and Rescue Service.

Verbatim wording from the response
“I am responding in relation to the first Matter of Concern raised in your Report, regarding the provision of smoke alarms within rented accommodation. The second Matter of Concern relates to the possible removal by South Wales Police (SWP) of relevant items from the scene of the fire, and to the working relationship between SWP and Mid and West Wales Fire and Rescue Service (MWWFRS). Those are operational matters for SWP and MWWFRS over which the Welsh Government has no control; as such there is no action we can take which would address this concern. However, I note your Report has also been issued to the Head of Mid and West Wales Fire and Rescue Service and I understand that he will respond on that Matter.”

Source location
Response from Welsh Government
Page 1 · response
Published 26 November 2024
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
Police retain responsibility for scene management and decisions to remove or seize items in fatality or suspected-criminality fire investigations.

Verbatim wording from the response
“With regard to the second MATTER OF CONCERN. In fire cases involving fatalities or suspected criminality, the Police are the lead agency with primacy over the investigation. For incidents within its area, Mid & West Wales Fire and Rescue Service will often support the Police with their investigation alongside Crime Scene Investigators and forensic scientists commissioned by the Police, as in this case. A decision to remove items for laboratory testing is undertaken by the Senior Police Officer and any evidence subsequently seized is done under the authority offered by the Police and Criminal Evidence Act (PACE).”

Source location
Response from Mid and West Wales Fire and Rescue Service
Page 2 · response
Published 26 November 2024
Open published response
19 Jan2024
East Riding and Hull
Concerns raised1
1. Failure to preserve time-sensitive CCTV evidence relevant to suspect identification
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.
Actions described in response 2
1. Action
  Refresh fast-track actions and Golden Hour Principles through continuing professional development for patrol constables and sergeants.
  Stated by Humberside PoliceStated in progress
2. Action
  Review the sudden and unexpected death policy and amend it to address drug-related deaths and recordable drug deliveries.
  Stated by Humberside PoliceStated in progress
AI-generated summary

William Steven Helstrip · 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

William Steven Helstrip, aged 18, was found deceased on 26 May 2022 after taking various drugs sourced from the internet, which led to cardiorespiratory depression and death. His parents reported that the drugs had been bought on the Dark Web and sent by recorded delivery, but the initial police investigation concluded that there were no suspicious circumstances or third-party involvement. A later investigation was compromised because time-sensitive CCTV footage had been irretrievably lost, affecting the identification of the suspect.

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 preserve time-sensitive CCTV evidence relevant to suspect identification
Wider context from the report
“The Deceased’s parents informed the attending police officer that Mr Helstrip had been buying drugs from the “Dark Web” and that packages containing these drugs had been sent, recorded delivery, via Royal Mail to his premises. Despite this, the police investigation concluded that there were no suspicious circumstances or third-party involvement surrounding Mr Helstrip’s death and hence no criminal investigation took place. This was based on the attending officer’s impression, which did not appear to take into consideration the information about the sourcing and method of delivery of the drugs. Subsequently, Mr Helstrip’s parents contacted the then Chief Constable of Humberside Police, in 2023 informing him of their concerns about the lack of investigation on the part of the police. A senior investigating officer was then allocated to the case, who looked at the issue of illicit drugs being sent via Royal Mail, by recorded delivery, to see whether the vendor of these substances could be identified and help police with their inquiries. Evidence was heard from this detective, that whilst the investigation is still on-going, time sensitive evidence in the form of CCTV footage from the post office from whence the package was sent, is irretrievably lost, and that this has compromised the identification of the suspect. ”
Source location
William Steven Helstrip · 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
Refresh fast-track actions and Golden Hour Principles through continuing professional development for patrol constables and sergeants.

Verbatim wording from the response
“2. Fast-track actions and Golden Hour Principles to be refreshed during CPD sessions for Patrol PC’s and Sergeants. Officers need to be directed to conduct critical enquiries at the point of first attendance and not wait for a formal request to prevent evidence loss.”

Source location
Response from Humberside Police
Page 2 · response
Published 25 January 2024
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
Review the sudden and unexpected death policy and amend it to address drug-related deaths and recordable drug deliveries.

Verbatim wording from the response
“3. Review of sudden and unexpected death policy – with an amendment regarding drug related deaths and advice given to follow lines of enquiry where a drug is believed to have been posted through a recordable means.”

Source location
Response from Humberside Police
Page 2 · response
Published 25 January 2024
Open published response
16 May2023
Cornwall and Isles of Scilly
Concerns raised1
1. Delays of over a month in obtaining best evidence through video interview or otherwise
This report raised 5 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 1
1. Action
  Prepare a business case considering an uplift in sexual offences liaison officers to improve timely access to specialist victim interviews.
  Stated by Devon & Cornwall PoliceStated in progress
Respondent positions 1
1. Position
  Some delays in obtaining victim video-interview accounts arise from factors outside police control.
  Stated by Devon & Cornwall PoliceUnable to act
AI-generated summary

Tamsin Ann Dolamore · 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

Tamsin Ann Dolamore died aged 24 after falling from a railway bridge onto railway lines on 8 January 2018; the inquest recorded an Open Conclusion and the medical cause of death as effects of multiple injuries. The substantive concerns included delays in appointing a Sexual Offence Liaison Officer, delays and gaps in mental-health and support services, and insufficient police resources causing delays in progressing rape and serious sexual assault complaints.

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
Delays of over a month in obtaining best evidence through video interview or otherwise
Wider context from the report
“I was informed by ████████ that as of January this year, there were 600 open cases of rape or serious sexual assault. I was told additionally that there are over 20 vacancies for DCs to progress these complaints. One consequence was that it was taking over a month to achieve best evidence through video interview or otherwise. ████████ agreed that the lack of available DCs meant that both the quality and amount of work that could be done were affected. ”
Source location
Tamsin Ann Dolamore · 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
Prepare a business case considering an uplift in sexual offences liaison officers to improve timely access to specialist victim interviews.

Verbatim wording from the response
“Cornwall currently has 9 sexual offences liaison officers (SOLO) who perform the majority of the specialist video interview role (ABE). DC’s can also complete ABE interviews however they generally rely upon the SOLO for this support. It would be a fair assumption that if there were no DC vacancies then we may be able to use the additional capacity to assist with the ABE backlog. There are no SOLO vacancies, however we are currently preparing a business case to consider an uplift of SOLOs as we are aware of the good practice findings of the national Op Soteria Bluestone project which evidences the value of obtaining early victim accounts by correctly trained staff. The delay in obtaining an ABE account can be due to a number of factors, some of which are outside Police control.”

Source location
Response from Dorset Police
Page 2 · response
Published 19 May 2023
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
Some delays in obtaining victim video-interview accounts arise from factors outside police control.

Verbatim wording from the response
“Cornwall currently has 9 sexual offences liaison officers (SOLO) who perform the majority of the specialist video interview role (ABE). DC’s can also complete ABE interviews however they generally rely upon the SOLO for this support. It would be a fair assumption that if there were no DC vacancies then we may be able to use the additional capacity to assist with the ABE backlog. There are no SOLO vacancies, however we are currently preparing a business case to consider an uplift of SOLOs as we are aware of the good practice findings of the national Op Soteria Bluestone project which evidences the value of obtaining early victim accounts by correctly trained staff. The delay in obtaining an ABE account can be due to a number of factors, some of which are outside Police control.”

Source location
Response from Dorset Police
Page 2 · response
Published 19 May 2023
Open published response
19 Nov2019
Manchester South
Concerns raised3
1. Failure to establish available recordings and the scope of relevant social media evidence before case closure
2. Failure to conduct a further face-to-face conversation with the child
3. Delays in seizing key digital evidence
This report raised 12 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

Katie Croft · 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

Katie Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.

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 establish available recordings and the scope of relevant social media evidence before case closure
Wider context from the report
“1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie; ”
Source location
Katie Croft · 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 conduct a further face-to-face conversation with the child
Wider context from the report
“1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie; ”
Source location
Katie Croft · 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
Delays in seizing key digital evidence
Wider context from the report
“1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie; ”
Source location
Katie Croft · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Jul2018
Inner North London
Concerns raised2
1. Failure to obtain statements from available witnesses
2. Failure to investigate a volunteered admission of hammer possession
This report raised 17 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

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 obtain statements from available witnesses
Wider context from the report
“3. Only one statement was taken, though there were other witnesses on scene. ”
Source location
Jeroen ENSINK · 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 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
7 Aug2015
Manchester South
Concerns raised2
1. Failure to take fingerprints at the crime scene
2. Failure to investigate unexplained blood without relying on an unsupported assumption
This report raised 6 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

Ronald Arthur Laidlar · 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

Ronald Arthur Laidlar was discovered deceased in the driveway of his house, naked from the waist down and with a considerable amount of blood around his head. The report raised concerns about missing personal property, inadequate searches and scene investigation, failure to test blood evidence or take fingerprints, and insufficient consideration of possible third-party involvement.

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 take fingerprints at the crime scene
Wider context from the report
“7. No fingerprints were taken at the scene. ”
Source location
Ronald Arthur Laidlar · Prevention of Future Deaths report
Page 1 · 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 unexplained blood without relying on an unsupported assumption
Wider context from the report
“5. The officer confirmed that they (the police) were told the deceased suffered from frequent nosebleeds and therefore assumed this accounted for the blood. The consultant pathologist confirmed there was no sign of any blood in or around the nose or mouth. There was again a lack of “curiosity” on the part of the officers. ”
Source location
Ronald Arthur Laidlar · Prevention of Future Deaths report
Page 1 · concerns
Open source report
29 May2014
London (North)
Concerns raised2
1. Failure to video record fatal police shooting scenes
2. Failure to obtain prompt comprehensive statements from all police witnesses to fatal shootings
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 11
1. Action
  Consider including scene video recording requirements in the statutory guidance.
  Stated by Independent Office for Police ConductStated planned
2. Action
  Consider how to reflect earliest-possible scene video recording in College of Policing APP post-incident procedures.
  Stated by National Police Chiefs’ CouncilStated planned
3. Action
  Conduct a feasibility study on assigning an operations team officer to record pre-planned shooting scenes until specialist investigators or support services arrive.
  Stated by Metropolitan Police ServiceStated in progress
1. Action
  Issue draft statutory guidance on obtaining best evidence in death or serious injury matters for consultation.
  Stated by Independent Office for Police ConductStated completed
2. Action
  Review consultation responses and produce a revised statutory guidance document for submission to the Secretary of State.
  Stated by Independent Office for Police ConductStated in progress
3. Action
  Review post-incident procedures in light of issues arising from Mark Duggan’s death.
  Stated by National Police Chiefs’ CouncilStated in progress
4. Action
  Ensure a senior officer is present while officers prepare initial accounts after a death or serious injury incident.
  Stated by National Police Chiefs’ CouncilStated completed
5. Action
  Commission an expert review of research underpinning delayed formal accounts after traumatic firearms incidents.
  Stated by National Police Chiefs’ CouncilStated completed
6. Action
  Revise the APP to restrict staff association representatives’ pre-account intervention to welfare considerations, working with the College of Policing.
  Stated by National Police Chiefs’ CouncilStated planned
7. Action
  Require a senior officer to attend the Post Incident Management suite while officers produce statements, ensuring accounts contain sufficient detail.
  Stated by Metropolitan Police ServiceStated completed
8. Action
  Work with law firms representing firearms officers to clarify expectations for detailed post-incident accounts.
  Stated by Metropolitan Police ServiceStated in progress
Respondent positions 7
1. Position
  The IPCC, through its senior investigating officer, holds ultimate responsibility for recording the scene of a fatal police shooting.
  Stated by Metropolitan Police ServiceRedirects responsibility
1. Position
  Firearms officers’ priorities of saving life, protecting the public and securing the scene were treated as limiting the feasibility of comprehensively recording every aspect.
  Stated by Metropolitan Police ServiceExisting arrangements considered sufficient
2. Position
  Firearms officers should not be responsible for recording post-incident scene preservation; responsibility should fall to investigators or an assigned operations team officer.
  Stated by Metropolitan Police ServiceRedirects responsibility
3. Position
  Further comment on police witness accounts was deferred because statutory guidance had not been finalised and consultation responses were still under review.
  Stated by Independent Office for Police ConductUnable to act
4. Position
  The existing APP’s flexible, balanced approach is considered sufficient; wholesale separation of officers is not supported as fit for purpose.
  Stated by National Police Chiefs’ CouncilExisting arrangements considered sufficient
5. Position
  Separating officers may be operationally, logistically and practically impractical, particularly where numerous witnesses and operational imperatives are involved.
  Stated by National Police Chiefs’ CouncilUnable to act
6. Position
  Taking full statements immediately from officers affected by shock, distress or extreme fatigue was considered counterproductive and of limited forensic value.
  Stated by Metropolitan Police ServiceUnable to act
AI-generated summary

Mark Duggan · 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

On 4 August 2011, Mark Duggan was shot by an armed police officer during an enforced vehicle stop in London and was pronounced dead at the scene. The report raises concerns about intelligence sharing and operational decisions before the shooting, the investigation and preservation of evidence at the scene, the recording of the operation, and the coordination and access to intelligence during the investigation and inquest.

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 video record fatal police shooting scenes
Wider context from the report
“Concern 4: The scene of the fatal police shooting was not video recorded I believe that it is important to minimise distrust in the police in connection with fatal shootings, as that distrust can then permeate the entire investigation which follows and may mean that civilian witnesses will not come forward. That plainly has the capacity to prevent lessons being learned which could prevent deaths in the future. This concern is addressed to the MPS, the IPCC and ACPO. ”
Source location
Mark Duggan · Prevention of Future Deaths report
Page 28 · 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 obtain prompt comprehensive statements from all police witnesses to fatal shootings
Wider context from the report
“Concern 2: Comprehensive accounts were not taken from police witnesses at the first possible opportunity I am concerned that fatal police shootings are not as rigorously examined as they could be and that doubts about the accuracy of police accounts are not minimised. Lessons learned after a death should be as complete as possible. My concern is that not all witnesses to a fatal shooting are asked to give full statements as soon as possible after the event, giving a detailed account of what they saw. I am also concerned about whether there is any purpose in seeking to distinguish between “principal officers” and other police officers save that, where there is any reason to caution an officer, then of course that must be done. I am concerned that witnesses who perceived a threat from the person who was shot did not set that out in their statements. I therefore invite ACPO and the MPS to deal with what I have said when they respond to the IPCC consultation. ”
Source location
Mark Duggan · Prevention of Future Deaths report
Page 22 · 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
Consider including scene video recording requirements in the statutory guidance.

Verbatim wording from the response
“21. The IPCC can see the benefit of early video recording a scene as part of the process of evidencing where items have been found. Therefore, the IPCC will be considering whether reference to video recording scenes should be included in the statutory guidance. The IPCC anticipates being able to submit finalised statutory guidance to the Secretary of State for her approval by the end of March 2015.”

Source location
2014-0182-Response-by-IPPC
Page 7 · response
Published 29 May 2014
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
Consider how to reflect earliest-possible scene video recording in College of Policing APP post-incident procedures.

Verbatim wording from the response
“The National Policing portfolios concur with your view that is important to minimise distrust in the police in connection with fatal shootings, and notwithstanding any development over the use of body worn video (BWV), will consider how best to reflect changes in the College of Policing’s APP on post incident procedures to ensure standard operational procedures encompass the benefits of the earliest possible commencement of the video recording of scenes, subject of course to ongoing operational imperatives to protect public and individual safety and to continue to mitigate any risk of harm.”

Source location
2014-0182-Response-by-ACPO
Page 12 · response
Published 29 May 2014
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
Conduct a feasibility study on assigning an operations team officer to record pre-planned shooting scenes until specialist investigators or support services arrive.

Verbatim wording from the response
“Another option that is currently being explored by the MPS in the case of pre-planned operations is to assign this role to an operations team officer. This officer’s primary responsibility would be to record the scene in the event of a police shooting until such time that either a police helicopter (if available or able to deploy), independent investigators (DPS/IPCC) or any specialist support services deployed by them (for example, Crime Scene Managers or the Computer Aided Modelling Bureau - see below) arrive on scene. A feasibility study is currently being conducted to ensure that any issues associated with this option can be considered.”

Source location
2014-0182-Response-by-Metropolitan-Police-Service
Page 7 · response
Published 29 May 2014
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
Issue draft statutory guidance on obtaining best evidence in death or serious injury matters for consultation.

Verbatim wording from the response
“7. The Coroner makes reference to the IPCC consultation on post incident procedures. On 5 March 2014 the IPCC issued for consultation draft statutory guidance to the police service on achieving best evidence in death or serious injury matters (the draft statutory guidance is enclosed with this response). Paragraphs 21–24 of the draft statutory guidance set out the IPCC’s preliminary position on acquiring ‘detailed individual factual accounts’ and addresses a number of the concerns raised by the Coroner in his Report.”

Source location
2014-0182-Response-by-IPPC
Page 3 · response
Published 29 May 2014
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
Review consultation responses and produce a revised statutory guidance document for submission to the Secretary of State.

Verbatim wording from the response
“8. The consultation period for the draft statutory guidance closed on 27 May 2014 and the IPCC is reviewing the many consultation responses received. The IPCC will then, taking account of the consultation responses, produce a revised document that will require the approval of the Secretary of State before being issued. Police officers will then be under a duty to have regard to”

Source location
2014-0182-Response-by-IPPC
Page 3 · response
Published 29 May 2014
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
Review post-incident procedures in light of issues arising from Mark Duggan’s death.

Verbatim wording from the response
“The National Policing portfolios are currently undertaking a further review of these procedures, in part at least as a direct result of the issues arising from the death of Mark Duggan. We have already taken steps to ensure that as part of immediate post incident procedures, a senior officer is present when officers are preparing initial accounts. This senior officer will be in a position to confirm and reassure that either conferring did not take place or, if it did, it was for a necessary purpose as provided by the APP, which sets out in clear terms that an officer should not confer about any honestly held belief relating to the use of force. In addition, we have made clear the post incident process can and should be more transparent to both a host force’s initial investigating officers and to the IPCC’s investigators.”

Source location
2014-0182-Response-by-ACPO
Page 3 · response
Published 29 May 2014
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
Ensure a senior officer is present while officers prepare initial accounts after a death or serious injury incident.

Verbatim wording from the response
“The National Policing portfolios are currently undertaking a further review of these procedures, in part at least as a direct result of the issues arising from the death of Mark Duggan. We have already taken steps to ensure that as part of immediate post incident procedures, a senior officer is present when officers are preparing initial accounts. This senior officer will be in a position to confirm and reassure that either conferring did not take place or, if it did, it was for a necessary purpose as provided by the APP, which sets out in clear terms that an officer should not confer about any honestly held belief relating to the use of force. In addition, we have made clear the post incident process can and should be more transparent to both a host force’s initial investigating officers and to the IPCC’s investigators.”

Source location
2014-0182-Response-by-ACPO
Page 3 · response
Published 29 May 2014
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
Commission an expert review of research underpinning delayed formal accounts after traumatic firearms incidents.

Verbatim wording from the response
“In paragraph 66 you make specific reference to the apparent inconsistencies in findings between earlier Home Office Study Papers (which lends some support to the practice of allowing a period between a traumatic event and a statement being given) and a more recent paper by Dr William Lewinski. As part of the National Policing response to the earlier IPCC consultation, we recently commissioned Professor Gudjonsson, Emeritus Professor of Forensic Psychology at King’s College, London to conduct a review of the conclusions of Home Office Study Papers of 1986 and 1993, taking into account subsequent relevant studies.”

Source location
2014-0182-Response-by-ACPO
Page 6 · response
Published 29 May 2014
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
Revise the APP to restrict staff association representatives’ pre-account intervention to welfare considerations, working with the College of Policing.

Verbatim wording from the response
“Many police forces in England and Wales quite properly and responsibly ensure staff association representatives receive accredited training in post incident management. Whilst such representative play a crucial part in these post incident procedures under the direction and control of the post incident manager, it is equally important that such representatives do not duplicate or intrude into the provision of legal advice.”

Source location
2014-0182-Response-by-ACPO
Page 9 · response
Published 29 May 2014
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
Require a senior officer to attend the Post Incident Management suite while officers produce statements, ensuring accounts contain sufficient detail.

Verbatim wording from the response
“The MPS understands the need to prevent any perception that the systems employed lack integrity. The MPS can and does in striving to achieve best practice adopt and implement procedures which go beyond but are consistent with national practice and guidance. Thus, for example, a senior officer must now be present in the Post Incident Management [‘PIM’] suite whilst officers produce witness statements, with a view to ensuring the openness and transparency of the process. The MPS agrees that the current Post Incident Procedure (PIP) does not attract public confidence and needs to be made more transparent.”

Source location
2014-0182-Response-by-Metropolitan-Police-Service
Page 4 · response
Published 29 May 2014
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
Work with law firms representing firearms officers to clarify expectations for detailed post-incident accounts.

Verbatim wording from the response
“a. The MPS agrees that ‘bland and uninformative’ accounts, if and whenever provided, are not acceptable. The MPS now requires a senior officer to be present in the PIM suite, whose functions include ensuring the inclusion of sufficient detail in initial and subsequent accounts. Sufficient detail includes the presence or absence of any perceived threat and the officer’s response thereto. The MPS is working with law firms who represent firearms officers to ensure that its expectations are clearly understood. The success of these measures was demonstrated by the post incident processes adopted following the events of May 2013 in Woolwich and the quality of the witness statements produced through those processes.”

Source location
2014-0182-Response-by-Metropolitan-Police-Service
Page 4 · response
Published 29 May 2014
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 IPCC, through its senior investigating officer, holds ultimate responsibility for recording the scene of a fatal police shooting.

Verbatim wording from the response
“The MPS acknowledges that the recording of the scene of a fatal police shooting is a desirable aspect of crime scene management and recognises the importance of securing best evidence in the immediate aftermath and ongoing investigation of a police shooting. This is the ultimate responsibility of the senior investigating officer (SIO); in the case of a fatal police shooting; that”

Source location
2014-0182-Response-by-Metropolitan-Police-Service
Page 6 · response
Published 29 May 2014
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
Firearms officers’ priorities of saving life, protecting the public and securing the scene were treated as limiting the feasibility of comprehensively recording every aspect.

Verbatim wording from the response
“In the immediate aftermath of a police shooting, it is inevitable that only the officers on scene will be available to carry out an immediate video or photographic capture. The convoy of cars on 4th August 2011 was equipped with both video and still cameras. The primary purpose for which that equipment is provided is to capture images of locations and environments to assist in tactical planning. Armed officers are not currently trained or equipped to record scenes to an evidential standard. On 4th August 2011, officers were able to and did, as an incidence of individual decision making and availability in the circumstances of the particular case of resources, use both cameras to record some parts of the scene, in particular, the provision of first aid.”

Source location
2014-0182-Response-by-Metropolitan-Police-Service
Page 7 · response
Published 29 May 2014
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
Firearms officers should not be responsible for recording post-incident scene preservation; responsibility should fall to investigators or an assigned operations team officer.

Verbatim wording from the response
“It is the view of the MPS that firearms officers should not be responsible for recording post incident scene preservation. MPS firearms officers are due to commence the piloting of Body Worn Cameras (see Concern 6, below). This may provide some level of recording of the actions taken to preserve the scene in the immediate aftermath but they have limitations in that they will only capture a certain camera angle. In a spontaneous incident, it is likely that this will be the only method of immediately recording the scene.”

Source location
2014-0182-Response-by-Metropolitan-Police-Service
Page 7 · response
Published 29 May 2014
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
Further comment on police witness accounts was deferred because statutory guidance had not been finalised and consultation responses were still under review.

Verbatim wording from the response
“9. However, bearing in mind that the IPCC has not issued the final version of this statutory guidance, the IPCC does not consider it appropriate to comment further on this issue until it has completed the consultation exercise and submitted its final position to the Secretary of State.”

Source location
2014-0182-Response-by-IPPC
Page 4 · response
Published 29 May 2014
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 existing APP’s flexible, balanced approach is considered sufficient; wholesale separation of officers is not supported as fit for purpose.

Verbatim wording from the response
“The IPCC’s draft guidance promotes the third factor at the expense of the first, second and fourth factors. The National Policing portfolios’ view is that post incident procedures should strike an appropriate balance between all four factors, a position that Module 7 of the APP seeks to achieve.”

Source location
2014-0182-Response-by-ACPO
Page 10 · response
Published 29 May 2014
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
Separating officers may be operationally, logistically and practically impractical, particularly where numerous witnesses and operational imperatives are involved.

Verbatim wording from the response
“Seeking to ensure the separation of officers engaged and involved in a critical incident for what may prove to be a significant period of time before an opportunity to rationally collect thoughts and compose an initial account – no matter how brief - is of course a legitimate and laudable aim but one that has to be set into context. Where officers have been together at the time of such an incident, as is in the case of many armed policing operations, the separation of officers may prove operationally or logistically impractical, as there are often large numbers of officers who will fall into the definition of a key policing witness. Such officers may have been together for a substantial period of time before it is practical to separate them, negating the rationale for separation.”

Source location
2014-0182-Response-by-ACPO
Page 10 · response
Published 29 May 2014
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
Taking full statements immediately from officers affected by shock, distress or extreme fatigue was considered counterproductive and of limited forensic value.

Verbatim wording from the response
“d. Officers involved in a fatal shooting are under intense scrutiny. A decision about criminal or disciplinary proceedings may not be made for months or years after such a shooting. Such officers are required to carry out difficult and/or dangerous tasks, at not infrequently, great personal risk. Any witness may speak to a solicitor prior to giving information to police. The same is true of any suspect. A witness is entitled to provide their account in the manner of their choosing. Officers involved in a fatal shooting should be entitled to no lesser protections and support than any other member of the public who is a witness. This is codified in the Ministry of Justice 2011 guidance for Achieving Best Evidence [‘ABE’] regarding the timing of any interview and the provision of a full and detailed account.”

Source location
2014-0182-Response-by-Metropolitan-Police-Service
Page 5 · response
Published 29 May 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to investigate suspected tablet-supply activity referred by another police force

Concerns raised1

Failure to seize and retain relevant scene samples and evidence for later investigation

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.3

Concerns raised2

Absence of a Police-HSE memorandum of understanding or protocol for domestic explosion evidence requirements

Lack of understanding of evidence requiring preservation during domestic explosion investigations

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to preserve fire scenes until all instructed investigations are completed

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to preserve time-sensitive CCTV evidence relevant to suspect identification

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.2

Concerns raised1

Delays of over a month in obtaining best evidence through video interview or otherwise

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.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised3

Failure to establish available recordings and the scope of relevant social media evidence before case closure

Failure to conduct a further face-to-face conversation with the child

Delays in seizing key digital evidence

Actions described in response 3

Actions described in response 3

Respondent positions 3

Respondent positions 3

Actions described in response 2

Actions described in response 1

Respondent positions 1