8 Jun 2023 Ivan Rumenov Ignatov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1
Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Dorset & Wiltshire Fire and Rescue Service Dorset Police His Majesty's Coastguard ("HM Coastguard National Fire Chiefs Council National Police Air Service NHS England Royal National Lifeboat Institution South Western Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 27
Dorset & Wiltshire Fire and Rescue Service
Train all incident commanders in the JESIP joint doctrine interoperability framework and its principles of joint working.
View source
Dorset & Wiltshire Fire and Rescue Service
Represent the Service at the Dorset Blue Light Group meeting to address interoperability challenges involving partners’ different radio communications.
View source
National Police Air Service
Hold joint familiarisation briefings for all NPAS and HMCG staff, including communications teams.
View source
National Police Air Service
Consider extending familiarisation briefings to relevant force communications teams and approach the RNLI about equivalent engagement.
View source
National Police Air Service
Develop and distribute a joint quick-action card prioritising establishment of an Emergency Services Airwave channel, with national partners asked to support dissemination.
View source
National Police Air Service
Hold monthly communications meetings between NPAS and HMCG operations-centre leads to debrief notable incidents and assess lessons learned.
View source
His Majesty's Coastguard ("HM Coastguard
Participate in inter-agency debriefs, workshops, capability reviews, training and operational-learning meetings with emergency-service and search-and-rescue partners.
View source
His Majesty's Coastguard ("HM Coastguard
Facilitate continuing Dorset Police incident-commander CPD sessions covering Coastguard capabilities, early JRCC contact and coastal staff roles.
View source
His Majesty's Coastguard ("HM Coastguard
Provide Joint Rescue Coordination Centre staff with structured visits to police, fire and ambulance control rooms to build understanding of roles, capabilities, processes and communications.
View source
His Majesty's Coastguard ("HM Coastguard
Host emergency-service visits to the Joint Rescue Coordination Centre using bespoke presentations and operational-learning content to explain Coastguard roles, capabilities, processes and communications.
View source
His Majesty's Coastguard ("HM Coastguard
Collect visit feedback, review objectives and presentation content monthly, adjust materials and communicate identified learning to Joint Rescue Coordination Centre teams.
View source
His Majesty's Coastguard ("HM Coastguard
Update the Coastguard Capability Matrix with communications information and publish it on ResilienceDirect for emergency-service partners.
View source
His Majesty's Coastguard ("HM Coastguard
Include maritime rescue ‘connect call’ capability in routine exercises with stakeholders and Emergency Services Control Room visits.
View source
Dorset Police
Hold joint Dorset Police–Coastguard meetings every six months to review working practices and terminology.
View source
National Fire Chiefs Council
Engage with Dorset and Wiltshire Fire and Rescue Service to support effective multi-agency communication during incident response.
View source
National Fire Chiefs Council
Continue encouraging fire and rescue services to follow existing JESIP doctrine and operational guidance.
View source
National Fire Chiefs Council
Continue developing existing operational guidance to make its application more effective.
View source
Royal National Lifeboat Institution
Update the ResilienceDirect page with RNLI capability information for emergency services and search-and-rescue partners.
View source
Royal National Lifeboat Institution
Prepare materials for direct sharing with emergency-services partners covering RNLI capabilities and limitations, including search equipment and communication capabilities.
View source
South Western Ambulance Service NHS Foundation Trust
Implement JESIP joint-working principles through commander, staff and control-room training, policies and procedures.
View source
South Western Ambulance Service NHS Foundation Trust
Extend JESIP course invitations to HM Coastguard colleagues.
View source
South Western Ambulance Service NHS Foundation Trust
Strengthen SWASFT–HM Coastguard coordination through commander visits and control-room shadowing.
View source
South Western Ambulance Service NHS Foundation Trust
Introduce effective aide-mémoires for control-room dispatchers and commanders supporting joint working with HM Coastguard.
View source
South Western Ambulance Service NHS Foundation Trust
Maintain a standard operating procedure for notifying other emergency services and relevant utility providers about incidents.
View source
South Western Ambulance Service NHS Foundation Trust
Implement and routinely exercise a three-way control-room call process enabling direct communication between ambulance, police and fire services during major incidents.
View source
South Western Ambulance Service NHS Foundation Trust
Provide inter-control hailing and multiagency talkgroups enabling direct ambulance, police and fire control-room communication during major or significant incidents.
View source
South Western Ambulance Service NHS Foundation Trust
Maintain a trained NILO cohort with two officers available around the clock to support incident commanders and partner agencies.
View source See 24 more actions
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AI-generated summary
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.
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 Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
Wider context from the report “iv. There is a lack of knowledge and/or understanding amongst emergency services and search and rescue services, especially around terminology, process and communication for them to be able to work together when an incident arises without confusion or misunderstanding arising . I would request that consideration is given to further national and local training or guidance across emergency and search and rescue services to ensure communication can be facilitated without delay, and ensure terms and processes are understood to avoid any doubt of what action is being taken when an incident is ongoing.
” Source location Ivan Rumenov Ignatov · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train all incident commanders in the JESIP joint doctrine interoperability framework and its principles of joint working.
Verbatim wording from the response “Although the Service was not directly involved in the search and rescue operation on this occasion, we work closely with our colleagues in the wider emergency services and search and rescue services, including police, ambulance, and His Majesty’s Coastguard. It is for the reasons you identify that we remain committed to the Joint Emergency Services Interoperability Principles (JESIP). The JESIP joint doctrine interoperability framework forms the foundation on which we train all our incident commanders and contains the five principles of joint working:” Source location Response from Dorset and Wiltshire Fire and Rescue
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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 Represent the Service at the Dorset Blue Light Group meeting to address interoperability challenges involving partners’ different radio communications.
Verbatim wording from the response “The Service is an active member of the Dorset Local Resilience Forum, who consider JESIP as a key area for continuous improvement. Through this forum, the challenges of intra-operability with partners, who have different radio communications, is an area of focus for the Blue Light Group on 18 September 2023. Our Service will be appropriately represented at this meeting.” Source location Response from Dorset and Wiltshire Fire and Rescue
Open published response
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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 Hold joint familiarisation briefings for all NPAS and HMCG staff, including communications teams.
Verbatim wording from the response “• A series of joint familiarisation briefings to be held between HMCG and NPAS - this will encompass all staff to ensure corporacy across both organisations and to reflect the fact that as a National Service, there may be occasions when landlocked bases do have to respond to incidents involving HMCG/ Water rescue. It will also include the Comms departments of both agencies.” Source location Response from National Police Air Service
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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 extending familiarisation briefings to relevant force communications teams and approach the RNLI about equivalent engagement.
Verbatim wording from the response “• This familiarisation briefing will be considered for roll-out to Comms element of Forces where water-based rescue is frequent i.e.; South Coast, North Yorkshire, Northumberland, Lancashire to ensure they have awareness of each agency and capabilities of each. An approach for the same to be made to the RNLI.” Source location Response from National Police Air Service
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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 and distribute a joint quick-action card prioritising establishment of an Emergency Services Airwave channel, with national partners asked to support dissemination.
Verbatim wording from the response “• Work to be commenced to develop a joint "quick action card" which will be distributed to all Forces and which prioritises the need for the Host Force ( in this case Dorset Police) to set an Emergency Services channel on Airwave which would allow early communication. We will be asking for Chief Coastguard and NPCC assistance to push this course of action.” Source location Response from National Police Air Service
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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 Hold monthly communications meetings between NPAS and HMCG operations-centre leads to debrief notable incidents and assess lessons learned.
Verbatim wording from the response “• Monthly Comms meetings to be held between Head of Ops Centre/ Equivalent HMCG staff member to de-brief incidents of note and assess lessons learnt.” Source location Response from National Police Air Service
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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 Participate in inter-agency debriefs, workshops, capability reviews, training and operational-learning meetings with emergency-service and search-and-rescue partners.
Verbatim wording from the response “Ongoing Inter-Agency Liaison
During the inquest, we provided HM Coroner with a statement from ████████, HM Coastguard's Lead for Civil Resilience. This statement provided an overview of the joint exercising and training events that take place at a local level, via the Local Resilience Forum (LRF), Dorset Local Search and Rescue Committee (LSARC) and the Dorset Blue Light Group.” Source location Response from Maritime and Coastguard Agency
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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 Facilitate continuing Dorset Police incident-commander CPD sessions covering Coastguard capabilities, early JRCC contact and coastal staff roles.
Verbatim wording from the response “A number of these meetings have provided an opportunity to directly address your concerns and improve understanding between partner organisations. For example, Area Commander ████████ attended the Dorset Police Force Incident Commander CPD on 12 July to update the force on the capabilities of HM Coastguard and its declared facilities, the importance of calling HM Coastguard's coordination centre the Joint Rescue Coordination Centre (JRCC) early, and the on-the-ground roles undertaken by full-time coastal staff at incidents. This is part of an initiative set up between HM Coastguard and Dorset Police to promote effective working between the two agencies and will be the first of many CPD sessions HM Coastguard will facilitate with the Dorset Force Incident Managers, with the next one scheduled for 26 September 2023.” Source location Response from Maritime and Coastguard Agency
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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 Provide Joint Rescue Coordination Centre staff with structured visits to police, fire and ambulance control rooms to build understanding of roles, capabilities, processes and communications.
Verbatim wording from the response “HM Coastguard External Visits
In order to address the Senior Coroner's concerns around control room level communication and understanding, all staff based at the Joint Rescue Coordination Centre in Fareham will partake in a series of Emergency Services Control Room visits (Police, Fire and Ambulance) commencing in September 2023.” Source location Response from Maritime and Coastguard Agency
Open published response
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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 Host emergency-service visits to the Joint Rescue Coordination Centre using bespoke presentations and operational-learning content to explain Coastguard roles, capabilities, processes and communications.
Verbatim wording from the response “Emergency Services and Search and Rescue Partner visits to the JRCC
Additionally, other Emergency Services have been invited to visit the JRCC to enhance their understanding of HM Coastguard's operations.” Source location Response from Maritime and Coastguard Agency
Open published response
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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 Collect visit feedback, review objectives and presentation content monthly, adjust materials and communicate identified learning to Joint Rescue Coordination Centre teams.
Verbatim wording from the response “Feedback from partners on visits to the JRCC will be collated following each visit and following external visits via HM Coastguard Team Leaders. Content will then be reviewed by the JRCC Rescue Coordination Centre Manager through monthly meetings to ensure that objectives and presentation content is reviewed and adjusted accordingly. Any identified learning will be communicated within the teams at the JRCC.” Source location Response from Maritime and Coastguard Agency
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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 the Coastguard Capability Matrix with communications information and publish it on ResilienceDirect for emergency-service partners.
Verbatim wording from the response “Following the inquest, this was updated to provide further information around our communications capabilities. We enclosed a copy of the updated Capability Matrix with this response. This has also been uploaded to the MCA's ResilienceDirect page, where it can be downloaded and viewed by our emergency services partners. ResilienceDirect is a web-based platform used by emergency services that allows for real time information sharing between services.” Source location Response from Maritime and Coastguard Agency
Open published response
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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 maritime rescue ‘connect call’ capability in routine exercises with stakeholders and Emergency Services Control Room visits.
Verbatim wording from the response “HM Coastguard has the technical capability to put a maritime rescue asset (such as an RNLI lifeboat) into a ‘connect call’ with shore-side responders (such as the police) using mobile phones via its Maritime Rescue Coordination Centres ("MRCC"). This capability facilitates the connection of a mobile phone to a marine VHF radio, with the HM Coastguard control room able to participate in the call to ensure that information is shared accurately between partners and that appropriate actions are taken by the coordinating team within the MRCC.” Source location Response from Maritime and Coastguard Agency
Open published response
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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 Hold joint Dorset Police–Coastguard meetings every six months to review working practices and terminology.
Verbatim wording from the response “A Senior Manager from HMCG also attended the Force Incident Manager and Deployment Manager Continuing Professional Development days in July 2023. These Events are held several times a year to generate discussions about policies, processes, and deployments. These particular sessions served to improve understanding in terms of the respective obligations of Dorset Police and HMCG. This meeting was so positive and productive, that Dorset Police and HMCG have agreed to similar meetings every six months, for the specific purpose of reviewing our working practices and ensuring compliance. We also believe that these meetings will serve to improve the understanding of agency-specific terminology.” Source location Response from Dorset Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage with Dorset and Wiltshire Fire and Rescue Service to support effective multi-agency communication during incident response.
Verbatim wording from the response “The NFCC have engaged with Dorset and Wiltshire FRS. The JESIP principles are well embedded within their service. They lead on multi agency training and working closely with the Local Resilience Forum to embed effective multiagency communication during the response phase.” Source location Response from National Fire Chiefs Council
Open published response
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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 Continue encouraging fire and rescue services to follow existing JESIP doctrine and operational guidance.
Verbatim wording from the response “In response to the recommendations made the NFCC believes that appropriate guidance is available, and we will continue to encourage all FRSs to follow existing JESIP doctrine and operational guidance while continuing to develop existing guidance to make its application more effective.” Source location Response from National Fire Chiefs Council
Open published response
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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 Continue developing existing operational guidance to make its application more effective.
Verbatim wording from the response “In response to the recommendations made the NFCC believes that appropriate guidance is available, and we will continue to encourage all FRSs to follow existing JESIP doctrine and operational guidance while continuing to develop existing guidance to make its application more effective.” Source location Response from National Fire Chiefs Council
Open published response
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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 the ResilienceDirect page with RNLI capability information for emergency services and search-and-rescue partners.
Verbatim wording from the response “7. It is clear from the inquest that more work needs to be undertaken so that other emergency services/search and rescue partners understand the RNLI’s capabilities and how it operates.” Source location Response from Royal National Lifeboat Institution
Open published response
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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 materials for direct sharing with emergency-services partners covering RNLI capabilities and limitations, including search equipment and communication capabilities.
Verbatim wording from the response “8. Further it is also clear that more work needs to be undertaken to ensure emergency services/search and rescue partners understand the terminology that is used in relation to the RNLI to avoid any confusion or misunderstanding with those emergency services/search and rescue partners. By way of example around the difference between tasking and launching.” Source location Response from Royal National Lifeboat Institution
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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 Implement JESIP joint-working principles through commander, staff and control-room training, policies and procedures.
Verbatim wording from the response “The JESIP Joint Doctrine (edition 3 published in October 2021) sets out principles for joint working between the different services, which SWASFT ensures are implemented through training and its own policies and standard operating procedures. Those principles include communicating using language which is clear, and free from technical jargon and abbreviations.” Source location Response from South Western Ambulance Service NHS Foundation Trust
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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 Extend JESIP course invitations to HM Coastguard colleagues.
Verbatim wording from the response “Invitations to attend JESIP courses are extended to colleagues from HM Coastguard. In addition, SWASFT is currently strengthening relationships by participating in a programme of visits by SWASFT and HM Coastguard commanders and other key role holders to other control rooms. This aims to further promoting shared understanding between SWASFT and HM Coastguard commanders of how each emergency service co-ordinates its response to incidents, and the terminology used by each service. During such a visit the visiting commander shadows the resident control commander, observing processes in operation and listening to communications with officers on-scene.” Source location Response from South Western Ambulance Service NHS Foundation Trust
Open published response
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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 Strengthen SWASFT–HM Coastguard coordination through commander visits and control-room shadowing.
Verbatim wording from the response “Invitations to attend JESIP courses are extended to colleagues from HM Coastguard. In addition, SWASFT is currently strengthening relationships by participating in a programme of visits by SWASFT and HM Coastguard commanders and other key role holders to other control rooms. This aims to further promoting shared understanding between SWASFT and HM Coastguard commanders of how each emergency service co-ordinates its response to incidents, and the terminology used by each service. During such a visit the visiting commander shadows the resident control commander, observing processes in operation and listening to communications with officers on-scene.” Source location Response from South Western Ambulance Service NHS Foundation Trust
Open published response
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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 Introduce effective aide-mémoires for control-room dispatchers and commanders supporting joint working with HM Coastguard.
Verbatim wording from the response “We are also ensuring effective aide memoirs are in place for our dispatchers and commanders within our control room to support effective joint working with the HM Coastguard. This work has begun over the last few months and will be finalised during the forthcoming couple of months. The aim is to ensure that business-as-usual working between SWASFT and HM Coastguard is well embedded with key relationships formed, making sure that when the larger incidents happen we already have a strong working relationship.” Source location Response from South Western Ambulance Service NHS Foundation Trust
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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 Maintain a standard operating procedure for notifying other emergency services and relevant utility providers about incidents.
Verbatim wording from the response “A standard operating procedure is in place to guide the Emergency Medical Dispatchers in our Emergency Operations Centres (the EOCs – our control rooms in Bristol and Exeter) regarding receiving emergency calls from other emergency services, and when to notify the police, fire service, coastguard or utility providers of an incident to which an ambulance has been called. Outgoing calls to other services are made to dedicated blue light service lines into their control rooms in most cases.” Source location Response from South Western Ambulance Service NHS Foundation Trust
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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 Implement and routinely exercise a three-way control-room call process enabling direct communication between ambulance, police and fire services during major incidents.
Verbatim wording from the response “In 2019 multiagencies implemented a 3 way call process which can be instigated in the event of a Major Incident, to enable SWASFT and the police and fire services to directly communicate through control rooms. This process enables control rooms to effectively communicate on an open call (or via MSTEAMS in some areas) prior to the arrival of resources at the scene of an incident and facilitates effective command and control in the initial stages of an incident. The setting up of these calls are routinely exercised within the SWASFT EOCs.” Source location Response from South Western Ambulance Service NHS Foundation Trust
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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 Provide inter-control hailing and multiagency talkgroups enabling direct ambulance, police and fire control-room communication during major or significant incidents.
Verbatim wording from the response “In the event of a Major or Significant Incident (Standby or Declared), each of SWASFT’s two EOCs can also notify, or be notified by, the police or fire services via an Inter Control Hailing Talkgroup. Following the initial notification, communications will be transferred to a specific multiagency talk group which will allow the three services to directly communicate regarding that incident through control rooms (while leaving the inter-control talkgroup free for any other notifications). This has been in place since late 2020.” Source location Response from South Western Ambulance Service NHS Foundation Trust
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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 Maintain a trained NILO cohort with two officers available around the clock to support incident commanders and partner agencies.
Verbatim wording from the response “The Trust has a cohort of NILOs, who are trained to advise and support Incident Commanders, Police, Fire, military and other Government agencies on SWASFT’s operational capacity and capability to reduce risk and safely resolve incidents at which a SWASFT attendance may be required, including major incidents, complex or protracted multi-agency incidents. The Trust has two individuals on call 24/7 who can advise and deploy to support the response to incidents to ensure effective multiagency communication.” Source location Response from South Western Ambulance Service NHS Foundation Trust
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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 JESIP-based training, assessment and resilience-forum arrangements address communication and interoperability concerns.
Verbatim wording from the response “Although the Service was not directly involved in the search and rescue operation on this occasion, we work closely with our colleagues in the wider emergency services and search and rescue services, including police, ambulance, and His Majesty’s Coastguard. It is for the reasons you identify that we remain committed to the Joint Emergency Services Interoperability Principles (JESIP). The JESIP joint doctrine interoperability framework forms the foundation on which we train all our incident commanders and contains the five principles of joint working:” Source location Response from Dorset and Wiltshire Fire and Rescue
Open published response
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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 Home Force, rather than NPAS, should open the Emergency Services channel to enable communication between the relevant emergency services.
Verbatim wording from the response “The second actions related to Section 5 subsection 2 part vi of the report and concentrated on the communication between the relevant emergency services. In brief, the home force, NPAS and HMCG all have access to Airwave and an Emergency Services channel should have been opened by the Home Force. This would have allowed the 3 services to communicate easily and is covered by the JESIP principles for matters of this type. RNLI do not have Airwave but have access to VHF which the HMCG also has so they are able to communicate in this way.” Source location Response from National Police Air Service
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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 RNLI and HMCG can communicate using VHF, so RNLI’s lack of Airwave access does not prevent communication by existing arrangements.
Verbatim wording from the response “The second actions related to Section 5 subsection 2 part vi of the report and concentrated on the communication between the relevant emergency services. In brief, the home force, NPAS and HMCG all have access to Airwave and an Emergency Services channel should have been opened by the Home Force. This would have allowed the 3 services to communicate easily and is covered by the JESIP principles for matters of this type. RNLI do not have Airwave but have access to VHF which the HMCG also has so they are able to communicate in this way.” Source location Response from National Police Air Service
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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 JESIP doctrine and NFCC operational guidance provide an appropriate response to interagency communication concerns, so no additional guidance is required.
Verbatim wording from the response “In response to the recommendations made the NFCC believes that appropriate guidance is available, and we will continue to encourage all FRSs to follow existing JESIP doctrine and operational guidance while continuing to develop existing guidance to make its application more effective.” Source location Response from National Fire Chiefs Council
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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 Lifeboat communications should remain routed through Coastguard tasking; direct contact by other agencies is inappropriate because conflicting messages could distract crews.
Verbatim wording from the response “5. As the Coastguard is the tasking authority and responsible for coordinating searches, the method of communication with the Lifeboat is via the Coastguard following IMSAR protocols as a maritime search and rescue capability. Having other multiple organisations able to communicate with the Lifeboat is not effective. It can lead to conflicting information being given and undermine effective tasking as well as creating a distraction for the crews receiving multiple messages. This, in turn, could hamper the effectiveness of the lifesaving service and lives could be lost if the crew are distracted or given conflicting information.” Source location Response from Royal National Lifeboat Institution
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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 Search and rescue services are tasked through the Police and do not fall under NHS England’s remit.
Verbatim wording from the response “Search and rescue services such as Coastguard and Mountain Rescue are tasked through the Police and do not fall under NHS remit. Any multi-agency working such as that which took place during the search for Ivan should be governed by the Joint Emergency Services Interoperability Principles: Home - JESIP Website.” Source location Response from NHS England
Open published response
27 Jan 2023 Jayden Andrew Booroff · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Lack of a senior single point of contact for ongoing communications with emergency services across shift changes View source Miscommunication between mental health, police and other emergency services View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Essex Partnership University NHS Foundation Trust Essex Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Essex Partnership University NHS Foundation Trust
Appoint a senior single point of contact and provide a prioritised emergency-services line to appropriate senior and out-of-hours managers.
View source
Essex Partnership University NHS Foundation Trust
Create and disseminate an SBARD aide-mémoire guiding staff escalation to police for patients absent from authorised leave or absconded, including Mental Health Act status and risk information.
View source
Essex Partnership University NHS Foundation Trust
Audit missing-person calls with Essex Police to assess the aide-mémoire’s effectiveness and establish and share further learning.
View source
Essex Partnership University NHS Foundation Trust
Enable Essex Police to join twice-daily Trust SITREPs with service managers and Matrons to support escalation and communication.
View source
Essex Partnership University NHS Foundation Trust
Share learning from the patient-safety incident and Prevention of Future Deaths report at the Essex Crisis Concordat and reinforce communication pathways.
View source
Essex Police
Progress collaborative implementation of the national framework for adults missing from health and care settings through multi-agency planning and a Task and Finish group.
View source
Essex Police
Embed dedicated constable and inspector liaison capacity at the Linden Centre to improve local identification, information sharing, partnership working and strategic oversight.
View source See 4 more actions
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AI-generated summary
Jayden Andrew Booroff · 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
Jayden Andrew Booroff died after absconding from The Linden Centre and being struck by a train on 23 October 2020. The report identified concerns about risk assessments, observation levels, ward security, absconsion procedures, record keeping, medication, and communication between healthcare professionals and emergency services.
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 Lack of a senior single point of contact for ongoing communications with emergency services across shift changes
Wider context from the report “(4) Lack of an Essex Partnership NHS Foundation Trust senior single point of contact for communications with emergency services who would provide any further information or receive updates and how this could be managed across change of shifts .
” Source location Jayden Andrew Booroff · Prevention of Future Deaths report
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 Miscommunication between mental health, police and other emergency services
Wider context from the report “(3) Miscommunication between:
a. Essex Partnership NHS Foundation Trust to emergency services
b. Essex Police to Essex Partnership NHS Foundation Trust
c. Essex Police to other emergency services
In seeking further information, how a risk managed within the confines of a secure mental health ward may change for an escaped patient and whether there is real and immediate risk of serious or fatal harm to self or others, rather than assumptions that language is being used in the same way by different services.
” Source location Jayden Andrew Booroff · Prevention of Future Deaths report
Open source report
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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 Appoint a senior single point of contact and provide a prioritised emergency-services line to appropriate senior and out-of-hours managers.
Verbatim wording from the response “Since the incident, the Trust has appointed a single point of contact where emergency services can request to speak the appropriate senior manager managing the incident. The Trust, Essex Police, British Transport Police and EEAST Ambulance Leads are continuing to build good relationships and communication as described below:” Source location Response from Essex Partnership University
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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 Create and disseminate an SBARD aide-mémoire guiding staff escalation to police for patients absent from authorised leave or absconded, including Mental Health Act status and risk information.
Verbatim wording from the response “In light of communication with emergency services, in collaboration with the Trust’s Lessons Team, a one-page aide-mémoire was created to support staff to escalate concerns to the police for incidents where a patient does not return from leave or they have absconded from the ward. This guidance provided information regarding the impact factors that should be verbalised to the police when reporting a person missing. This would then enable the police to make an informed decision in relation to their response. This document uses the SBARD communication tool (Situation, Background, Assessment, Recommendation, Decision). This document was shared with operational managers for cascading to front line staff and calls will be audited between EPUT and Essex Police to ascertain the effectiveness of the tool.” Source location Response from Essex Partnership University
Open published response
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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 Audit missing-person calls with Essex Police to assess the aide-mémoire’s effectiveness and establish and share further learning.
Verbatim wording from the response “In light of communication with emergency services, in collaboration with the Trust’s Lessons Team, a one-page aide-mémoire was created to support staff to escalate concerns to the police for incidents where a patient does not return from leave or they have absconded from the ward. This guidance provided information regarding the impact factors that should be verbalised to the police when reporting a person missing. This would then enable the police to make an informed decision in relation to their response. This document uses the SBARD communication tool (Situation, Background, Assessment, Recommendation, Decision). This document was shared with operational managers for cascading to front line staff and calls will be audited between EPUT and Essex Police to ascertain the effectiveness of the tool.” Source location Response from Essex Partnership University
Open published response
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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 Enable Essex Police to join twice-daily Trust SITREPs with service managers and Matrons to support escalation and communication.
Verbatim wording from the response “• The Trust have developed good relationships with the police, who are now able to join the Trust twice daily SITREPS on Microsoft Teams with service managers and Matrons to support escalation and communication. This commenced at the beginning of February 2023.” Source location Response from Essex Partnership University
Open published response
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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 Share learning from the patient-safety incident and Prevention of Future Deaths report at the Essex Crisis Concordat and reinforce communication pathways.
Verbatim wording from the response “• The Trust co-chairs the Essex Crisis Concordat with Essex Police. British Transport Police and EEAST Ambulance Leads also attend. The next meeting is on 4th April 2023, where learning from this Patient Safety Incident and prevention of Future Deaths report will be shared and communication pathways will be reinforced.” Source location Response from Essex Partnership University
Open published response
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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 Progress collaborative implementation of the national framework for adults missing from health and care settings through multi-agency planning and a Task and Finish group.
Verbatim wording from the response “b. This team are also working towards the implementation of ‘The multi-agency response for adults missing from health and care settings - A national framework for England’. This is collaborative guidance produced by the Home Office, NPCC, and the Missing Persons charity. The team held a multi-agency collaborative conference in September 2022 with Essex Local Authorities, local Integrated Care Boards, and third sector organisations and achieved buy-in to a Task & Finish group looking at how to roll out this framework in Essex.” Source location Response from Essex Police
Open published response
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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 Embed dedicated constable and inspector liaison capacity at the Linden Centre to improve local identification, information sharing, partnership working and strategic oversight.
Verbatim wording from the response “10. At a more local level, Essex Police have embedded dedicated police liaison working within the Linden Centre in Chelmsford. This liaison role is resourced by a constable, with an Inspector providing a local strategic overview.” Source location Response from Essex Police
Open published response
24 Nov 2022 Keith Andrew WESTON · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 1
Failure of the HMRC investigator to respond to firearms licensing contact about the concern View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Keith Andrew WESTON · 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
Keith Andrew WESTON was found in the garden of his home on 9 March 2022 after shooting himself with a licensed firearm. The principal concern was that prosecutions by non-police authorities did not automatically trigger checks of the Police National Computer, meaning firearms licensing authorities might not be alerted to assess a person's continuing suitability to possess firearms.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the HMRC investigator to respond to firearms licensing contact about the concern
Wider context from the report “During the course of the inquest, evidence was heard from a Detective Inspector with North Yorkshire Police who is a Firearms Licensing Manager. The evidence was that, unlike standard police prosecutions, prosecutions of individuals by other authorities do not involve automatic checks of the Police National Computer which would flag whether that individual is licensed to possess a firearm. The appearance of such an alert allows the firearms licensing authority to assess the individual’s continuing suitability to possess a firearm in the context of the prosecution and its possible outcomes.
In this instance, the deceased was being prosecuted for tax fraud by HMRC and was due to make a court appearance on the day of his death. He left a note of intent, indicating that the prosecution and its likely outcome were central to his decision to end his life. Had it been flagged that the deceased was facing such a prosecution, I was informed that it was 'highly likely' that his access to licensed firearms would have been restricted and the weapons removed from him in accordance with statutory guidance. While it cannot be said that this would have prevented the deceased's death by his own hand from some other means, it would have prevented the unlawful discharge of the weapon as a means of suicide. I understand that this issue has been escalated to the NPCC Lead for firearms licensing with a view to highlighting the concern with all non-police prosecuting authorities. I also understand the HMRC investigator did not respond to the officer's contact with the agency to flag this issue . I am writing to HMRC to draw this concern to its attention and to invite it to respond directly, as well as to engage with the NPCC in this regard.
” Source location Keith Andrew WESTON · Prevention of Future Deaths report
Open source report
5 Sep 2022 Stephen WELLS · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Ongoing firewall problems between the two Trusts causing reliance on email rather than automatic electronic systems View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Stephen WELLS · 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
Stephen Wells was treated for colon cancer with liver metastases, but after liver surgery he received no further contact or oncology follow-up for one year because communication and referral processes between two NHS trusts failed. He later developed widespread liver and lung metastases and died at home on 4 October 2021. The report raises concerns about inter-provider referrals, tracking systems, communication between trusts, use of the Datix system, and clarity over patients’ key contacts.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Ongoing firewall problems between the two Trusts causing reliance on email rather than automatic electronic systems
Wider context from the report “b) I also heard evidence from SASH that they would not have expected Mr Wells to be transferred back to them after the liver surgery as further chemotherapy was needed. Conversely, RSFT were unable to explain why Mr Wells did not remain on the Somerset Cancer Registry (SCR) tracking system following discharge and the MDT discussion on 10 August 2020. I was told that the safety net to avoid a cancer patient such as Mr Wells failing to receive further treatment is an inter-provider transfer (IPT) to ensure the responsibility for care is further transferred. In this case, a local process of consultant-to- consultant referrals, in other words a workaround, had evolved and both the hardcopy letter between doctors and an email from the CNS to two separate doctor’s secretaries had failed resulting in no further appointment being made. It was accepted that the communication failure was not identified in a timely manner and that communication systems between both Trusts had blurred with the suggestion that these could be clarified by a renegotiation of the Service Level Agreement (SLA). I was provided with a copy of the current SLA dated 1 January 2015 and note that the particulars state the contract term was 36 months with an end date of 31 December 2017. Given the importance of good systems of communication between Trusts and the IPT system I remain concerned about:
i. the lack of progress made in reviewing/renegotiating the SLA bearing in mind the difficulties in this case were drawn to the attention of the Trusts in September 2021.
ii. an ongoing firewall problem between the two Trusts as this places a current reliance on email rather than automatic electronic systems especially given the failure of emails in this case to secure a much-needed appointment.
” Source location Stephen WELLS · Prevention of Future Deaths report
Open source report
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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 Resolve the inter-Trust firewall problem and establish electronic data connections between the RSFT and SASH E-Tertiary systems.
Verbatim wording from the response “The firewall problem has been resolved between the two Trusts and electronic data connections can be seen between the RSFT and SASH E-Tertiary systems. This data transfer is due to be further tested by the IT and Cancer teams in the week commencing the 7th November. The system will then be tested clinically as part of a planned move of Upper Gastrointestinal Oncology patients currently managed by SASH to the care of RSFT later in November when each patient will require a transfer of information.” Source location Response from Royal Surrey Foundation Trust NHS
Open published response
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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 Test the E-Tertiary data transfer technically and clinically during the planned oncology patient transfer.
Verbatim wording from the response “The firewall problem has been resolved between the two Trusts and electronic data connections can be seen between the RSFT and SASH E-Tertiary systems. This data transfer is due to be further tested by the IT and Cancer teams in the week commencing the 7th November. The system will then be tested clinically as part of a planned move of Upper Gastrointestinal Oncology patients currently managed by SASH to the care of RSFT later in November when each patient will require a transfer of information.” Source location Response from Royal Surrey Foundation Trust NHS
Open published response
12 Aug 2022 Brandon James Pryde and David Ernest Faulkner · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to communicate clearly whether Command and Control has been taken View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Greater Manchester Police North West Motorway Patrol Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 17
Greater Manchester Police
Establish and operate a Pursuit Management Working Group to review and redevelop training for pursuit dispatch operators and commanders.
View source
Greater Manchester Police
Deliver the devised one-day initial pursuit course to supervisors and operators managing initial-phase pursuits.
View source
Greater Manchester Police
Complete design and deliver a four-day tactical-phase commanders’ course to Force Duty Officers and Assistant Force Duty Officers.
View source
Greater Manchester Police
Design accreditation, retraining and continuing professional development for personnel involved in pursuit management.
View source
Greater Manchester Police
Revise the managing pursuits protocol to clarify command and control responsibilities for pursuits, including cross-border pursuits.
View source
Greater Manchester Police
Circulate the revised managing pursuits protocol to all GMP control room staff involved in managing police pursuits.
View source
Greater Manchester Police
Revise and clarify the managing pursuits protocol to remove ambiguity about command and control.
View source
Greater Manchester Police
Develop and deliver a one-day initial pursuit course for supervisors and operators managing initial-phase pursuits.
View source
Greater Manchester Police
Complete design and deliver a four-day tactical-phase commanders’ course for GMP force duty and assistant force duty officers.
View source
Greater Manchester Police
Design accreditation, retraining and continuing professional development for pursuit management staff.
View source
Greater Manchester Police
Circulate the revised managing pursuits protocol to GMP control-room staff involved in managing police pursuits.
View source
North West Motorway Patrol Group
Deliver command-protocol training for cross-border pursuits and track rollout through bi-monthly governance meetings.
View source
North West Motorway Patrol Group
Revise the managing-pursuits protocol to clarify command-and-control responsibilities.
View source
North West Motorway Patrol Group
Circulate the revised managing-pursuits protocol to all relevant NWMPG control-room staff.
View source
North West Motorway Patrol Group
Deliver command-protocol training for cross-border pursuits and track its rollout through governance meetings.
View source
North West Motorway Patrol Group
Revise the managing-pursuits protocol to clarify command-and-control responsibilities.
View source
North West Motorway Patrol Group
Circulate the revised managing-pursuits protocol to relevant NWMPG control-room staff.
View source See 14 more actions
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AI-generated summary
Brandon James Pryde and David Ernest Faulkner · 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
Brandon Pryde and David Faulkner died at the scene after a stolen BMW, driven by Brandon Pryde, travelled against the flow of traffic on the M60 and collided with David Faulkner’s vehicle at high speed. Concerns arose that the protocol for transferring command and control of police pursuits between GMP and NWMPG did not operate in practice, resulting in no effective command and control during the pursuit.
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× 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 clearly whether Command and Control has been taken
Wider context from the report “I received evidence in both inquests that there is a Protocol between GMP and NWMPG (which is based at the Cheshire Constabulary) dated June 2015 in accordance with the College of Police Authorised Professional Practice for Police Pursuits, for the Command and Control of pursuits. That Protocol is intended to provide a mechanism for Command and Control to be undertaken and transferred between GMP and NWMPG when pursuits move between the normal road network and the motorway network, so that Command and Control is maintained throughout. The Supervising Officer in the control room has the authority to direct that a pursuit be discontinued if they assess that it is right to do so, having regard to all of the circumstances which are known to them, which may include information not immediately available to the police officer(s) involved in the pursuit.
Although I found that the absence of any control-room Command and Control had not contributed to either death in this case, the following matters gave rise to concern, having regard to the inherent risk of pursuits, which are likely to move between ordinary road and motorway networks in the Greater Manchester area;
(1) The GMP Force Duty Supervisor assumed that the NWMPG Supervisor had taken Command and Control when they had not done so;
(2) The NWMPG Supervisor did not communicate whether they had taken Command and Control clearly ;
(3) The GMP Force Duty Supervisor did not consider that they had any authority to perform Command and Control of the pursuit once it had entered the motorway network; and
(4) The Protocol did not operate in practice so that there was no effective Command and Control at any point during the pursuit.
” Source location Brandon James Pryde and David Ernest Faulkner · Prevention of Future Deaths report
Open source report
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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 and operate a Pursuit Management Working Group to review and redevelop training for pursuit dispatch operators and commanders.
Verbatim wording from the response “GMP have committed to further training for all those who may be involved in the command and control of police pursuits. It was identified that whilst drivers had received significant investment over recent years this had not been the case for officers and staff engaged on the command-and-control element of pursuit management.” Source location Response from Greater Manchester Police
Open published response
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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 Deliver the devised one-day initial pursuit course to supervisors and operators managing initial-phase pursuits.
Verbatim wording from the response “GMP have committed to further training for all those who may be involved in the command and control of police pursuits. It was identified that whilst drivers had received significant investment over recent years this had not been the case for officers and staff engaged on the command-and-control element of pursuit management.” Source location Response from Greater Manchester Police
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 Complete design and deliver a four-day tactical-phase commanders’ course to Force Duty Officers and Assistant Force Duty Officers.
Verbatim wording from the response “• A 4-day tactical phase commanders’ course is in the final stages of design by the Driver Training Unit and Command Training (Specialist Operations). This will be delivered to the 8 Force Duty Officers (FDO) and 7 Assistant Force Duty Officers (AFDO) within GMP. This will enable a policy change with the authorisation of pursuits moving from the Force Duty Supervisor to the FDO/AFDO role. A training schedule is being drawn up and delivery anticipated within the next 6 months.” Source location Response from Greater Manchester Police
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 Design accreditation, retraining and continuing professional development for personnel involved in pursuit management.
Verbatim wording from the response “• Accreditation, re-training and Continuous Professional Development (CPD) are in design and final details will be confirmed through the working group.” Source location Response from Greater Manchester Police
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 managing pursuits protocol to clarify command and control responsibilities for pursuits, including cross-border pursuits.
Verbatim wording from the response “As a result of this tragic incident GMP and Cheshire Police (on behalf of the NWMPG) have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all GMP control room staff involved in the management of police pursuits.” Source location Response from Greater Manchester Police
Open published response
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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 Circulate the revised managing pursuits protocol to all GMP control room staff involved in managing police pursuits.
Verbatim wording from the response “As a result of this tragic incident GMP and Cheshire Police (on behalf of the NWMPG) have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all GMP control room staff involved in the management of police pursuits.” Source location Response from Greater Manchester Police
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 and clarify the managing pursuits protocol to remove ambiguity about command and control.
Verbatim wording from the response “As a result of this tragic incident GMP and Cheshire Police (on behalf of the NWMPG) have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all GMP control room staff involved in the management of police pursuits.” Source location Response from Greater Manchester Police
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 and deliver a one-day initial pursuit course for supervisors and operators managing initial-phase pursuits.
Verbatim wording from the response “• A 1-day initial pursuit course has been devised by the Driver Training Unit. This will be delivered to Supervisors and operators involved in the management of initial phase pursuit and will align with training provided to Police drivers who have completed the Initial Pursuit course (IPP). A training schedule is being drawn up now for delivery anticipated to be completed within the next 6-9 months due to high numbers requiring training.” Source location Response from Greater Manchester Police
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 Complete design and deliver a four-day tactical-phase commanders’ course for GMP force duty and assistant force duty officers.
Verbatim wording from the response “• A 4-day tactical phase commanders’ course is in the final stages of design by the Driver Training Unit and Command Training (Specialist Operations). This will be delivered to the 8 Force Duty Officers (FDO) and 7 Assistant Force Duty Officers (AFDO) within GMP. This will enable a policy change with the authorisation of pursuits moving from the Force Duty Supervisor to the FDO/AFDO role. A training schedule is being drawn up and delivery anticipated within the next 6 months.” Source location Response from Greater Manchester Police
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 Design accreditation, retraining and continuing professional development for pursuit management staff.
Verbatim wording from the response “• Accreditation, re-training and Continuous Professional Development (CPD) are in design and final details will be confirmed through the working group.” Source location Response from Greater Manchester Police
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 Circulate the revised managing pursuits protocol to GMP control-room staff involved in managing police pursuits.
Verbatim wording from the response “As a result of this tragic incident GMP and Cheshire Police (on behalf of the NWMPG) have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all GMP control room staff involved in the management of police pursuits.” Source location Response from Greater Manchester Police
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 Deliver command-protocol training for cross-border pursuits and track rollout through bi-monthly governance meetings.
Verbatim wording from the response “Cheshire Constabulary acting as lead force on behalf of the collaborative forces is committed to ensuring continuous professional development and training for all staff within the regional control centre.” Source location Response from Cheshire Constabulary
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 managing-pursuits protocol to clarify command-and-control responsibilities.
Verbatim wording from the response “Cheshire Police (on behalf of the NWMPG) and GMP have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all NWMPG control room staff involved in the management of police pursuits.” Source location Response from Cheshire Constabulary
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 Circulate the revised managing-pursuits protocol to all relevant NWMPG control-room staff.
Verbatim wording from the response “Cheshire Police (on behalf of the NWMPG) and GMP have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all NWMPG control room staff involved in the management of police pursuits.” Source location Response from Cheshire Constabulary
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 Deliver command-protocol training for cross-border pursuits and track its rollout through governance meetings.
Verbatim wording from the response “Cheshire Constabulary acting as lead force on behalf of the collaborative forces is committed to ensuring continuous professional development and training for all staff within the regional control centre.” Source location Response from Cheshire Constabulary
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 managing-pursuits protocol to clarify command-and-control responsibilities.
Verbatim wording from the response “Cheshire Police (on behalf of the NWMPG) and GMP have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all NWMPG control room staff involved in the management of police pursuits.” Source location Response from Cheshire Constabulary
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 Circulate the revised managing-pursuits protocol to relevant NWMPG control-room staff.
Verbatim wording from the response “Cheshire Police (on behalf of the NWMPG) and GMP have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all NWMPG control room staff involved in the management of police pursuits.” Source location Response from Cheshire Constabulary
Open published response
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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 Command and control remains with the originating authority until an appropriate handover, rather than automatically transferring to NWMPG.
Verbatim wording from the response “If a pursuit moves from one command area to another, or the pursuit commences on a different command area to which the communication platform is aligned then communications links will be established between the respective control rooms, but the command and control will remain with the originating authority until such a point in time as is deemed appropriate by the respective control room supervisors to hand over command and control.” Source location Response from Cheshire Constabulary
Open published response
3 Aug 2022 Kellum Paul Thomas · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Delays in sending outpatient letters containing important clinical information View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Kellum Paul Thomas · 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
Kellum Paul Thomas, aged thirteen, collapsed at home on 9 June 2021 and died after a cardiac arrest caused by ventricular tachycardia deteriorating into ventricular fibrillation. Concerns included an 18-month gap without a functioning REVEAL heart-monitoring device, delayed replacement processes, and a significantly delayed outpatient letter containing medication and investigation information. The report also identified stretched team capacity and resources and stated that necessary actions to address these issues were not confirmed.
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× 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 sending outpatient letters containing important clinical information
Wider context from the report “2. Kellum’s outpatient letter from ████████ to both the GP and to Nottingham University Hospitals NHS Trust (where shared care was provided) was very delayed , with the outpatient appointment completed in March 21, and the letter not reaching its destinations until mid June 21, after Kellums death . This letter contained important information re a change in medication dosage and a request for NUH to arrange a further investigation. Again this issue appeared to be one of team capacity and resources.
” Source location Kellum Paul Thomas · Prevention of Future Deaths report
Open source report
29 Jul 2022 Christopher Dominic Boughton · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Lack of requirements for direct discussion between police forces during investigation tasking and transfers View source
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AI-generated summary
Christopher Dominic Boughton · 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
Christopher Dominic Boughton left home on 3 November 2021 and was later found deceased in a wooded location in Oxshott, Surrey, after friends searched areas he was known to visit. The inquest found that he took his own life by hanging at some point between being dropped off by taxi on 3 November and being found on the morning of 5 November. The principal concern was insufficient direct communication and coordination between bordering police forces when tasking and transferring investigations, which could delay effective action and the sharing of relevant information.
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 Lack of requirements for direct discussion between police forces during investigation tasking and transfers
Wider context from the report “The evidence of Detective Inspector ████████, Tactical and Policy Lead for MPS, highlighted a concern that in tasking and transferring investigations between bordering Police forces, there is a lack of ownership and discussion between officers at Inspector level or above between forces, which would ensure effective tasking and, when necessary, smooth transfer of investigations . Requests were made by email and CAD, without discussions between officers.
This was confirmed in the evidence of Detective Chief Constable ████████ of SP, who stated that from her perspective there was a lack of feedback from SP to manage MPS’ expectations regarding a search for Mr Boughton.
In respect of the initial search, this meant that SP did not advise MPS that they considered the search request unfeasible given the extent of land outlined and the limitations on searching wooded areas during winter night hours.
In respect of the request for a further search with more precise location detailed provided, MPS did not disclose all of the information available regarding Family and friends potentially being able to assist in finding the location based upon where Mr Boughton used to visit. There was no feedback from SP regarding when a search might take place, leading MPS to consider deploying its own search team.
Whilst contact telephone numbers for Officers at MPS and SP were provided on the CAD, there is no evidence that direct contact was made between the forces to discuss the investigation and how best to move this forward. A SP officer recorded on the CAD that until the transfer document was received from MPS, SP were unable to arrange a search or contact the specialist search team.
Whilst DI ████████ gave evidence that he is aware the NPCC is reviewing issuing guidance around tasking and transfers between bordering Police forces, at present there appears to be no requirement for appropriate Police Officers to make telephone contact between forces to ensure effective tasking and transferring, in addition to the required written requests. This means an opportunity to discuss and pass on all relevant information between forces may be lost.
1. The lack of any detailed requirement for telephone discussion between appropriate police officers on sending through written tasking requests and considering transfers of investigation means that an opportunity to discuss and ensure smooth transition and passing on of relevant information is lost. This may cause delay in effective action being taken by the tasked Force, or (in the case of transfers) by the Force to whom it is considered a transfer will be made.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Source location Christopher Dominic Boughton · Prevention of Future Deaths report
Open source report
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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 Initiate a Task and Finishing Group focused on cross-border missing-person investigations and investigation transfers.
Verbatim wording from the response “Further to the APP guidance a Task and Finishing Group has been initiated focusing on the very issue you have outlined. Draft NPCC advice on ‘Requesting Missing Person Enquiries in Another Force and Transfers of Investigations’ has been developed and has now been circulated for comment prior to finalisation and wider circulation.” Source location 2022-0235 - Response from NPCC
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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 and circulate draft NPCC advice on requesting missing-person enquiries in another force and transferring investigations for comment before finalisation and wider circulation.
Verbatim wording from the response “Further to the APP guidance a Task and Finishing Group has been initiated focusing on the very issue you have outlined. Draft NPCC advice on ‘Requesting Missing Person Enquiries in Another Force and Transfers of Investigations’ has been developed and has now been circulated for comment prior to finalisation and wider circulation.” Source location 2022-0235 - Response from NPCC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing APP guidance and information-transfer procedures address the concerns about cross-border investigation tasking and transfers.
Verbatim wording from the response “Difficulties can arise when a person reported missing resides outside the area where the report is being made, for example, a student in temporary accommodation or a day trip visitor. The police area that receives the report must record it and carry out all necessary initial actions. If the responsibility for a case is subsequently transferred to another force area, the rationale for doing so must be recorded. Written acknowledgement from the receiving force should be obtained.
When deciding where ownership of the investigation lies, the principal issue is to consider where the majority of the enquiries are and who has the greatest opportunity of locating the missing person. It is probable that the area where the person was last seen would generate the majority of the initial enquiries (although this is not always the case, see also Out-of-area placements).” Source location 2022-0235 - Response from NPCC
Open published response
Concerns raised 1
Lack of policy, procedure or guidance on considering when to hold multi-agency information-sharing meetings View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Lewis Martyn POWTER · 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
Lewis Martyn Powter, an IPP offender with emotionally unstable personality disorder and a long history of drug addiction, died from a self-administered overdose on 10 May 2020 after a period of abstinence and reduced drug tolerance. The concern was that there was no policy or guidance encouraging multi-agency meetings to share information about complex-needs IPP offenders, particularly where one care provider lacked access to the shared record system.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of policy, procedure or guidance on considering when to hold multi-agency information-sharing meetings
Wider context from the report “that, where an IPP offender with complex needs is released and is not subject to MAPPA, but is subject to multi-agency intervention co-ordinated by the National Probation Service, there is no policy/procedure/guidance encouraging consideration to be given to the issues of whether and when to hold multi-agency meetings for the purposes of sharing information about the offender . The need for consideration to be given to holding such meetings is particularly acute where one of the organisations responsible for delivering care/treatment does not have access to the shared record system used by the other two parties.
” Source location Lewis Martyn POWTER · Prevention of Future Deaths report
Open source report
27 Jun 2022 Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 2
Lack of information sharing between agencies View source Unavailability of a shared database for agencies to input common concerns View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Ministry of Justice
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AI-generated summary
Jessica Louise LAVERACK “Jessie” · 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
Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.
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 Lack of information sharing between agencies
Wider context from the report “(3) There was a lack of information sharing between all agencies , even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Source location Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report
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 Unavailability of a shared database for agencies to input common concerns
Wider context from the report “(3) There was a lack of information sharing between all agencies, even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Source location Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report
Open source report
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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 Confidential patient information cannot be shared without satisfying data protection law, public interest requirements and the Common Law Duty of Confidentiality case by case.
Verbatim wording from the response “With regard to your concerns around the general lack of information sharing between agencies, healthcare professionals must believe there is a significant public interest and satisfy data protection law, and the ‘Common Law Duty of Confidentiality’ when sharing any confidential patient information. This requires requestors to meet specific purposes on a case-by-case basis to ensure the confidentiality of this data is maintained.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Home Office and Department of Health and Social Care hold responsibility for the majority of concerns and lead related recommendations.
Verbatim wording from the response “Responsibility for the majority of the concerns raised in your report sits with the Home Office and Department of Health and Social Care and we have seen and support the response that the Home Office sent you on 23rd August. However, we have separately considered the third concern in your Report where you refer to a lack of information sharing between agencies, including no singular database for all agencies to input common concerns and a lack of robust policy of information sharing regarding both suicidal ideation, self-harm as well as identification of the vulnerable.” Source location Response from Ministry of Justice
Open published response
19 May 2022 Spencer George BARR · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Lack of central points of contact for inter-agency referrals and information sharing View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham Women'S and Children'S NHS Foundation Trust Change, Grow, Live Probation Young Adults Central Team Birmingham
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Probation Young Adults Central Team Birmingham
Establish and operate a central Probation point-of-contact email for inter-agency information sharing.
View source
Probation Young Adults Central Team Birmingham
Raise partner-agency awareness of the central point of contact to facilitate ongoing information sharing.
View source
Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, Live
Grant CGL licences to access important clinical patient details.
View source
Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, Live
Include alternative contact details in out-of-office messages when named professionals are unavailable.
View source See 1 more action
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AI-generated summary
Spencer George BARR · 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
Spencer George BARR was found unresponsive at home on 9 December 2021 and was declared deceased by paramedics after an overdose involving opioids, cocaine and pregabalin. He had a long history of substance misuse and labile mental health and was under the care of probation, addiction and mental health services. The principal concerns were inadequate sharing of information and cooperation between agencies, the lack of central points of contact, and limitations on inter-agency referrals.
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× 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 central points of contact for inter-agency referrals and information sharing
Wider context from the report “4. Additionally, I am concerned that there appear to be no central points of contact for agencies to facilitate that co-operation . I heard evidence that CGL has no central point of contact for referrals being made/to allow sharing of information - instead relying on information being conveyed via specific individuals. I am therefore concerned that where there is no central point of contact, there is a risk of information not being passed on in a timely manner when a specified person is absent from work for whatever reason . Consideration should be given to central points of contact being created within each agency, and ensuring that those points of contact are shared between agencies to ensure information can flow freely between them.
” Source location Spencer George BARR · Prevention of Future Deaths report
Open source report
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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 and operate a central Probation point-of-contact email for inter-agency information sharing.
Verbatim wording from the response “Response – Probation now has a central point of contact e-mail wmps.birminghamcstransfers@justice.gov.uk. Probation is taking steps to raise awareness of this SPOC with partner agencies to ensure this central point of contact facilitates information to be shared at all times.” Source location Response from Probation Service
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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 partner-agency awareness of the central point of contact to facilitate ongoing information sharing.
Verbatim wording from the response “Response – Probation now has a central point of contact e-mail wmps.birminghamcstransfers@justice.gov.uk. Probation is taking steps to raise awareness of this SPOC with partner agencies to ensure this central point of contact facilitates information to be shared at all times.” Source location Response from Probation Service
Open published response
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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 Grant CGL licences to access important clinical patient details.
Verbatim wording from the response “Response to matters of concern 4 & 5
In FTB both the service user’s named Core Worker and Lead Professional act as central point of contact. Additionally, each clinical team has a Duty Worker who is allocated at each shift and acts as a point of contact if the service user’s named Core Worker or lead professional is not available this ensures that there is always a specific allocated point of contact in the working day to share essential information. FTB is committed to ensuring information is shared across agencies to support patient safety and we have agreed to grant licences to CGL that will enable them to access important clinical patient details.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
Open published response
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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 alternative contact details in out-of-office messages when named professionals are unavailable.
Verbatim wording from the response “When the Core Worker or lead professional is not available the out of office message will include the telephone number for colleagues who can redirect queries and make arrangements to make contact with patients in a crisis.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
Open published response
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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 named workers, duty workers and out-of-office arrangements provide central points of contact for information sharing and crisis queries.
Verbatim wording from the response “Response to matters of concern 4 & 5
In FTB both the service user’s named Core Worker and Lead Professional act as central point of contact. Additionally, each clinical team has a Duty Worker who is allocated at each shift and acts as a point of contact if the service user’s named Core Worker or lead professional is not available this ensures that there is always a specific allocated point of contact in the working day to share essential information. FTB is committed to ensuring information is shared across agencies to support patient safety and we have agreed to grant licences to CGL that will enable them to access important clinical patient details.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
Open published response
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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 CGL disputes that it lacks a central contact or accepts only GP referrals, citing established contacts and referrals from multiple agencies.
Verbatim wording from the response “We would like to reassure you that CGL have an established central point of contact and have accepted referrals from any individual and agency since March 2015 when the service was commissioned in Birmingham. Referrals can be made via the telephone or the CGL website at the following link https://www.changegrowlive.org/drug-alcohol-service-birmingham/referrals.” Source location Response from Birmingham Women's and Children's NHS Foundation Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.