Recurring concern

Unreliable provision and readiness of torches for safety-critical site and search work

First to latest report 22 Jun 2018 — 30 Mar 2026

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
3

What this concern includes

Includes failures to provide, select, maintain, charge, check or replace torches used by site-security officers, search personnel or comparable safety-critical operational staff where inadequate torch readiness or suitability can impair safe visibility, searching or emergency response.

What is not included
  • Excludes ordinary personal or domestic torch use where no safety-critical site, search or operational function is identified.
  • Excludes general lighting deficiencies in premises, roads or public areas where the issue is fixed illumination rather than torch provision or readiness.
  • Excludes unrelated failures of mobile phones, radios or other equipment unless the assertion also identifies a deficient torch control.
  • Excludes generic staffing, training or search-planning deficiencies where torch suitability or readiness is not the unsafe condition.

Reports and published responses 2 reports

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

  1. Teesside and Hartlepool

    AI-generated summary

    Grant Nicholas LOWRY · 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

    Grant Nicholas LOWRY left home on 1 June 2022 after sending a text indicating suicidal intent and was found deceased in the early hours of 3 June 2022 following an uncoordinated search. Concerns included inaccurate and incomplete recording of search information, communication failures, delayed requests for additional search resources, and inadequate operational equipment for one officer. The inquest found that missed opportunities in mental health care and the search deficiencies contributed to the circumstances surrounding his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain charged batteries for search equipment and work mobile phones

    Wider context from the report

    “There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include: 1. The location of the first NPAS heat source was not recorded accurately. 2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area. 3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded. 4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search. 5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas. 6. The family were told that no heat sources had been identified by NPAS. 7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces. 8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat. ”

    Source location

    Grant Nicholas LOWRY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review officer equipment and personal protective equipment requirements for searches through the Dress and Equipment Group and Health and Safety Group.

    Verbatim wording from the response

    “This will be referred to the force’s Dress and Equipment Group and the Heath & Safety Group to review the matter and learning from the inquest. Both the Dress and Equipment Group and the Health and Safety Group will review officer equipment requirements and personal protective equipment. Both Groups will consider whether the current provision and equipment requirements meet the requirements of conducting searches. In addition, direct one-to-one reflective learning will be included regarding individual officers’ responsibilities in respect of operational equipment and escalating issues with equipment to their supervisor.”

    Source location

    Response from Cleveland Police
    Page 5 · response
    Published 7 April 2026

    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

    Provide one-to-one reflective learning on officers’ operational equipment responsibilities and escalation of equipment problems to supervisors.

    Verbatim wording from the response

    “This will be referred to the force’s Dress and Equipment Group and the Heath & Safety Group to review the matter and learning from the inquest. Both the Dress and Equipment Group and the Health and Safety Group will review officer equipment requirements and personal protective equipment. Both Groups will consider whether the current provision and equipment requirements meet the requirements of conducting searches. In addition, direct one-to-one reflective learning will be included regarding individual officers’ responsibilities in respect of operational equipment and escalating issues with equipment to their supervisor.”

    Source location

    Response from Cleveland Police
    Page 5 · response
    Published 7 April 2026

    Open published response

  2. Inner North London

    AI-generated summary

    Samuel Patrick CLARKE · 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

    Samuel Patrick Clarke, aged 19, accessed a construction site in the early hours of New Year’s Day 2018 and fell from height. He was not found until 2 January 2018 and had died from postural asphyxia following the fall and traumatic injury, with ethanol intoxication also recorded. Concerns included continued unauthorised access through a turnstile, the absence of a company contingency plan to support searches for intruders, and the adequacy of security officers’ torches.

    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

    Inadequate torch equipment for site security officers

    Wider context from the report

    “3. The site security officers explained to me that they were equipped with battery operated regular sized torches, rather than large flashlights. No consideration has been given to improving their equipment in this regard. Could it be? ”

    Source location

    Samuel Patrick CLARKE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Replace guards’ night-patrol torches with INFRAY flashlights providing an 800-lumen, 240-metre beam.

    Verbatim wording from the response

    “The torches used by the security guards during night time patrol were Maglite 2 Cell torches. These torches are designed for harsh environments and used by the emergency services. Although they are believed to be sufficiently adequate and appropriate for night time patrols, the security guards now use a more powerful INFRAY flashlight, which has a beam distance of 240 metres and 800 lumens.”

    Source location

    2018-0191-Response-by-Canary-Wharf-Group-Plc_Redacted
    Page 6 · response
    Published 9 July 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The previous Maglite torches were considered sufficiently adequate and appropriate for night-time security patrols.

    Verbatim wording from the response

    “The torches used by the security guards during night time patrol were Maglite 2 Cell torches. These torches are designed for harsh environments and used by the emergency services. Although they are believed to be sufficiently adequate and appropriate for night time patrols, the security guards now use a more powerful INFRAY flashlight, which has a beam distance of 240 metres and 800 lumens.”

    Source location

    2018-0191-Response-by-Canary-Wharf-Group-Plc_Redacted
    Page 6 · response
    Published 9 July 2018

    Open published response

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

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Data last updated 7 September 2026