Recurring concern

Unreliable forensic collision investigations in fatal incidents

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First reported 23 May 2025•Latest report 25 Jun 2025

Definition

What this concern includes

Includes failures in forensic collision investigations following fatal incidents that affect commissioning, scope, evidence gathering, investigative terms of reference, required measurements, completion or availability of the final investigation report.

Not included

Excludes general police, IOPC, homicide or forensic investigations that are not specifically forensic collision investigations following fatal incidents.
Excludes routine road-collision reporting, highway-risk assessment and remedial-road processes where no forensic collision investigation deficiency is identified.
Excludes failures in applying lessons or policies after a complete forensic collision investigation unless the investigation process itself was incomplete or unavailable.
Excludes generic evidence-gathering, specialist-support or scene-management failures that are not directly part of a forensic collision investigation.

Reports: 2
Individual concerns: 2
Date range: 2025–2025
Stated actions: 4

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Independent Office for Police Conduct2

College of Policing1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

25 Jun2025
Birmingham and Solihull
Concerns raised1
1. Failure to obtain full forensic collision investigation reports in fatal incidents
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Require lead investigators to assess each fatal road traffic incident and consult the Coroner early about whether a full forensic collision investigation report is needed.
  Stated by Independent Office for Police ConductStated planned
2. Action
  Update internal guidance for lead investigators to address securing full forensic collision reports and consulting the Coroner about the investigative approach.
  Stated by Independent Office for Police ConductStated planned
3. Action
  Have internal technical leads liaise with investigators early in road traffic fatality investigations to support appropriate evidence considerations.
  Stated by Independent Office for Police ConductStated planned
Respondent positions 3
1. Position
  The respondent lacks the technical skills and expertise to undertake collision investigation work itself.
  Stated by Independent Office for Police ConductUnable to act
1. Position
  Policing partners are responsible for providing independent collision investigation assistance within their technical expertise.
  Stated by Independent Office for Police ConductRedirects responsibility
2. Position
  The streamlined collision investigation report was considered sufficient because evidence indicated the police vehicle had not caused the collision through physical contact.
  Stated by Independent Office for Police ConductExisting arrangements considered sufficient
AI-generated summary

Muhammad QASIM · 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

Muhammad QASIM died on 2 October 2023 after a high-speed BMW collision in which the vehicle left the road and struck two trees; he suffered unsurvivable traumatic head injuries. The report raises concerns about differing interpretations and training regarding spontaneous police pursuits, and about investigative responsibilities and the absence of a full forensic collision investigation report in fatal incidents involving a conduct investigation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to obtain full forensic collision investigation reports in fatal incidents
Wider context from the report
“2. For the IOPC: The IOPC were investigating the conduct of the police driver in this case. As a result of their investigation no full forensic collision investigation report was obtained. The IOPC need to confirm where investigative responsibilities lie when a conduct investigation is being conducted in all fatal incidents to ensure lessons are learnt from the death and adequate evidence is obtained. The lack of a full forensic collision investigation report in this case creates a risk of future deaths and action should be taken. ”
Source location
Muhammad QASIM · 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
Require lead investigators to assess each fatal road traffic incident and consult the Coroner early about whether a full forensic collision investigation report is needed.

Verbatim wording from the response
“Going forward, all lead investigators will need to assess the circumstances of an incident and have early contact with the Coroner to determine whether a full Forensic Collision Investigation Report is required. If one is required, we will either request this from a police force or source an independent report if necessary.”

Source location
Response from the IOPC
Page 4 · response
Published 5 September 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Update internal guidance for lead investigators to address securing full forensic collision reports and consulting the Coroner about the investigative approach.

Verbatim wording from the response
“We will update the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Our internal guidance will be updated within the next six weeks but in the meantime, our internal technical leads will liaise with investigators in the early stages of any investigations involving a road traffic fatality to ensure the correct considerations are made.”

Source location
Response from the IOPC
Page 4 · response
Published 5 September 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Have internal technical leads liaise with investigators early in road traffic fatality investigations to support appropriate evidence considerations.

Verbatim wording from the response
“We will update the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Our internal guidance will be updated within the next six weeks but in the meantime, our internal technical leads will liaise with investigators in the early stages of any investigations involving a road traffic fatality to ensure the correct considerations are made.”

Source location
Response from the IOPC
Page 4 · response
Published 5 September 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The respondent lacks the technical skills and expertise to undertake collision investigation work itself.

Verbatim wording from the response
“With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of”

Source location
Response from the IOPC
Page 1 · response
Published 5 September 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Policing partners are responsible for providing independent collision investigation assistance within their technical expertise.

Verbatim wording from the response
“With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of”

Source location
Response from the IOPC
Page 1 · response
Published 5 September 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The streamlined collision investigation report was considered sufficient because evidence indicated the police vehicle had not caused the collision through physical contact.

Verbatim wording from the response
“The IOPC lead investigator was advised that a full forensic collision report into the crash would not ordinarily be produced because Mr Qasim’s vehicle had not collided with another vehicle– it had left the road and impacted with a tree.”

Source location
Response from the IOPC
Page 2 · response
Published 5 September 2025
Open published response
23 May2025
Inner North London
Concerns raised1
1. Failure to include measurement of the distance between pursuing and subject vehicles in forensic collision investigation terms of reference
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Update internal guidance to require investigators to consider distance calculations in collision-investigator terms of reference and consult the Coroner about the investigative approach.
  Stated by Independent Office for Police ConductStated in progress
Respondent positions 2
1. Position
  Collision investigation, including measuring vehicle distances, is assigned to specialist Forensic Collision Investigators rather than undertaken by the IOPC.
  Stated by Independent Office for Police ConductRedirects responsibility
1. Position
  Distance measurement may not be possible or proportionate in every road traffic collision investigation because the process can be complicated and time-consuming.
  Stated by Independent Office for Police ConductUnable to act
AI-generated summary

Lewis Dean JOHNSON · 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 Johnson died aged 18 as a consequence of a road traffic collision while riding a motorcycle during a police pursuit in London on 9 February 2016. The inquest identified that the forensic collision investigation had not been instructed to measure the distance between the pursuing police vehicle and the motorcycle, leaving the jury without clear objective evidence on that issue.

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 include measurement of the distance between pursuing and subject vehicles in forensic collision investigation terms of reference
Wider context from the report
“At inquest I heard that the terms of reference set out for the forensic collision investigator by the IOPC (then IPCC) at the outset of the investigation, did not include an instruction to attempt to measure the distance between the pursuing vehicle and the subject vehicle at points when the two appeared to be closer together. Obviously this omission did not have an impact upon Lewis Johnson’s death, but it did have an impact upon the inquest. It meant that the jury had no clear objective evidence about the distance between his motor cycle and the police car behind. Given that learning and at times policy are informed by such findings, it appears that this would be helpful to include in future investigations when death follows a police pursuit. ”
Source location
Lewis Dean JOHNSON · 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
Update internal guidance to require investigators to consider distance calculations in collision-investigator terms of reference and consult the Coroner about the investigative approach.

Verbatim wording from the response
“We are in the process of updating the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Following your Preventing Future Deaths Report, our guidance will now also require investigators to consider if a distance calculation should form part of the terms of reference for the Forensic Collision Investigator. This guidance will be available to IOPC lead investigators within the next fortnight.”

Source location
Response from Independent Office for Police Conduct
Page 2 · response
Published 29 May 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Collision investigation, including measuring vehicle distances, is assigned to specialist Forensic Collision Investigators rather than undertaken by the IOPC.

Verbatim wording from the response
“We work to ensure we gather all relevant and available evidence and seek expert advice where it is necessary and proportionate to the circumstances of the case. Collectively, this helps to inform the investigation and our ability to reach evidence-based decisions. With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of objective and unbiased opinion in relation to matters within their expertise. The reports produced by Forensic Collision Investigators are provided to the IOPC and the salient points are then included in the IOPC investigation report.”

Source location
Response from Independent Office for Police Conduct
Page 1 · response
Published 29 May 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Distance measurement may not be possible or proportionate in every road traffic collision investigation because the process can be complicated and time-consuming.

Verbatim wording from the response
“The Forensic Collision Investigator would be the expert responsible for measuring distance between two vehicles. However, it is our understanding that this process is not always possible or straightforward and can, on occasion, be particularly complicated and take a significant amount of time. In light of this it may not be possible, or proportionate, in every road traffic collision investigation to pursue this line of enquiry.”

Source location
Response from Independent Office for Police Conduct
Page 2 · response
Published 29 May 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to obtain full forensic collision investigation reports in fatal incidents

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

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

Concerns raised1

Failure to include measurement of the distance between pursuing and subject vehicles in forensic collision investigation terms of reference

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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

Actions described in response 3

Respondent positions 3

Actions described in response 1

Respondent positions 2