Recurring concern

Failure of police operational communications to reliably share safety-critical information

First to latest report 21 Oct 2013 — 17 Mar 2026

Reports that mention this concern
34
Times this concern has been raised
40
Stated actions linked to this concern
65

What this concern includes

Includes failures in police force control, incident, custody or inter-force communications where relevant risk or safety information is not reliably shared with attending personnel or partner services, including the anchor's omission of recent s136 detention information and failures to pass complete incident information to attending officers.

What is not included
  • Excludes generic clinical, social-care or non-police handover and documentation failures unless they are explicitly part of a police operational communication pathway.
  • Excludes failures concerning the content, training or policy of a police process where communication of safety-critical information is not itself the shared unsafe condition.
  • Excludes generic information-technology, staffing or supervision deficiencies that are not explicitly tied to the reliability of police operational communications.
  • Excludes communications about non-safety-critical administrative information.

Reports and published responses 34 reports

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

  1. County Durham and Darlington

    AI-generated summary

    Natalie Louise AINSWORTH · 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

    Natalie Louise Ainsworth, aged 29, was found deceased on 13 February 2025 at an address in Stanley, County Durham. Police were informed that she had earlier threatened to take her own life, but this information was not known to key officers and was not included in the subsequent risk assessment or response. The report also identified that the risk assessment failed to properly consider known or expected information about her vulnerability and history of mental health issues, self-harm and substance abuse.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to communicate critical missing-person welfare information to relevant officers

    Wider context from the report

    “Natalie was a vulnerable missing person considered to be at medium risk. A call was made to Police on the 13th February 2025 at 15:01 hours expressing concern for Natalie's welfare and informing Police of a new address where she may be and informing Police that she had earlier threatened to take her own life. Although the control room recorded that information was passed on to the relevant officer, neither the Inspector who undertook an updated a risk assessment some two hours later, nor the Officer making enquiries, was aware that Natalie had threatened to take her own life. This important information was therefore not part of the risk assessment and not factored into subsequent Police actions, including in terms of whether to force entry to the property which was visited by the Police. Further the risk assessment carried out at 1704 hours was not a robust assessment of the risks which were known, or ought to have been known, by Police at that time. In particular the risk assessment fails to consider Natalie's vulnerability as a person with a history of mental health issues, self harm and substance abuse, records incorrectly that there is no indication that the person is likely to take their own life, records incorrectly that the person has no mental health issues, and records incorrectly that the person has not been involved in a violent incident prior to them disappearing. An accurate and robust assessment of risk is essential to ensure that the nature and extent of any Police response is proportionate, and resources deployed appropriately, particularly when welfare/safety concerns are raised, as they were in Natalie's case. ”

    Source location

    Natalie Louise AINSWORTH · Prevention of Future Deaths report
    Page 1 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a process for directly recording and sharing new or updated missing-person information with investigating officers and reviewing supervisors.

    Verbatim wording from the response

    “Since the issuing of the notice the Force have reviewed processes around the recording of additional information received into the Force Control Room as part of a missing person investigation.”

    Source location

    Response from Durham Constabulary
    Page 1 · response
    Published 26 March 2026

    Open published response

  2. Essex

    AI-generated summary

    Aminata Coulibaly · 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

    Aminata Coulibaly died at home between the evening of 24 June and the morning of 25 June 2022 from acute alcohol toxicity, with respiratory depression as the mechanism; the manner in which the alcohol entered her system could not be determined. The report identifies concerns about safeguarding, information-sharing and recording by Essex Police and the mental health trust, including failures relating to her expressed suicidal thoughts and the handling of the hate crime 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 share relevant police contacts with the mental health Trust

    Wider context from the report

    “(1) Essex Police were aware that Aminata Coulibaly was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime. Essex Police did not update the mental health Trust that Aminata Coulibaly sent 2 emails on 22 June 2022 in response to her being informed (incorrectly) that the Hate Crime investigation by Essex Police had been closed: i. to the officer in the case, setting out elements of how she is being treated, elements of the hate crime and that she is not happy with the decisions made by Essex Police and she feels like taking her life. ii. to the Quality Service Team that was forwarded to the Hate Crime police sergeant on 23 June 2022, stating that Aminata Coulibaly wants to contest the decision made by the officer to close the case and that she is facing suicidal thoughts, anxiety and depression. These were not uploaded to Athena or the shared with the mental health Trust. 2. Aminata made a very distressed phone call to the officer in the case on 24 June 2022 and this was not placed on Athena or shared with the mental health Trust. 3. On 26 June 2022 the mental health Trust called Essex Police reporting concerns for Ms Coulibaly’s welfare. The Essex Police contact handler did not record important information reported by the mental health Trust that: a. Aminata had suffered assault and racial abuse by her neighbours b. The mental health Trust had texted Aminata Coulibaly to say that if they did not hear from her by 5pm then they would contact the police for a welfare check. c. Aminata Coulibaly has been having strong thoughts to end her life. 4. On 26 June 2022 a different Essex Police contact handler contacted the mental health Trust to update them on the outcome of their concern for welfare that the police would not attend as it did not meet the criteria. The contact did not ask for clarification when the mental health Trust nurse raised concern when informed that the decision was made that police were not going to attend when he asked, “even though it is life and limb?”. The contact handler did not clarify if there had been any update in the circumstances, these words had not been used by the Trust nurse in the first call. The evidence from the Force Control Room Inspector was that the contact handlers should have recorded relevant information and sought further clarification that this should have been relayed back to her. This would not have made a difference for Aminata Coulibaly as she was probably deceased but is relevant to prevent a future death and ensure that the Inspector has all relevant information when applying THRIVE to assess risk and response. ”

    Source location

    Aminata Coulibaly · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update investigation policy and procedure to require safeguarding reassessment, referrals, referral documentation, outcomes and recorded justification before case closure.

    Verbatim wording from the response

    “• Essex Police has updated policy and procedure to direct action to be taken to investigate crime, support victims, and share information. Of key importance is procedure B0602 Investigation of Crime, updated in September 2025 which states at 3.7:”

    Source location

    Response from Essex Police
    Page 2 · response
    Published 1 December 2025

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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 a Mental Health Triage team within the Strategic Vulnerability Centre to improve police, health and social-care safeguarding pathways and information sharing.

    Verbatim wording from the response

    “Since 2022, Essex Police have established a Mental Health Triage team to improve safeguarding pathways and referrals. They are a strategic department within our Strategic Vulnerability Centre (SVC) that works with partners to provide a holistic overview of mental health across Essex and exists to bridge the gap between the police and partner agencies. They work with partners regarding mental health policies and procedures to ensure they are collaborative and fit for purpose. This has been achieved by:”

    Source location

    Response from Essex Police
    Page 8 · response
    Published 1 December 2025

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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

    Where police are not primarily responsible, incidents should be referred or directed to the appropriate agency, subject to specified police duties.

    Verbatim wording from the response

    “• The Concern for Welfare policy which was detailed during the inquest hearing and sets out the police response to such calls has been superseded by the Right Care, Right Person (RCRP) policy D 0800 and procedures D 0801 to 803. These came into effect in early 2024 and follows national guidance which was developed with partner agencies including the NHS. These procedures establish that the right agency deals at first point of contact, and then throughout an incident. This provides clarity to Essex Police officers and staff to make operational decisions when responding to call for service involving medical support, physical, and mental health, from members of the public or partner agencies.”

    Source location

    Response from Essex Police
    Page 4 · response
    Published 1 December 2025

    Open published response

  3. South Yorkshire (Western)

    AI-generated summary

    Andrew Herrin Dodds · 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

    Andrew Herrin Dodds was assessed and detained under section 136 after expressing suicidal thoughts and threatening to harm himself, but was later released and allowed to board a train. He took his own life on the train and was pronounced deceased at Tamworth train station. The principal concerns were failures to pass on next-of-kin and recent section 136 information, and missing information that might have prompted further contact with mental health 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

    Failure to include recent s136 detention information in force control communications

    Wider context from the report

    “(2) There was missing information on the PNC check which meant that Andrew was not flagged as recently being held under s136. The further email from force control also did not mention that he was recently detained under s136. I was told if this had been on the system BTP would have contacted mental health services for more information. ”

    Source location

    Andrew Herrin Dodds · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

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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

    Failure to pass relevant details, including next-of-kin information, to the s136 suite

    Wider context from the report

    “(1) Police did not pass over relevant details including next of kin to the s136 suite meaning next of kin could not be contacted. They also did not inform next of kin to contact the s136 directly and did not provide any further updates. This happened shortly after a shift change over so whether a full handover was provided between officers to allow this information to be given is not clear. ”

    Source location

    Andrew Herrin Dodds · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. East London

    AI-generated summary

    Jake Hickey Girton · 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

    Jake Hickey Girton was admitted to psychiatric hospital following suicidal ideation and serious, sustained alcohol misuse, and was later arrested after an incident on the ward. He was released from police custody without the psychiatric Trust being informed and was subsequently found deceased at home on 26 January 2024; the inquest identified concerns about the failure to notify the Trust and the lack of evidence of reflection or remediation by the Metropolitan Police Service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to inform the hospital of release from police custody

    Wider context from the report

    “1. Evidence heard from a Metropolitan Police Inspector at inquest indicated that the police officer who was investigating the offence for which Jake was arrested was under an obligation to inform that complainant (the hospital) of Jake’s release from custody. There is no evidence to suggest this was done. Evidence from the Psychiatric trust at inquest indicates that on the 17th January 2024, there were under the impression that Jake would remain in police custody, and had they known he was released, greater efforts may have occurred to support Jake in the community. ”

    Source location

    Jake Hickey Girton · 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

    Complete mapping of existing information-sharing pathways for releases from custody.

    Verbatim wording from the response

    “A review has already been undertaken in relation to information sharing with Mental Health Trusts which has identified a gap in current arrangements. Specifically, there is no consistent mechanism to ensure Mental Health services are notified when an individual is released from custody. This gap can result in missed opportunities for early intervention and continuity of care.”

    Source location

    Response from Metropolitan Police
    Page 4 · response
    Published 3 October 2025

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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 a protocol for lawful, prompt notification of appropriate mental health services when people in crisis are released from custody.

    Verbatim wording from the response

    “2. The MPS is developing a protocol, agreed through local partnership governance to ensure that when a person identified as being in mental health crisis or having been arrested in a mental health setting, is released from custody, relevant information can be shared promptly and lawfully with the appropriate Mental Health Trust or Community Mental Health Team, if known. This protocol is being aligned with data protection and safeguarding requirements under existing information governance frameworks.”

    Source location

    Response from Metropolitan Police
    Page 4 · response
    Published 3 October 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with mental health partners to develop consistent London-wide arrangements, accountability lines and welfare escalation routes after release.

    Verbatim wording from the response

    “3. The MPS is working with Mental Health Trust Leads and the Joint Mental Health and Police Group (JMHPG) to develop consistent arrangements across London. This includes establishing clear lines of accountability and escalation routes where concerns arise about a person’s welfare post release.”

    Source location

    Response from Metropolitan Police
    Page 4 · response
    Published 3 October 2025

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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 guidance for custody and investigating officers on identifying risk, recording indicators and initiating referrals or notifications before release.

    Verbatim wording from the response

    “4. Additional guidance is being developed for custody and investigating officers, supported by the MPS Mental Health Lead. This will reinforce the importance of identifying those at risk, recording relevant indicators and initiating the appropriate referral or notification before release.”

    Source location

    Response from Metropolitan Police
    Page 4 · response
    Published 3 October 2025

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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 DPS review was appropriate and went as far as expected because it identified no conduct, performance or organisational learning.

    Verbatim wording from the response

    “The MPS Directorate of Professional Standards (DPS) conducted a comprehensive review into this matter as per their remit and standard operating procedure. It was determined that this incident did not meet the definition of a Death or Serious Injury¹ (DSI) following police contact as defined in the Independent Office for Police Conduct (IOPC) Statutory Guidance. Upon conducting DSI reviews, the expectation is for DPS to also consider whether there is an obvious conduct matter, performance matter or opportunity for individual or organisational learning. In this instance, the review did not identify any such learning.”

    Source location

    Response from Metropolitan Police
    Page 5 · response
    Published 3 October 2025

    Open published response

  5. Dorset

    AI-generated summary

    Jairus Joshua Timothy Earl · 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

    Jairus Joshua Timothy Earl, aged 15, died by suicide on 14 April 2024 after using one of his father’s shotguns at the family’s Dorset property. The concerns relate to gaps in the regulation of shotgun licences, including the lack of requirements to notify police about additional properties, inadequate information-sharing and address flagging between police forces, and limited access to medical information about other people living at a licence holder’s property.

    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 inter-force sharing and flagging of information about shotgun licence holders and shotgun locations

    Wider context from the report

    “(1) I have concerns in relation to gaps in the regulation of shotgun licences especially when a licence holder has more than one property where the guns may be used or stored. The Firearms Act 1968 (The Act) is the primary legislation that governs the possession and handling of firearms. This is supported by statutory guidance, Firearms Licensing: Statutory Guidance for Chief Officers of Police and non statutory Home Office guidance, Guide on firearms Licensing Law. Section 2 of the Act deals with the requirement of certificate for possession of shotguns. Evidence was given at the Inquest by Acting Chief Inspector ████████ of Dorset Police who works within the Dorset Firearms and Explosive Licensing Unit and also works with the College of Policing and the national Firearms & Explosive Licencing Working Group to review and update the Home Office statutory guidance and support the national training effort in response to the Prevention of Future Deaths report from the Inquest touching upon the deaths in Keyham on 12th August 2021. He gave evidence that the regulation for shotguns is different to the regulations for firearms which is governed by Section 1 of The Act. There seems to be a great deal of difference in the regulation of firearms and the regulation of shotguns, however both can equally cause death. I am concerned that the lack of regulation around shotguns could lead to future deaths. For example, he explained that there is no obligation on a licence holder of a shotgun licence to notify the approving force they are moving to or visiting another property In his written evidence to the Court, which was further expanded on orally at the Inquest, he explained: “Under section 26B(1) of the 1968 Act, an application for the grant of a shotgun shall be made to the chief officer of police where the applicant resides, there is nothing within the firearms act to define a residence or when applicants have properties in different force areas, the non-statutory guide tells me that where an applicant has a residences in different force areas, it is for the individual to decide which force issues their certificate. Shotgun certificates are issued by individual forces’ and will display the force crest and signature of the chief officer of the issuing force, however they are valid throughout England and Wales, and allows the holder to travel with their shotguns anywhere in the United Kingdom. … Shotgun certificates differ from firearm certificates in a number of ways, for firearms, possession of each and every gun must satisfy individual good reason, whereas a good reason for a shotgun is a collective term, and more relaxed, for example a request for a firearms certificate for target shooting will require that the applicant is a member of a Home Office approved club and shoots regularly, whereas a mere intention to undertake clay pigeon shooting would satisfy good reason for a shotgun certificate. A shotgun certificate also will also authorise a person to have in their possession, purchase or acquire and unlimited number of shotguns without the need for approval in respect of individual guns, that is to say that so long as the shotguns are stored securely a person may have as many as they want. Another nuance of the shotgun certificate is the ’72-hour rule’ that it will allow a certificate holder to borrow a shotgun for up to 72 hours without the need to have to record the shotgun on the certificate or notify the police of the transfer. … Section 28(2)(a) of the 1968 Act provides that a shotgun certificate is granted subject to any prescribed conditions, and no others, that is that these conditions must be applied to the certificate, but the chief officer cannot add additional conditions. … There is no onus on an applicant to notify another force area where they hold a certificate and have another address in that force area, this is only the case if the certificate holder changes their permanent address that this would be captured by the third condition. There is also no obligation on a certificate holder to notify a chief officer of police when they intent to visit another force area in possession of their shotguns. Acting Chief Inspector ████████ explained that on the Tuesday following Jairus’ death he briefed the national coordinator from the Firearms & Explosive Licencing Working Group to raise matters arising from the circumstances of Jairus’ death so there is awareness of the issues relating to second homes, however, there is no legal requirement for second homes to be declared by licence holders. He further told the Court that in 2015, HM Inspection of Firearms Licencing recommended that forces must have a notification system on their local records to identify addresses and people where firearms are held. He explained that these systems are local rather than national and his recommendation to the Firearms & Explosive Licencing Working Group following Jairus’s death was that where an applicant declares a second home, the force where that home is located should be notified. Dorset Police have taken action and put a system in place that when they are notified of the above, they will create a record on their system to flag the address as if that were a Dorset certificate holder, however it is not a legal requirement for forces to do this, and it is unknown if other forces nationally are doing this. I therefore have concerns there is a lack of a system of sharing and flagging information between Police forces regarding shotgun licence holders and the location of shotguns, which could lead to future deaths. Accordingly, emergency services may attend an address where shotguns are held without knowledge of that fact due to the lack of a marker being placed on the address. This causes a risk to all those attending unmarked addresses as they would potentially be ill prepared for what they could face which could lead to future deaths. Additionally failing to have such markers on additional homes means that if the police are called to the address for other reasons such as a concern for welfare, they may miss the opportunity to put in place additional security measures ,or even revoke the licences, as required for the safety of the occupants at the address, and others. Evidence was heard that Dorset Police were called to Jairus’s family address in Dorset on the 28th March 2024 following a report that Jairus was missing. It was not apparent from the Police system at the time that there would be shotguns at the address. Jairus’s mental health was discussed during the report of this incident. Had the flag system been in place then, consideration could have been given to the continued possession of the shotgun in a property where Jairus could access them. ”

    Source location

    Jairus Joshua Timothy Earl · Prevention of Future Deaths report
    Page 4 · 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

    Develop proposed changes with the Home Office to require declaration of second-home firearm storage in statutory guidance and application forms.

    Verbatim wording from the response

    “would become too complicated for example if new rules were created for licence holders without second homes to inform policing every time their firearms are temporarily away from home when attending shooting locations. We would not have the capacity to check and authorise such short-term arrangements.”

    Source location

    Response from National Police Chief's Council
    Page 2 · response
    Published 16 July 2025

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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 the National Firearms Licensing Management System to provide consistent national licensing processes and enable second-home firearm notifications to local force systems.

    Verbatim wording from the response

    “In addition to the above there is a significant programme of works underway chaired by the NPCC Firearms Licensing Lead and project managed by Police Digital Services (PDS) to develop a brand-new National Firearms Licensing Management System (NFLMS). Of the various aspirations with this new system, it will deliver the much-needed consistency required as all firearms licensing teams, licence holders and applicants will use it. It will align with many systems already used by policing and in relation to this tragic incident there would be opportunities for second homes to subsequently alert local force systems that firearms may be present on those premises.”

    Source location

    Response from National Police Chief's Council
    Page 2 · response
    Published 16 July 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Amend firearm and shotgun applications to capture additional residences and update NFLMS to record those locations.

    Verbatim wording from the response

    “light of your Regulation 28 Report, we will be amending the firearm and shotgun application form as soon as is practicable to request details of any second (or additional) residences where guns may be held, so that police are aware of where firearms are being stored, including where guns are being stored in different police force areas. This change to the application form will be implemented via Statutory Instrument and will also require a change to the NFLMS to ensure such details are recorded. We are therefore adding this change to planned adjustments to the system, which we expect to be completed in early 2026. In the meantime, this issue will be addressed by the police when undertaking suitability interviews with applicants or certificate holders.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 16 July 2025

    Open published response

  6. Inner West London

    AI-generated summary

    Oladeji Adeyemi Omishore · 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

    Oladeji Adeyemi Omishore died on 4 June 2022 after being tasered during an incident involving police officers on Chelsea Bridge and then entering the River Thames; his medical cause of death was complications arising from drowning. The report identified concerns about the recording and transmission of mental health information by call handlers and dispatchers, and about training for responding officers in tactical options before taser deployment.

    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 dispatcher training on information to pass to responding officers

    Wider context from the report

    “9. That dispatchers may require training in relation to what to pass out more generally given the confusion in the evidence about other units being assigned by CAD, which dispatchers themselves did not seem to appreciate and understand let alone pass such information out to responding officers. ”

    Source location

    Oladeji Adeyemi Omishore · Prevention of Future Deaths report
    Page 5 · 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

    Enhance dispatcher training and lesson plans on communicating CAD-assigned units to responding officers.

    Verbatim wording from the response

    “We recognise the need for greater clarity and understanding among dispatchers regarding what information needs to be communicated more generally. Training will be enhanced to address the confusion identified in the evidence, specifically in relation to other units being assigned via Computer Aided Despatch (CAD) and the necessity for dispatchers to fully understand and communicate this to responding officers. Lesson plans will be updated accordingly.”

    Source location

    Response from Metropolitan Police
    Page 4 · response
    Published 27 March 2025

    Open published response

  7. Cornwall and Isles of Scilly

    AI-generated summary

    Lachlan Charles Campbell · 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

    Lachlan Charles Campbell was found unconscious outside a railway station after taking drugs and died in hospital on 1 November 2022 following hypothermia, bronchopneumonia and combined drug intoxication. The report identifies concerns about delayed ambulance attendance, delays in hospital handovers, inadequate care by responding police officers, and information sharing between police and ambulance 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

    Failure to share information about ambulance delays between police and ambulance services

    Wider context from the report

    “2) Information Sharing There is a concern also about how information was shared between the police and ambulance service. Both police officers said that, had they been aware of the extent of ambulance delays, they may have considered other options, notably, conveying Lachlan to hospital in a police car. I am writing separately to SWAST and Devon & Cornwall Police in this regard and you do not need to address this concern. ”

    Source location

    Lachlan Charles Campbell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The South Western Ambulance Service NHS Foundation Trust is responsible for addressing information-sharing concerns raised in the report.

    Verbatim wording from the response

    “The report raises concerns over emergency service pressures, including ambulance response times and handover delays, and information sharing between police and ambulance emergency services. I recognise the concerns raised with health and care delivery in the region, which align with representations from local members of parliament. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. I understand that the South Western Ambulance Service NHS Foundation Trust is also writing to you separately to address the matters of concern you have raised for them which include the issues with information sharing.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 4 March 2025

    Open published response

  8. Cornwall and Isles of Scilly

    AI-generated summary

    Lachlan Charles Campbell · 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

    Lachlan Charles Campbell died on 1 November 2022 after being found outside a railway station in a distressed and possibly drug-affected state, where he remained for several hours in heavy rain and cold conditions. The report identifies concerns about delays in ambulance attendance, incomplete information sharing between ambulance and police services, and police officers not providing shelter, warmth, or timely medical attention. The inquest concluded that these failures contributed to 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 obtain and share complete contact information for ambulance disposition decisions

    Wider context from the report

    “2) Information sharing between SWAST and D&CP. A number of issues were revealed during the course of the evidence. a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours. b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate. c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.) d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached. e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options. f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial? ”

    Source location

    Lachlan Charles Campbell · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Train SWAST control-room staff to obtain accurate contact and incident information during calls with police.

    Verbatim wording from the response

    “Both the police and SWAST control room staff are trained to ensure that they have asked for and received accurate information in the course of any calls held with one another. In the future this will ensure that that SWAST have a contact number for the scene of the incident.”

    Source location

    Response from South Western Ambulance Service NHS Foundation Trust
    Page 2 · response
    Published 4 March 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

    Require officers using the police control room to explain why they cannot call 999 directly, and train police and ambulance personnel to record relevant information when liaising.

    Verbatim wording from the response

    “If our officers call for an ambulance through the police control room, they are asked if there is a reason that they cannot do this themselves (such as the need to commence CPR, or other environmental factors). Police control room and SWAST personnel are trained to record all relevant information when contacting or otherwise liaising with SWAST.”

    Source location

    Response from Devon and Cornwall Police
    Page 2 · response
    Published 4 March 2025

    Open published response

  9. Birmingham and Solihull

    AI-generated summary

    Sebastian Benjamin OLIVER · 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

    Sebastian Benjamin Oliver was found unresponsive on 29 November 2023 after sustaining an incised wound to his left hand while climbing a spiked fence under the influence of drugs, and he later died in hospital. The report identified concerns about West Midlands Police closing a safe-and-well-check log after Mr Oliver absconded from hospital, relying on an earlier capacity assessment despite a later assessment that he lacked capacity, and about shortcomings in training and communication with ambulance staff.

    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 seek clarification and communicate effectively with medical colleagues about fluctuating or lacking capacity

    Wider context from the report

    “3. WMAS notified West Midlands Police ("WMP") and requested a "safe and well check". After determining he was not at the last known location, the decision was made by officers of WMP to close the log because WMAS had earlier deemed him to have capacity (following the 22:18 call). 4. However, the decision to close the log was an error - as a person's capacity can fluctuate, it was inappropriate for WMP to rely upon a past capacity assessment taken hours earlier in the evening, particularly when a more recent capacity assessment indicated that he lacked capacity and where WMAS were concerned enough to request a "safe and well check". 5. I stress that the evidence was clear at inquest that even if WMP had not closed the log, they may not have been able to find Mr Oliver as it was not known where he went in the two hours or so after he left hospital, before being recorded on CCTV at 02:55 at ████████, and being subsequently found unresponsive at 06:21. On the balance of probabilities therefore, it cannot be said that Mr Oliver would have been found had the log not been closed. 6. However, I am concerned that the decision to not seek clarification from WMAS as to Mr Oliver's capacity represents shortcomings in training and/or a failure to ensure that WMP properly and effectively communicate with medical colleagues in WMAS when dealing with incidents where patients have fluctuating or lack capacity and abscond from treatment centres. It is not clear whether this was a "one-off" issue localised to a specific officer, or whether it represents a larger or institutional issue. 7. It is easy to anticipate a similar situation occurring in the future which leads to a death that is preventable, particularly those involving vulnerable persons and those lacking capacity. ”

    Source location

    Sebastian Benjamin OLIVER · 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 officers to obtain, record and share treating-clinician rationale when partner risk assessments differ, with learning fed into relevant working groups.

    Verbatim wording from the response

    “(iii) Collaboration with partners: Officers will be reminded that they must consider risk from the stakeholder/partner perspective and obtain the rationale of the treating clinician where there is a difference. This should then be recorded utilising WMP systems and fed back to WMP supervisors and shared with the reporting partner agency. Whilst WMP can professionally challenge partners it is more appropriate to follow the process in the best interest of the public and inaccuracies be fed back within working groups such as Joint Strategic Operation Groups (JSOG) to aid future learning.”

    Source location

    Response from West Midlands Police
    Page 5 · response
    Published 1 November 2024

    Open published response

  10. Surrey

    AI-generated summary

    Helen Jane Kerr · 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

    Helen Jane Kerr had a history of drug and alcohol abuse, developed psychosis, and died by hanging after being found dead at a refuge on 3 April 2023. The report identified concerns about failures to respond appropriately and promptly to information about her deteriorating mental health, inadequate assessment and treatment, limited out-of-hours information sharing, and failure to inform the refuge about risks associated with her presentation.

    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 inform refuge workers of a relevant police presentation

    Wider context from the report

    “(4) The refuge was not made aware of Ms Kerr’s presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger. ”

    Source location

    Helen Jane Kerr · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Adult Social Care is responsible for facilitating any appropriate onward information sharing with the refuge after multi-agency assessment.

    Verbatim wording from the response

    “Information sharing protocols are in place with statutory partners. The refuge is not a statutory partner, so with regard to the sharing of SCARF, there would be no existing process that would include them in Surrey Police’s safeguarding information sharing protocols. Adult Social Care would be responsible and facilitate any onward information sharing if appropriate, based on a multi-agency assessment.”

    Source location

    Response from Surrey Police
    Page 3 · response
    Published 18 September 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Surrey Police is responsible for addressing the other matters raised in the PFD report.

    Verbatim wording from the response

    “The other matters within the PFD Report relate solely to Surrey Police and I will therefore allow that organisation to address those issues directly.”

    Source location

    Response from Surrey and Borders Partnership
    Page 3 · response
    Published 18 September 2024

    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