Recurring concern

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

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First reported 21 Oct 2013•Latest report 17 Mar 2026

Definition

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.

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
34

Distinct published reports

Individual concerns
40

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
65

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care7
Metropolitan Police Service7
Home Office6
National Police Chiefs’ Council6
College of Policing5
West Midlands Police5
Crown Prosecution Service2
Devon & Cornwall Police2
Greater Manchester Police2
London Ambulance Service NHS Trust2
Ministry of Justice2
NHS England2
Northumbria Police2
Pennine Care NHS Foundation Trust2
South Western Ambulance Service NHS Foundation Trust2

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.

  1. Exeter and Greater Devon

    AI-generated summary

    Jason Geoffrey PALMER · 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

    Jason Geoffrey PALMER died from a shotgun injury to the head after consuming a large quantity of alcohol; he and his wife had separated, and the inquest concluded that he had taken his own life. The report raised concerns that information about domestic incidents held in restricted police logs was not available to the Firearms Unit when his shotgun certificate was renewed, limiting the robustness of suitability enquiries.

    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 make relevant police incident information available to the Firearms Unit for firearms suitability assessment

    Wider context from the report

    “(1) Mr Palmer applied for a shotgun certificate in December 2004. His licence was granted in January 2005. The licence was for renewal in 2009 and the Firearms Officers were aware there had been certain domestic incidents involving Mr Palmer and his wife but were assured by Mr Palmer these were no longer of significance. Mr Palmer's licence was renewed on 19 January 2010. The Firearms Licensing Operations Officer ████████ commented in a Statement at the Inquest that if he and his colleagues had been aware the number of police incidents relating to Mr Palmer's domestic situation, then they would have made more robust enquiries into the suitability of Mr Palmer to possess shotguns at the time of his renewal. That information was contained within secure Police Logs for the protection of Officers. Whilst it is understandable for confidentiality reasons and the protection of Officers in circumstances where personal incidents had occurred, if Mr Palmer had been a member of the public, as opposed to a serving Police Officer, then the Firearms Unit would have been aware of these incidents from the Police logs. It may be prudent for such information to be made available to the Firearms Unit and the restricted logs reviewed perhaps at Senior Officer level and if appropriate that information passed to the Firearms Unit for assessment. ”

    Source location

    Jason Geoffrey PALMER · Prevention of Future Deaths report
    Page 1 · 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 firearms licensing procedures and policies to address restricted incident-log information concerns.

    Verbatim wording from the response

    “A thorough review has been undertaken of the procedures and policies in place to ensure that this concern is addressed.”

    Source location

    2014-0534-Response-by-Devon-Cornwall-Police
    Page 1 · response
    Published 12 December 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop a written working practice formally recording how Firearms Enquiry Officers obtain and use information from restricted incident logs.

    Verbatim wording from the response

    “The process which is followed upon receipt of an application for the granting or renewal of a certificate is that a Firearms Enquiry Officer (FEO) will interrogate the relevant police systems for any incidents of concern, as part of their investigation into the applicant’s suitability to possess firearms. As part of this process, all logs relating to the applicant will be seen by the FEO. This includes the presence of any restricted logs, albeit that the content can only be viewed by an officer of the rank of Inspector or above. The FEO is required to make contact with the Control Room in order that the content of any restricted log is viewed, and any relevant information contained therein is communicated to the FEO for the purposes of any decision regarding the application.”

    Source location

    2014-0534-Response-by-Devon-Cornwall-Police
    Page 1 · response
    Published 12 December 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use an electronic system to scan police incident logs every ten minutes and immediately alert the Firearms Licensing Unit about logs concerning existing certificate holders.

    Verbatim wording from the response

    “In addition, a significant change has been made to the method by which the Firearms Licensing Unit are alerted to any incident log which relate to an existing certificate holder. An electronic system has now been introduced which “sweeps” all police incident logs every ten minutes. In the event that any log relates to an existing certificate holder, an immediate alert is sent to the Firearms Licensing Unit, where the log content will be checked to identify whether any concern arises as a result of that individual’s suitability to possess a firearm. In the event that the log is restricted, a request can be made to the control room for the log to be reviewed and any relevant information provided.”

    Source location

    2014-0534-Response-by-Devon-Cornwall-Police
    Page 2 · response
    Published 12 December 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing firearms licensing procedures adequately address restricted incident information when assessing applicants’ suitability to possess firearms.

    Verbatim wording from the response

    “The process which is followed upon receipt of an application for the granting or renewal of a certificate is that a Firearms Enquiry Officer (FEO) will interrogate the relevant police systems for any incidents of concern, as part of their investigation into the applicant’s suitability to possess firearms. As part of this process, all logs relating to the applicant will be seen by the FEO. This includes the presence of any restricted logs, albeit that the content can only be viewed by an officer of the rank of Inspector or above. The FEO is required to make contact with the Control Room in order that the content of any restricted log is viewed, and any relevant information contained therein is communicated to the FEO for the purposes of any decision regarding the application.”

    Source location

    2014-0534-Response-by-Devon-Cornwall-Police
    Page 1 · response
    Published 12 December 2014

    Open published response

  2. Oxfordshire

    AI-generated summary

    Suzanne Cammell · 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

    Suzanne Cammell died on 3 October 2013 after lying beneath the wheels of a lorry in a layby near Burford Golf Club; she sustained severe blunt head injuries when the lorry drove away. The principal concern was that high-risk information about the incident and a previous similar incident may not have been communicated by Thames Valley Police to Gloucestershire Constabulary or made available to the officer conducting a welfare check.

    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 make high-risk information available to responding officers

    Wider context from the report

    “(1) There was also an incident on 23 September 2013 in Gloucestershire when Ms Cammell had been sectioned under Section 136 of the MHA because she had been seen placing her head under the wheels of a recycling lorry where she lived. She was seen by neighbours and/or the driver in time. This information about the incident on 23 September 2013 was held on the Police National Database which, presumably, Gloucestershire control and ████████ would have had access to. The concern therefore is in relation to communication between TVP and Gloucestershire Constabulary and, in turn, communication between Gloucestershire Control and its Officers. At Inquest, I did not have available to me details of the specific information passed by TVP control to Gloucestershire control in the early hours which subsequently led to ████████ and his colleague carrying out the welfare check at approximately 03.30. The evidence of ████████ at Inquest was that he did not know that she had been found lying underneath the wheels of the lorry earlier in the morning. He gave evidence that, if he had known this, he would have put in hand arrangements for a MHA assessment. ████████ also gave evidence that he did not know about the previous similar incident on 23 September despite the fact that it was on the PND and, furthermore, on Gloucestershire’s “Unified” Intelligence database. The issue of concern therefore is the fact that specific information, of a high risk nature, was not or may not have been passed by TVP to Gloucestershire Constabulary or, if it was, it may not have been available to ████████. I appreciate that ████████ carried out a prompt welfare check and that Ms Cammell’s presentation was such that ████████ did not consider her to be at risk but it appears he did not have available crucial information. ”

    Source location

    Suzanne Cammell · 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 a thorough review of the information-sharing concern, consulting senior colleagues across relevant departments.

    Verbatim wording from the response

    “████████ of our Professional Standards Department has carried out a thorough review of this matter, in the course of which he has consulted with senior colleagues from the Control Room & Enquiries Department, the Force Intelligence Bureau and the Partnership Team (which covers mental health).”

    Source location

    2014-0579-Response-by-Thames-Valley-Police
    Page 1 · response
    Published 28 July 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Gloucestershire Police addressed the concern about using the Police National Database in its own response.

    Verbatim wording from the response

    “I understand that you posed to Gloucestershire a question in respect of the use of the Police National Database and that they have covered this in their response. Furthermore, I gather that at the Inquest you expressed concern in relation to a lack of information sharing between the Professional Standards Department and the officer who prepared the report for you. ████████ has put in place measures to address this. He has taken the liberty of making an appointment with you on 4 November 2014 to brief you on these measures and, of course, deal with any further questions you might have in respect of the case of Ms Cammell.”

    Source location

    2014-0579-Response-by-Thames-Valley-Police
    Page 4 · response
    Published 28 July 2014

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    MELVIN BANDTOCK · 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

    MELVIN BANDTOCK, aged 55, died after losing control of his motorcycle on black ice and colliding with an oncoming bus on 28 December 2013. The road had not been treated under the local authority’s gritting or salting regime. Concerns included information sharing between Durham Constabulary and the local authority and reviewing procedures to ensure a timely and proportionate response to potentially dangerous road conditions.

    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 collective information sharing between police and the local authority

    Wider context from the report

    “Evidence was given that there is a Duty Manager on call to assess changing weather reports and the collation of information obtained from other sources, in particular the police, in order to decide whether salting/gritting machines should be deployed either on a local or County wide basis. On the day in question the Duty Manager believed that weather temperatures would increase in a relatively short period of time whereas in reality they did not do so. There were a high number of collision incidents reported to the police that morning some of which resulted in report being made to the County Council. Some gritting/salting vehicles were deployed. It will take about an hour for gritting/salting lorries to be able to commence their work and a route would take up to three hours to complete. The time that it therefore takes to complete a gritting/salting run is a factor which is considered by the Duty Manager on the question of whether to deploy or not in conjunction with the weather condition reports and as a result of information gleaned from road temperature monitoring. It was said that this procedure had been in place for many years and was tried and tested. A Regulation 28 report is being sent to Durham Constabulary and a copy provided to the local authority herewith and the evidence indicates that a better collective sharing of information between the two organisations may well be of benefit together with a review of the County Council's own practices and procedures to ensure that a timely and proportionate response to potentially dangerous road conditions can be delivered to promote the safety of all road users. The Highways Manager indicated that with the information that the Duty Manager had following receipt of the 6.00 a.m. weather report his decision not to deploy gritting/salting vehicles was a reasonable one but that with the benefit of hindsight knowing what happened with regard to ambient temperature conditions and incidents around the County on the road network this decision was regrettable. I confirmed that it was not my intention to blame or be seen to blame any individual for the death in this case but it was my statutory obligation to draw to the appropriate authorities attention relevant issues that might be appropriate to prevent future deaths. I also recognised that English weather can be unpredictable. ”

    Source location

    MELVIN BANDTOCK · Prevention of Future Deaths report
    Page 1 · 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 information-sharing protocols with Durham Constabulary to identify improvements.

    Verbatim wording from the response

    “Sharing of Information Following receipt of your letter we met with Durham Constabulary on 29th April 2014 to review existing information sharing protocols and to identify how these could be improved.”

    Source location

    2014-0147-Response-by-Durham-County-Council
    Page 2 · response
    Published 3 April 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing communication mechanisms and information-sharing protocols are considered effective for managing highways through partnership working.

    Verbatim wording from the response

    “Sharing of Information Following receipt of your letter we met with Durham Constabulary on 29th April 2014 to review existing information sharing protocols and to identify how these could be improved.”

    Source location

    2014-0147-Response-by-Durham-County-Council
    Page 2 · response
    Published 3 April 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Constabulary disputes that road incident reporting was ad hoc or lacked supervisory oversight.

    Verbatim wording from the response

    “The matter of concern by the Coroner for the Constabulary was that the process for contacting Durham County Council was done by an individual call handler on an ad hoc basis with no monitoring or supervision. There was also a concern that there was no oversight that might lead a supervisory officer to conclude a potentially serious situation was developing on the County’s roads. This is not the case for both issues.”

    Source location

    2014-0147-Response-by-Durham-Constabulary
    Page 1 · response
    Published 3 April 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Established procedures, supervision and communication arrangements with the Council are considered robust and fit for purpose.

    Verbatim wording from the response

    “The dispatchers for that area would then deploy officers to the incident and contact Durham County Council as appropriate. There is also a dispatch pod (call sign LA) which deals with all highways issues for the County. Any incident which was affecting the road network would have a ‘highways’ tag placed on it and would be managed in conjunction with the area response. The LA dispatcher, having overall view of the County’s road network, would normally be the dispatcher who would contact the Council, should issues become apparent. This would be recorded on the incident log so the area dispatcher would know what had been done and what actions were being taken. The dispatch room is overseen by 2 supervisors and an inspector is on duty at all times to manage critical incidents and firearms deployments.”

    Source location

    2014-0147-Response-by-Durham-Constabulary
    Page 2 · response
    Published 3 April 2014

    Open published response

  4. North London

    AI-generated summary

    Daniel Maurice McMahon · 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

    Daniel Maurice McMahon suffered severe head injuries after being hit by a train at Willesden Junction Station on 11 January 2012, following reports that he had fallen from a bridge and moved onto the railway track. The report raised concerns about the accuracy and completeness of information recorded by police about the location of a person trespassing on the railway, procedures for stopping trains when an unwell person is on the line, support during mental-health leave, and the use of lung-decompression needles without a valve.

    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 gather and pass accurate trespasser and track-section location information

    Wider context from the report

    “(1) Metropolitan Police :- That steps should be taken to ensure that when report is passed to the police concerning a person who is seen to be trespassing on the railway line that correct information is gathered to locate that person and the section of the track that person is on so that this information can be passed to those responsible for contacting the network covering that section of the track. This is in addition to the attendance location and the incident location normally recorded when a 999 call is made. ”

    Source location

    Daniel Maurice McMahon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026