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. South London

    AI-generated summary

    Neil Woodley · 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

    Neil Woodley was found ████████ at 7.25 am on 4 January 2024, and evidence from suicide notes suggested that he had killed himself overnight. A colleague called the police because he had not arrived at work, but an ambulance attended the following day after an alleged communication failure between Surrey Police and the Metropolitan Police. The concern was that failures in communication could result in avoidable fatalities in future cases, although the report states that earlier attendance would not have affected this outcome.

    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

    Failures in communication during welfare-check responses

    Wider context from the report

    “Mr Woodley’s brother and sister-in-law gave evidence at the hearing that a colleague of Mr Woodley called the police on the morning of 4 January concerned that he had not arrived at work. Their evidence was that an ambulance arrived to carry out a welfare check the following day (5 January) at around 1pm. They were told that the reason for the delay was confusion between Surrey Police and the Metropolitan Police. On the evidence before me, including that of Mr Woodley and his wife, I am satisfied that an earlier attendance would not have affected the outcome. However, I am concerned that failures in communication could result in avoidable fatalities in future cases. ”

    Source location

    Neil Woodley · 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

    Deliver learning to MPS staff and officers on district location sharing and compliance with relevant standard operating procedures.

    Verbatim wording from the response

    “As an organisation, learning will be delivered to MPS staff and officers, highlighting the importance of district location sharing and compliance with standard operating procedures designed to protect front line policing and prevent correlation errors such as this incident.”

    Source location

    Response from Metropolitan Police
    Page 3 · response
    Published 7 August 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

    The records do not show a communication failure between Surrey Police and the Metropolitan Police Service; both calls were handled correctly.

    Verbatim wording from the response

    “Having carefully considered the records relating to both calls, it is evident that they were handled correctly and were promptly passed to the MPS to manage. The policies and procedures that Surrey Police have in place to ensure the smooth transfer of calls to other police forces were followed appropriately. All relevant information was passed to the MPS in a timely manner and the informants were made aware of the transfer to the MPS to allow them to take appropriate action.”

    Source location

    Response from Surrey Police
    Page 2 · response
    Published 7 August 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

    Existing procedures for transferring calls to other police forces were followed appropriately and ensured timely information transfer.

    Verbatim wording from the response

    “Having carefully considered the records relating to both calls, it is evident that they were handled correctly and were promptly passed to the MPS to manage. The policies and procedures that Surrey Police have in place to ensure the smooth transfer of calls to other police forces were followed appropriately. All relevant information was passed to the MPS in a timely manner and the informants were made aware of the transfer to the MPS to allow them to take appropriate action.”

    Source location

    Response from Surrey Police
    Page 2 · response
    Published 7 August 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

    No communication failure between Surrey Police and the Metropolitan Police occurred because no record of a relevant 4 January call exists.

    Verbatim wording from the response

    “The MPS have no records of Mr Woodley’s work colleague or SPS contacting the MPS regarding an incident concerning Mr Woodley on 4th January 2024.”

    Source location

    Response from Metropolitan Police
    Page 2 · response
    Published 7 August 2024

    Open published response
  2. Birmingham and Solihull

    AI-generated summary

    Tcherno Bari · 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

    Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.

    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 ensure police access to the written risk assessment

    Wider context from the report

    “(7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment, or require attending constables, or later the Locate team, to request a copy of the risk assessment. In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category. ”

    Source location

    Tcherno Bari · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of police officer awareness of the required risk rating

    Wider context from the report

    “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’. ”

    Source location

    Tcherno Bari · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of formal notification of police disagreement about risk category

    Wider context from the report

    “(6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category. BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information. ”

    Source location

    Tcherno Bari · 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

    Replace Appendix C with a decision-recording form documenting the reasons for critical concern and provide it to attending police officers.

    Verbatim wording from the response

    “At the time of the inquest the Missing Persons Policy was being updated, in line with changes from Right Care Right Person (RCRP). Since this time the update has been completed and there have been a number of changes made. In addition the Trust have a new Executive Director of Quality and Safety/Chief Nursing officer who will be accountable for the policy. The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out ‘why is the risk is considered to be present’. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.”

    Source location

    Response from BSMHFT
    Page 1 · response
    Published 6 June 2024

    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

    Establish a process for officers to request electronic risk assessments through a central Locate Team inbox with overnight supervisory monitoring.

    Verbatim wording from the response

    “WMP recognise the importance that the BSMHFT risk assessment is shared with officers (referred to as ‘Appendix C’ in the PFD report) and that attending constables know to request this. Whilst officers will be reminded, within the policy update, to request a copy of the risk assessment and to take possession of it they will also be given an email address to provide to BSMHFT. BSMHFT will be asked to provide the risk assessment (Appendix C) electronically to this email address. The risk assessment will be received into the central Locate Team inbox ensuring a hard copy document is not misplaced and enabling timely supervisory review, if required. The Locate Team inbox is only monitored until 10pm. Therefore, for overnight issues the Duty Sergeant will be asked to monitor the inbox and to escalate any issues through supervision where appropriate.”

    Source location

    Response from West Midlands Police
    Page 4 · response
    Published 6 June 2024

    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

    Share information with health systems on establishing multi-agency governance, delivery structures, risk management, escalation and communication.

    Verbatim wording from the response

    “To support implementation, NHS England has shared information with health systems about setting up multi-agency governance and delivery structures to oversee delivery, manage risks and escalations and enable open communication between local”

    Source location

    Response from NHS England
    Page 1 · response
    Published 6 June 2024

    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

    Issue guidance to health systems covering multi-agency governance, delivery structures and real-time and retrospective escalation processes.

    Verbatim wording from the response

    “partners, including to resolve any challenges. Information has also been shared on escalation protocols, including the need for local partners to set up real-time escalation processes (in response to a situation that is currently live) and retrospective escalation processes (to review situations that have occurred, learn lessons and agree changes going forward). This information will be included in guidance that NHS England will issue to health systems shortly.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 June 2024

    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

    Review and update the WMP Missing Person Policy to address daily appraisal attendance, clinician risk assessments, recording, and investigation-closure notifications.

    Verbatim wording from the response

    “BSMHFT and send an appropriate staff member, as required. The WMP missing persons policy will be updated to reflect this.”

    Source location

    Response from West Midlands Police
    Page 4 · response
    Published 6 June 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

    Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.

    Verbatim wording from the response

    “Your report raises concerns about missing persons policy and Right Care, Right Person (RCRP), and I note that you have directed your report to the Department of Health and Social Care (DHSC) as a party to the National Partnership Agreement (NPA) on RCRP. I also note that you have raised concerns with other relevant partners, including representatives from Birmingham and Solihull Mental Health NHS Foundation Trust, West Midlands Police and NHS England. Given the operational independence of police forces and the autonomy of clinical decision making, those partners are best placed to respond to some of the concerns you raise. DHSC does have a role in setting guidance and direction to the mental health sector and I will respond on these points in particular.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 6 June 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

    Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.

    Verbatim wording from the response

    “As you are aware, police forces are operationally independent and so it is for the National Police Chiefs’ Council, the College of Policing and West Midlands Police to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Bari, and I know they have written to you separately on this matter.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 6 June 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

    Missing Persons is outside Right Care Right Person, so existing police procedures for police involvement should continue.

    Verbatim wording from the response

    “healthcare facilities. Missing Persons is not a part of this and existing police procedure regarding police involvement should continue to operate.”

    Source location

    Response from the Home Office
    Page 2 · response
    Published 6 June 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

    The APCC cannot mandate its members to undertake actions in response to the identified safety concerns.

    Verbatim wording from the response

    “As a membership body, the APCC cannot mandate actions upon its members. However, our role does include the provision of advice and recommendations to inform our members’ local activities, including the development of evidence-based guidance.”

    Source location

    Response from APCC
    Page 1 · response
    Published 6 June 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

    Operational implementation of Right Care, Right Person is assigned to Chief Constables rather than Police and Crime Commissioners.

    Verbatim wording from the response

    “At a local policing level, PCCs are not responsible for making operational policing decisions, including the implementation of Right Care, Right Person, this is a decision for Chief Constables. Rather, PCCs are responsible for scrutinising their Chief Constables and holding them to account for the delivery of their duties. Additionally, PCCs have responsibilities to commission services, and where necessary, to bring partners together and work with them.”

    Source location

    Response from APCC
    Page 1 · response
    Published 6 June 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

    The mental health trust cannot formally record differing risk opinions because it lacks access to police systems.

    Verbatim wording from the response

    “The PFD Report also addresses the issue of difference between the WMP and BSMHFT risk categories. BSMHFT does not have access to WMP systems or to the COMPACT log which is used to record a missing person investigation so could not use this to formally indicate a difference in opinion. However, the WMP missing persons policy will be updated to remind all officers, when attending such calls to identify the mental health trust’s risk category and to recognise the importance of clinician’s expertise in determining the risk assessment. 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 on COMPACT and fed back to WMP supervisors and shared with the reporting partner agency.”

    Source location

    Response from West Midlands Police
    Page 4 · response
    Published 6 June 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

    Each Chief Constable decides whether and when to implement Right Care Right Person and which elements of the national framework to adopt.

    Verbatim wording from the response

    “As Policing is operationally independent, each Chief Constable has to decide whether and when to implement Right Care Right Person and how much of the framework set out in the National Partnership Agreement and supporting guidance they wish to adopt.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 6 June 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

    RCRP did not apply because the case was treated as a missing person involving immediate risk requiring police response.

    Verbatim wording from the response

    “The Missing persons framework is another distinct policy area which falls outside of RCRP when it is established that a persons whereabouts cannot be ascertained and all reasonable enquiries have been made by the informant to ascertain their whereabouts.”

    Source location

    Response from NPCC
    Page 2 · response
    Published 6 June 2024

    Open published response
  3. Essex

    AI-generated summary

    Amanda Hitch · 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

    Amanda Hitch died on 12 February 2022 after deliberately jumping in front of a train intending to die. She was receiving community mental health treatment. Concerns included important clinical information not being visible to the care team, structured risk-management tools not being specifically considered, and railway-station attendances not being reliably passed to her care coordinator under a multi-agency support plan.

    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

    Unavailability of resources to identify and provide information about all unstaffed railway station attendances

    Wider context from the report

    “(3) There was also evidence about the measures that the British Transport Police had taken, seeking to provide additional support by setting up multi- agency support plan, which provided a system for alerting a number of people including the deceased’s care co-ordinator, when she attended at railway stations. In fact, for various reasons, although there are several known attendances at railway stations, none were passed on to the care co- Ordinator. The evidence at the inquest was that British Transport Police does not have the resources always to provide information about attendance at unstaffed stations (although in fact, one such attendance had been known about but was not passed on). The plan as presented does not make it entirely clear what the limitations in relation to information from attendances at unstaffed stations may be, and should it remain the position that BTP lacks the resources to identify all such attendances at railway stations by persons at specific risk of suicide on the railway, there is a risk that those expecting to receive information under such a plan may not realise that the plan will often not assist where its subject is attending unmanned stations. ”

    Source location

    Amanda Hitch · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Suffolk

    AI-generated summary

    Anthony John Raymond INGRAM · 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

    Anthony Ingram was found deceased at his second home in Suffolk on 29 March 2022, having died by hanging. The report identified poor communication between the Metropolitan Police and Suffolk Constabulary, including failure to share information that he had a rope and a collapsible bicycle, resulting in a missed opportunity to find him earlier. The principal concern was the lack of standardised information-sharing requirements or protocols for cross-border missing-person investigations, including cases involving suicidal missing people.

    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 standardised information-sharing requirements or protocols for cross-border missing-person investigations

    Wider context from the report

    “It was clear that crucial information (that Anthony had a rope in his possession, and a collapsible bicycle providing a secondary form of transport) was not passed between the Metropolitan Police and Suffolk Constabulary. It was heard that there was no set format, or prescribed information requirements to be shared by officers reporting missing persons between one force and another. Investigating officers in the Metropolitan police spoke to the Suffolk Constabulary control room, whose staff logged what they were told onto the CAD record. This information was then relayed to the officers on the ground. Witnesses in this case stated that there is no standardised information sharing requirement or protocol for cross border missing persons investigations (including missing persons with suicidal ideation). I am concerned that, as there is no standardised information sharing requirements or protocols in such cases, in the future a force receiving details of a suicidal missing person may also not be informed that an individual has taken a means of suicide with them. In addition, other important information that may assist in the search for that person may also not be passed. ”

    Source location

    Anthony John Raymond INGRAM · 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

    Develop and consult forces on NPCC advice for requesting missing-person enquiries in another force and transferring investigations.

    Verbatim wording from the response

    “Further to the APP guidance a Task and Finishing Group has been initiated focusing on the very issue you have outlined. Draft NPCC advice on ‘Requesting Missing Person Enquiries in Another Force and Transfers of Investigations’ has been developed and has now been circulated to all forces for consultation.”

    Source location

    Response from National Police Chiefs' Council
    Page 2 · response
    Published 28 February 2023

    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 the National Transfer form to capture requests for enquiries in another force, including direct telephone or video communication of risk and urgency.

    Verbatim wording from the response

    “In addition to the above The National Transfer form is being updated to include a section to be used for requesting enquiries in another force. One of the new recommendations is to require the officer requesting the enquiries or transfer to contact by telephone or video call the key decision-maker in the other force so that the level of risk and urgency of enquiries can be effectively communicated, rather than rely on what is written on an email or the incident log. We are still waiting for the new form to be completed, but there is a working party completing that task and it is anticipated that it will be available in the next few weeks when the new processes will go live.”

    Source location

    Response from National Police Chiefs' Council
    Page 2 · response
    Published 28 February 2023

    Open published response
  5. Cumbria

    AI-generated summary

    Nicholas Dumphreys · 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

    Nicholas Dumphreys, a 47-year-old serving police officer, died on 26 January 2020 after the engine of his police BMW failed catastrophically while he was responding to an emergency call on the M6. The vehicle veered across the carriageway, overturned and crashed, causing fatal head injuries. Concerns included the robustness of communication of safety-critical information, the lack of policy to prevent faulty vehicles being auctioned, and the absence of national standards for police garages and mechanics.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of the informal approach to ensure passage of safety-critical information to individual police forces

    Wider context from the report

    “(1) In the course of the inquest I heard evidence about the role of the National Association of Police Fleet Managers ('NAPFM'). BMW UK made several presentations to NAPFM with a view to them publicising concerns about the N57 engine to their members. However, I heard evidence from the current chair of NAPFM and it is important to make two observations. First, NAPFM membership is not mandatory. There are police fleet managers who, for whatever reason, might not choose to join. Second, NAPFM has no official standing, status, or budget. It is largely reliant on the goodwill of its members to function. I am concerned that this informal approach may not be sufficiently robust. It may not ensure that safety critical information is passed to individual police forces. ”

    Source location

    Nicholas Dumphreys · 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

    Establish the reorganised NPCC Fleet governance and delivery structure, including strategic and tactical groups.

    Verbatim wording from the response

    “A reorganisation of the NPCC Fleet structure has taken place and a new NPCC led governance and delivery structure is currently being established. This will ensure NPCC ownership and direction of all Police Fleet issues including the dissemination of safety critical information.”

    Source location

    Response from National Police Chief's Council
    Page 1 · response
    Published 24 January 2023

    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

    Issue NPCC Fleet direction and guidance to every NPCC police force and organisation.

    Verbatim wording from the response

    “• This governance structure will issue direction and guidance concerning Police Fleet to every NPCC Police Force/Organisation. This will be issued by the NPCC and not from NAPFM.”

    Source location

    Response from National Police Chief's Council
    Page 2 · response
    Published 24 January 2023

    Open published response
  6. Surrey

    AI-generated summary

    Christopher Dominic Boughton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christopher Dominic Boughton left home on 3 November 2021 and was later found deceased in a wooded location in Oxshott, Surrey, after friends searched areas he was known to visit. The inquest found that he took his own life by hanging at some point between being dropped off by taxi on 3 November and being found on the morning of 5 November. The principal concern was insufficient direct communication and coordination between bordering police forces when tasking and transferring investigations, which could delay effective action and the sharing of relevant information.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of requirements for direct discussion between police forces during investigation tasking and transfers

    Wider context from the report

    “The evidence of Detective Inspector ████████, Tactical and Policy Lead for MPS, highlighted a concern that in tasking and transferring investigations between bordering Police forces, there is a lack of ownership and discussion between officers at Inspector level or above between forces, which would ensure effective tasking and, when necessary, smooth transfer of investigations. Requests were made by email and CAD, without discussions between officers. This was confirmed in the evidence of Detective Chief Constable ████████ of SP, who stated that from her perspective there was a lack of feedback from SP to manage MPS’ expectations regarding a search for Mr Boughton. In respect of the initial search, this meant that SP did not advise MPS that they considered the search request unfeasible given the extent of land outlined and the limitations on searching wooded areas during winter night hours. In respect of the request for a further search with more precise location detailed provided, MPS did not disclose all of the information available regarding Family and friends potentially being able to assist in finding the location based upon where Mr Boughton used to visit. There was no feedback from SP regarding when a search might take place, leading MPS to consider deploying its own search team. Whilst contact telephone numbers for Officers at MPS and SP were provided on the CAD, there is no evidence that direct contact was made between the forces to discuss the investigation and how best to move this forward. A SP officer recorded on the CAD that until the transfer document was received from MPS, SP were unable to arrange a search or contact the specialist search team. Whilst DI ████████ gave evidence that he is aware the NPCC is reviewing issuing guidance around tasking and transfers between bordering Police forces, at present there appears to be no requirement for appropriate Police Officers to make telephone contact between forces to ensure effective tasking and transferring, in addition to the required written requests. This means an opportunity to discuss and pass on all relevant information between forces may be lost. 1. The lack of any detailed requirement for telephone discussion between appropriate police officers on sending through written tasking requests and considering transfers of investigation means that an opportunity to discuss and ensure smooth transition and passing on of relevant information is lost. This may cause delay in effective action being taken by the tasked Force, or (in the case of transfers) by the Force to whom it is considered a transfer will be made. Consideration should be given to whether any steps can be taken to address the above concerns. ”

    Source location

    Christopher Dominic Boughton · Prevention of Future Deaths report
    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

    Initiate a Task and Finishing Group focused on cross-border missing-person investigations and investigation transfers.

    Verbatim wording from the response

    “Further to the APP guidance a Task and Finishing Group has been initiated focusing on the very issue you have outlined. Draft NPCC advice on ‘Requesting Missing Person Enquiries in Another Force and Transfers of Investigations’ has been developed and has now been circulated for comment prior to finalisation and wider circulation.”

    Source location

    2022-0235 - Response from NPCC
    Page 2 · response
    Published 29 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and circulate draft NPCC advice on requesting missing-person enquiries in another force and transferring investigations for comment before finalisation and wider circulation.

    Verbatim wording from the response

    “Further to the APP guidance a Task and Finishing Group has been initiated focusing on the very issue you have outlined. Draft NPCC advice on ‘Requesting Missing Person Enquiries in Another Force and Transfers of Investigations’ has been developed and has now been circulated for comment prior to finalisation and wider circulation.”

    Source location

    2022-0235 - Response from NPCC
    Page 2 · response
    Published 29 September 2022

    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 APP guidance and information-transfer procedures address the concerns about cross-border investigation tasking and transfers.

    Verbatim wording from the response

    “Difficulties can arise when a person reported missing resides outside the area where the report is being made, for example, a student in temporary accommodation or a day trip visitor. The police area that receives the report must record it and carry out all necessary initial actions. If the responsibility for a case is subsequently transferred to another force area, the rationale for doing so must be recorded. Written acknowledgement from the receiving force should be obtained. When deciding where ownership of the investigation lies, the principal issue is to consider where the majority of the enquiries are and who has the greatest opportunity of locating the missing person. It is probable that the area where the person was last seen would generate the majority of the initial enquiries (although this is not always the case, see also Out-of-area placements).”

    Source location

    2022-0235 - Response from NPCC
    Page 1 · response
    Published 29 September 2022

    Open published response
  7. West Yorkshire Eastern

    AI-generated summary

    Andrew David Kitson · 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 David Kitson was walking on the pavement of the A61 Leeds Road on 9 June 2020 when a Peugeot being pursued by police lost control, mounted the pavement and struck him. He sustained multiple injuries and was pronounced dead at the scene. The concerns related to insufficient statistical evidence for evaluating spontaneous police pursuits and the burden placed on police personnel when assessing the safety of continuing high-speed pursuits in residential areas.

    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

    Unreliable availability of complete real-time information to pursuit managers

    Wider context from the report

    “(2) The rules governing spontaneous police pursuits in residential areas place an onerous burden upon police standards review continuously the safety of proceeding whilst at the same time driving at high speed. The pursuit manager who authorises the continuance of a pursuit is dependant upon fragments of verbal messages relayed over the radio, due to the perceived need to leave airtime for other TPAC units to input information. The Inquest heard evidence to the effect that real time camera pictures from the police vehicle are not always available due to IT issues. This means the pursuit manager must largely trust the judgement of the police driver. In order to lessen the burden upon the police driver in having to weigh numerous factors in a continuing, complex judgement, consideration should be given to a refinement of the parameters in which pursuits in residential areas are permitted. Such guidance to pursuit managers (informed by data regarding the effectiveness and risks arising in previous pursuits) would help to promote consistency and lessen the dependence upon a case-by-case judgement made in a pressured timescale. ”

    Source location

    Andrew David Kitson · Prevention of Future Deaths report
    Page 2 · 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

    Existing dynamic risk assessment, trained decision-makers and ground commander primacy are retained rather than imposing more limited pursuit parameters.

    Verbatim wording from the response

    “It is an operational reality that every pursuit has different and distinct dynamics which relate to: environmental factors; suspect identity, capability and intent; suspect vehicle capability; police officer capability; police vehicle capability; offence severity; and the ongoing risk assessment. Taking these into account, and in order to provide the best possible decision-making capability, West Yorkshire Police’s Driver Training utilises Authorised Professional (National) Practice, in conjunction with robust training around the use of the National Decision Model, which outlines the relevant roles and responsibilities as below.”

    Source location

    Response from West Yorkshire Police
    Page 3 · response
    Published 8 March 2022

    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

    Operational policing, including spontaneous pursuits, is assigned to the Chief Constable, while the Mayor’s role is limited to accountability without fettering operational independence.

    Verbatim wording from the response

    “The use of spontaneous police pursuits is a matter of operational policing concerning the deployment of police officers which falls under the direction and control of the Chief Constable. As the Mayor of West Yorkshire with Police and Crime Commissioner responsibilities, my statutory role is to hold the Chief Constable of West Yorkshire to account for the performance of his functions without compromising or fettering his operational independence (s.1 Police Reform and Social Responsibility Act 2011 and Policing Protocol Order 2011).”

    Source location

    Response from Mayor of West Yorkshire
    Page 2 · response
    Published 8 March 2022

    Open published response
  8. Dorset

    AI-generated summary

    Felicity Jane Clough · 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

    Felicity Jane Clough was taken to hospital on 24 November 2019 after being prescribed Tramadol, discharged during the early morning, and later found collapsed and unresponsive in a field. The concerns included limited information-sharing between healthcare trusts and police forces, and the failure to consistently review paramedic records containing potentially critical information at Yeovil District Hospital.

    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 access by other police forces to information held on individual police force systems

    Wider context from the report

    “ii. I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces, especially neighbouring forces who may both have contact with individuals. Whilst I understand there is some work being done on a regional basis to address this, I would request that the issue is considered nationally as to how information held on all Police systems, not just the Police National Database, can be shared to assist in the management and assessment of individuals and the risk they pose to themselves or others. ”

    Source location

    Felicity Jane Clough · 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

    Increase operational use of the Police National Database, including uploading safeguarding information and searching for information about vulnerable people.

    Verbatim wording from the response

    “Action 1: For Operational Police Officers/Police Staff to ensure greater utilisation of the Police National Database (PND). This would include encouraging uploading safeguarding information to PND, to ensure it is accessible country wide, as well as Officers asking for the PND to be searched against any vulnerable individuals when encountering seemingly vulnerable persons.”

    Source location

    Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
    Page 5 · response
    Published 29 November 2021

    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

    Actively consider referrals to safeguarding hubs or control-room triage services and recording relevant information on the Police National Database.

    Verbatim wording from the response

    “Action 2: For Operational Police Officers/Police Staff to actively consider making referrals into the Multi-Agency Safeguarding Hubs and/or Control Room Triage services, which should in turn record any relevant information determined through these collaborated units onto PND. This will ensure greater information sharing around vulnerability across all UK Police Forces.”

    Source location

    Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
    Page 5 · response
    Published 29 November 2021

    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

    Consider developing a safeguarding capability within the Police National Database transformation to improve operational effectiveness across safeguarding agencies.

    Verbatim wording from the response

    “Action 3: For Chief Officers and Home Office Officials involved in the design and delivery of the PND transformation, to consider the development of a safeguarding capability and how it can add greater operational effectiveness across safeguarding agencies/authorities.”

    Source location

    Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
    Page 5 · response
    Published 29 November 2021

    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 IMORCC working groups to deliver national information-sharing agreements, provide national-system and mobile-device data, and share data with partners where appropriate.

    Verbatim wording from the response

    “The National Police Chiefs Council (NPCC) Information Management and Operational Coordination Committee (IMORCC), aims to ensure that information is shared to reduce harm, make the public safe and reduce crime. The committee oversees several working groups that will deliver national information sharing agreements, provide data that is needed from national systems and on mobile devices and share data with partners where appropriate. IMORCC has recently set up a Data Board”

    Source location

    Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
    Page 9 · response
    Published 29 November 2021

    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

    Continue work to enable sharing of each police force’s records-management-system data across policing.

    Verbatim wording from the response

    “The Police Digital Service (PDS) was created in April 2021, with the ambition of delivering the Digital, Data and Technology Strategy 2020-2030. Part of the PDS is the creation of a new NPCC National Data Office and proposed Data Strategy (LEARN), that will look at the opportunities for better use of data including that of other agencies. Work has already commenced to try to address data issues to enable sharing of each forces RMS data across policing.”

    Source location

    Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
    Page 11 · response
    Published 29 November 2021

    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 exchange of information between police forces is outside NHS England’s remit for comment.

    Verbatim wording from the response

    “The initial focus is on sharing within the boundaries of the Integrated Care Systems – in this case within Dorset and within Somerset – and 41 of the 42 Integrated Care Systems have already implemented a basic solution. There is a commitment to get these to interwork and this was set out in the most recent NHS Priorities and Operational Planning Guidance for 2022/23. The intention is for this to work regionally by the end of 2022/23 and nationally no later than 2023/24. Details of the Dorset Care Record are at https://www.dorsetccg.nhs.uk/project/dorset-care-record/ and the Somerset Integrated Care Record at https://www.somersetccg.nhs.uk/about-us/digital-projects/sider/ The exchange of information between police forces is not a matter NHS England can comment on.”

    Source location

    Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
    Page 7 · response
    Published 29 November 2021

    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

    Each police force is responsible for its own budget, systems, staffing, and data management as its Chief Constable’s responsibility.

    Verbatim wording from the response

    “Each force is responsible for their own budget and how they allocate this will depend on their individual needs. This is reflected in their ICT infrastructure with regards to systems and staffing which equates to the capabilities across each force being significantly different. This can also be seen in the Records Management Systems (RMS) each force holds and as such there are several different suppliers and systems in use throughout the country that do not communicate easily with each other. Each Chief Constable is the Data Controller for their force and has ultimate responsibility for the management and use of data and information as defined by the Data Protection Act 2018.”

    Source location

    Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
    Page 10 · response
    Published 29 November 2021

    Open published response
  9. Birmingham and Solihull

    AI-generated summary

    Trevor Alton SMITH · 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

    Trevor Smith died after being shot by a member of a police armed response unit during an attempted arrest at his home. The principal concerns were that information about an alleged previous overdose was not recorded or cascaded to the firearms team, and that officers were confused about CPR rescue breaths and coordination during resuscitation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a clear process for cascading relevant MARAC information to involved officers

    Wider context from the report

    “1. MARAC Information: Before firearms officers deployed to Mr Smith’s address a MARAC (Multi Agency Risk Assessment Conference) meeting took place on 12/03/19 when agencies shared information about the alleged victim of domestic violence and the alleged suspect Mr Smith. The evidence at the inquest confirmed that it was likely that Birmingham and Solihull Mental Health NHS Foundation Trust shared information that Mr Smith had taken an overdose of medication in January 2019. This information was not minuted by WMP nor reported back to the Senior Investigating Officer or the firearms team. As a result, they were unaware of this information and Mr Smith was not declared EMD (emotionally and mentally distressed). The evidence at the inquest confirmed that actions would have been the same even had Mr Smith been declared EMD. It was clear during the evidence that there was no clear guidance/process for accurately recording information at MARAC by WMP and no clear process for ensuring relevant information is cascaded to officers involved in the case. Consideration should be given to updating existing processes and policies to ensure accurate and relevant information is cascaded from MARAC. 2. CPR coordinator. The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies and procedures and training to ensure one person is allocated to coordinate CPR if it is required. ”

    Source location

    Trevor Alton SMITH · 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

    Publish a national circular to chief officers raising the concerns and recommending that forces consider local MARAC information-recording and sharing practices.

    Verbatim wording from the response

    “Police forces implement localised policies and practice in terms of the recording and dissemination of intelligence. The College Authorised Professional Practice for Armed Policing (APP-AP) Armed policing (college.police.uk) provides guidance to firearms commanders in respect of information and intelligence gathering, and the importance of considering the potential that the subject of an operation may be emotionally or mentally distressed. I consider the relevant APP-AP content to be appropriate. My Armed Policing Team has, however, agreed with the National Police Chiefs’ Council (NPCC) portfolio lead for armed policing (Chief Constable Simon Chesterman), to publish a national circular for dissemination to chief officers.”

    Source location

    2021-0387-Response-from-College-of-Policing_Published
    Page 2 · response
    Published 19 November 2021

    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

    Centralise MARAC coordination and administration and introduce trained minute takers, MARAC coordinators and a regional lead.

    Verbatim wording from the response

    “The agency responsible for minute-taking and coordination in this case was Coventry Haven, who were commissioned to perform this duty up until the 31st March 2019, two weeks after the MARAC meeting in question took place. It was after this time that WMP took responsibility for the coordination and administration of all seven local authority areas, including Solihull, from 1st April 2019.”

    Source location

    2021-0387-Response-from-West-Midlands-Police_Published
    Page 1 · response
    Published 19 November 2021

    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

    Review links between the MARAC system and wider police systems and departments to improve information capture and sharing.

    Verbatim wording from the response

    “However, as all MARAC information is recorded on a system separate to Connect, which is where the vast majority of Police information is stored, this impacts upon transparency and speed of information sharing.”

    Source location

    2021-0387-Response-from-West-Midlands-Police_Published
    Page 2 · response
    Published 19 November 2021

    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

    Maintain a regional MARAC Operating Protocol governing agency engagement and information sharing.

    Verbatim wording from the response

    “Response: There is a regional MARAC Operating Protocol which has been in place since 1st April 2019. It governs WMP and wider agency engagement with the MARAC process and offers clear guidance on what is expected of them and what they can expect of Information Sharing within the process. Further, the MARAC Coordination team are responsible for ongoing MARAC training across the region which ensures that partners engaging in the process have staff trained and prepared to do so. In addition all MARAC minute takers are intensively trained when in role and are not permitted to take minutes alone until training is complete to the satisfaction of the local MARAC Coordinator.”

    Source location

    2021-0387-Response-from-West-Midlands-Police_Published
    Page 3 · response
    Published 19 November 2021

    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 ongoing regional MARAC training and require intensive training before minute takers work alone.

    Verbatim wording from the response

    “Response: There is a regional MARAC Operating Protocol which has been in place since 1st April 2019. It governs WMP and wider agency engagement with the MARAC process and offers clear guidance on what is expected of them and what they can expect of Information Sharing within the process. Further, the MARAC Coordination team are responsible for ongoing MARAC training across the region which ensures that partners engaging in the process have staff trained and prepared to do so. In addition all MARAC minute takers are intensively trained when in role and are not permitted to take minutes alone until training is complete to the satisfaction of the local MARAC Coordinator.”

    Source location

    2021-0387-Response-from-West-Midlands-Police_Published
    Page 3 · response
    Published 19 November 2021

    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

    West Midlands Police and other forces are responsible for local policies and practices governing MARAC information recording and dissemination.

    Verbatim wording from the response

    “The first concern raised in the report relates to the MARAC process undertaken by West Midlands police, and specifically that potentially significant information disclosed at a meeting to discuss Mr Smith was not effectively cascaded to the SIO or firearms team prior to the policing operation to arrest him. I understand that West Midlands police has provided a response to your concern.”

    Source location

    2021-0387-Response-from-College-of-Policing_Published
    Page 2 · response
    Published 19 November 2021

    Open published response
  10. London City

    AI-generated summary

    Saskia Jones and 2 others · 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

    On 29 November 2019, Usman Khan carried out a terrorist attack at Fishmongers’ Hall, fatally stabbing Saskia Jones and Jack Merritt before being fatally shot by firearms officers on London Bridge. The report raised concerns about risk assessment and communication for events involving high-risk offenders, and about the assessment, information-sharing, supervision and management of terrorist offenders released into the community.

    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 and consider counter-terrorism police intelligence in MAPPA management

    Wider context from the report

    “This case gives cause for concern that counter-terrorism police may be in possession of intelligence or information which may be useful to the management of an offender by the MAPPA panel, but that such intelligence or information may not be brought to the knowledge of or taken into account by MAPPA agencies. ”

    Source location

    Saskia Jones and 2 others · Prevention of Future Deaths report
    Page 35 · 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

    Operate the Joint Counter Terrorism Prison and Probation Hub to improve secure intelligence and information sharing into MAPPA.

    Verbatim wording from the response

    “22. A Joint Counter Terrorism Prison and Probation Hub (‘JCTPPH’) has been formed. This is a collaboration between HMPPS, CTPHQ and the Security Service. One of its core functions is to enhance the flow of intelligence and information between covert and overt functions, noting that there is an obvious and necessary ‘firewall’ between the two. MAPPA chairs will consider how core groups will contribute in each case. The creation of core groups will ensure a secure and clear pathway for the sharing of sensitive intelligence/information into MAPPA. CTPHQ have provided guidance through their Manual of Guidance to require CTP Nominal Management specialist officers and Lead Responsible Officers to ensure that all relevant information is at hand to develop effective risk management plans for their allocated nominals, including those managed under MAPPA.”

    Source location

    2021-0362-Response-from-West-Midlands-Police_Published
    Page 7 · response
    Published 3 November 2021

    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 relevant assessments and information to be available and incorporated into risk-management planning for allocated offenders.

    Verbatim wording from the response

    “22. A Joint Counter Terrorism Prison and Probation Hub (‘JCTPPH’) has been formed. This is a collaboration between HMPPS, CTPHQ and the Security Service. One of its core functions is to enhance the flow of intelligence and information between covert and overt functions, noting that there is an obvious and necessary ‘firewall’ between the two. MAPPA chairs will consider how core groups will contribute in each case. The creation of core groups will ensure a secure and clear pathway for the sharing of sensitive intelligence/information into MAPPA. CTPHQ have provided guidance through their Manual of Guidance to require CTP Nominal Management specialist officers and Lead Responsible Officers to ensure that all relevant information is at hand to develop effective risk management plans for their allocated nominals, including those managed under MAPPA.”

    Source location

    2021-0362-Response-from-West-Midlands-Police_Published
    Page 7 · response
    Published 3 November 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and operationalise the covert-overt bridge for reviewing, revealing and appropriately sharing sensitive intelligence with MAPPA.

    Verbatim wording from the response

    “31. The JCTPPH will ensure the right information gets to the right place at the right time. A major focus, in its first year, has been the development and operationalisation of a covert-overt bridge framework. This provides an effective, safe, process through which sensitive intelligence can be revealed and subsequently, appropriately, disclosed to support defensible decision making regarding risk management. Originally focused on supporting better disclosure into the Parole Board process learning has been taken and applied to MAPPA where the bridge has already been tested on five cases bringing to the attention of MAPPA information previously only known to the security service.”

    Source location

    2021-0362-Response-from-West-Midlands-Police_Published
    Page 9 · response
    Published 3 November 2021

    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

    Escalate delayed prison Form F submissions, challenge variable quality, and seek additional analytical support for security information.

    Verbatim wording from the response

    “26. Where there are delays in receipt of the Form F, these are escalated as a matter of urgency to the prison concerned. The quality of the Form F can be variable, and locally the West Midlands MAPPA chair is challenging this position, and seeking a greater level of analytical support from the JCTPPH around security information, to better support MAPPA decisions.”

    Source location

    2021-0362-Response-from-West-Midlands-Police_Published
    Page 8 · response
    Published 3 November 2021

    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

    Vet CT MAPPA Chairs and specialist offender-management staff, and use Joint Extremist Unit support to bring intelligence into MAPPA meetings.

    Verbatim wording from the response

    “34. CT MAPPA chairs are now Develop Vetted, and that the key staff (CTNM & National Security Division) who actively manage the offenders, have specialist roles, are also vetted to a level suitable for CT and work together outside of the formal MAPPA meetings. The Chairs now work with the Joint Extremist Unit to facilitate intelligence”

    Source location

    2021-0362-Response-from-West-Midlands-Police_Published
    Page 10 · response
    Published 3 November 2021

    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

    Establish the Joint Counter Terrorism Prisons and Probation Hub to coordinate multi-agency risk management and intelligence sharing.

    Verbatim wording from the response

    “At the time of the attack perpetrated by Usman Khan at Fishmongers’ Hall in 2019, the Security Service relied on counter-terrorism police (“CTP”) to pass intelligence to and represent the Security Service’s interest in MAPPA. As indicated to the inquest, CTP were the bridge between the Security Service and MAPPA. This is no longer the case. In direct response to Jonathan Hall QC’s MAPPA review, the Joint Counter Terrorism Prisons and Probation Hub (“JCTPPH”) was set up with the aim of ensuring that there is a shared understanding of who poses a risk, and why, and to enable management of those individuals”

    Source location

    2021-0362-Response-from-Home-Office_Published
    Page 3 · response
    Published 3 November 2021

    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

    Create and use the Covert/Overt Bridge to share sensitive intelligence directly with appropriately cleared MAPPA participants.

    Verbatim wording from the response

    “through multi-agency partnerships and engagement with the appropriate statutory bodies. The JCTPPH composes staff from the Security Service, CTP and HMPPS. The key piece of work that is being undertaken to achieve this aim is the JCTPPH-owned “Covert / Overt Bridge”. The Bridge will facilitate the sharing of sensitive intelligence into the MAPPA process and, importantly, other key forums. The JCTPPH has created a mechanism for directly sharing sensitive intelligence with those within the MAPPA process, most notably the MAPPA Chair(s), as well as others who hold appropriate clearances, regarding individuals subject to MAPPA. Use of the Bridge will support MAPPA in making informed decisions but will also ensure that the intelligence is shared in a way which ensures that the Security Service complies with the requirements as set out in the Security Service Act 1989.”

    Source location

    2021-0362-Response-from-Home-Office_Published
    Page 4 · response
    Published 3 November 2021

    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

    Work with relevant case-management forums to coordinate covert and overt risk management and share proportionate intelligence with HMPPS from prison entry.

    Verbatim wording from the response

    “The JCTPPH is also working with other forums in the case management of those of counter-terrorism interest in the Prisons and Probation sector to enable further co-ordination of covert and covert risk management, such as Pathfinder, the Parole Board and the Prison Separation Centre Management Committee. This will provide us with the ability to share intelligence, where assessed to be necessary and proportionate, with HMPPS from the moment an individual enters the Prison estate, meaning that case management decisions will be able to take into account the entirety of what is known about the individual rather than a part of the picture. Once in place, this means that towards the end of a prisoner’s sentence, when the individual is managed by MAPPA, there will be a full and detailed narrative that draws on all sources of information and intelligence to inform decision-making.”

    Source location

    2021-0362-Response-from-Home-Office_Published
    Page 4 · response
    Published 3 November 2021

    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

    Maintain Northern Hub intelligence support and information-sharing channels with WMCTU senior managers and CT MAPPA attendees for Staffordshire-linked nominals.

    Verbatim wording from the response

    “Part of the changes to this enhanced Regional collaboration saw Staffordshire Police personnel cease to attend CT MAPPA meetings. Further, the well-established working practices (Post November 2019) were maintained with the WMCTU Northern Hub continuing to provide intelligence support to CT Policing where nominals with established links to the Staffordshire Force area are subject to MAPPA proceedings.”

    Source location

    2021-0362-Response-from-Staffordshire-Police_Published
    Page 2 · response
    Published 3 November 2021

    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 the MAPPA document set and meeting template to retain prison information and record intelligence, ERG conclusions, and risk factors.

    Verbatim wording from the response

    “• We will amend the document set to ensure that key information from the MAPPA F is retained for future meetings post release from custody. The new MAPPA meeting template will include a section for key up-to-date intelligence, key conclusions of the most recent ERG assessment and provide for a clear record of risk factors.”

    Source location

    2021-0362-Response-from-MoJ_Published
    Page 11 · response
    Published 3 November 2021

    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

    Operate the covert-overt bridge framework to identify, review, reveal, and disclose sensitive intelligence for MAPPA risk-management decisions.

    Verbatim wording from the response

    “• The Joint Counter-Terrorism Prisons and Probation Hub (JCTPPH) is a collaboration between HMPS, CTP and the Security Service to ensure the right information gets to the right place at the right time. Launched in 2021, a major focus has been the development and operationalisation of a covert-overt bridge framework. This provides an effective, safe, process through which sensitive intelligence can be revealed and subsequently, appropriately, disclosed to support defensible decision-making regarding risk management. Originally focused on supporting better disclosure into the Parole Board, the framework is now being applied to MAPPA where the bridge has been tested using information previously only known to the Security Service.”

    Source location

    2021-0362-Response-from-MoJ_Published
    Page 12 · response
    Published 3 November 2021

    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

    Other bodies are taking forward substantive work on the concerns, so further College guidance or training would risk duplicating their work.

    Verbatim wording from the response

    “In developing our response, we are grateful to the other addressees (and national Counter Terrorism policing) who have shared their responses with us. We note from their responses that these addressees have taken forward, or plan to take forward, substantive work to address the seven MCs listed above.”

    Source location

    2021-0362-Response-from-College-of-Policing_Published
    Page 4 · response
    Published 3 November 2021

    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

    Matters concerning MAPPA intelligence sharing, security-sensitive information and police contact reporting are predominantly operational and assigned to other named bodies.

    Verbatim wording from the response

    “The Home Office has liaised closely with operational partners and other Government Departments regarding the collective Matters of Concern (MCs). Three MCs - 19, 20 and 21 - will be addressed by the Chief Constables of West Midlands Police and Staffordshire Police and the Secretary of State for Justice. The Home Office has reviewed these responses and agrees with their content.”

    Source location

    2021-0362-Response-from-Home-Office_Published
    Page 2 · response
    Published 3 November 2021

    Open published response
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Data last updated 7 September 2026