Recurring concern

Unreliable recording of police investigative actions and decisions

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First reported 13 Oct 2014•Latest report 27 Nov 2023

Definition

What this concern includes

Includes failures within police investigations to create, maintain and retain sufficiently detailed contemporaneous records of material investigative actions, conversations, advice, decisions and case-management steps, including police-CPS discussions where they form part of the investigation record.

Not included

Excludes generic clinical, care, probation or administrative record-keeping failures without a police investigative context.
Excludes failures to record reported crimes or offence classifications where the concern is crime recording rather than documenting investigative actions and decisions.
Excludes failures in investigating or reviewing a case where the investigation record itself is not deficient.
Excludes post-incident, coronial or regulatory reports unless the assertion specifically concerns recording police investigative actions or decisions.
Excludes generic police information-sharing failures where no deficient recording of investigative actions, discussions or decisions is identified.

Reports: 3
Individual concerns: 3
Date range: 2014–2023
Stated actions: 6

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Home Office2

Crown Prosecution Service1

Department of Health and Social Care1

Derbyshire Constabulary1

Greater Manchester Health and Social Care Partnership1

Greater Manchester Mental Health NHS Foundation Trust1

Greater Manchester Police1

Metropolitan Police Service1

Pennine Care NHS Foundation Trust1

Trafford Borough Council1

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.

27 Nov2023
Derby and Derbyshire
Concerns raised1
1. Failure to maintain contemporaneous and sufficiently detailed investigation records
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Refresh stalking training content to cover risk indicators, reasonable enquiries, pattern analysis, ongoing risk assessment and record keeping.
  Stated by Derbyshire ConstabularyStated completed
2. Action
  Refresh the Thrive policy to require documented ongoing reassessment of risk during investigations.
  Stated by Derbyshire ConstabularyStated in progress
3. Action
  Reinforce contemporaneous note taking and record keeping through senior messaging and refreshed training materials.
  Stated by Derbyshire ConstabularyStated completed
1. Action
  Deliver investigative-mindset workshops and embed robust record-keeping requirements in the improvement strategy, with governance and QATT monitoring.
  Stated by Derbyshire ConstabularyStated in progress
AI-generated summary

Gracie Elizabeth Spinks · 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

Gracie Elizabeth Spinks was unlawfully killed by a former work colleague on 18 June 2021, dying from a stab wound to the neck. The report describes serious police failings in investigating her stalking complaint and in dealing with a rucksack containing weapons, and raises concerns about stalking investigations, risk assessments, record keeping, dangerous items found in the community, and the availability of independent stalking advocates.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain contemporaneous and sufficiently detailed investigation records
Wider context from the report
“4. Contemporaneous note taking/record keeping – during the inquest I heard that police officers failed to make any contemporaneous notes of important steps in the police investigation including, for example, conversations with an informant/member of the public, words of advice given to a suspect, a telephone call to a potential witness and also an internal police discussion between a police constable and police sergeant discussing the closure of an investigation. The written crime reports reviewed during the inquest also lacked sufficient detail around these important conversations/investigative steps – in other words, the crime reports did not compensate for the lack of contemporaneous notes. I am concerned that a lack of contemporaneous notes/insufficient detail within a crime report may impact on the ability to make properly informed risk assessments which rely on the existence of a good written record of important conversations/steps taken during an investigation. This may become an issue where, for example, an investigation is re-allocated to another police officer who has had no prior involvement in the investigation such that the newly allocated police officer will be reliant upon the quality of the original police officer’s records/notes. ”
Source location
Gracie Elizabeth Spinks · 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
Refresh stalking training content to cover risk indicators, reasonable enquiries, pattern analysis, ongoing risk assessment and record keeping.

Verbatim wording from the response
“As a force, we are committed to improving our staff’s understanding and identification of stalking and vulnerability. Since the inquest, we have reviewed and refreshed the content of our training on stalking as part of the force’s vulnerability programme. This emphasises to our officers and staff the risk indicators of stalking behaviour and the importance of pursuing all reasonable lines of enquiry. A focus is also placed on the importance of broadening intelligence parameters to include multiple locations to assess cumulative risk, and that officers should undertake ongoing risk assessments throughout the course of an investigation and keep accurate records.”

Source location
Response from Derbyshire Constabulary
Page 1 · response
Published 1 December 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
Refresh the Thrive policy to require documented ongoing reassessment of risk during investigations.

Verbatim wording from the response
“A thematic review of stalking investigations between June 2023 and November 2023 has been undertaken. Unfortunately, this demonstrated a continuing need for improvement, and the revised training material, together with effective supervision and oversight is reinforcing this. The Thrive policy is being refreshed in January 2024 to include a greater focus on the ongoing need for ‘re-Thrive’ assessments during an investigation, and the expectation for this to be fully documented on the crime report.”

Source location
Response from Derbyshire Constabulary
Page 4 · response
Published 1 December 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
Reinforce contemporaneous note taking and record keeping through senior messaging and refreshed training materials.

Verbatim wording from the response
“Since the inquest, the importance of contemporaneous note taking and record keeping has formed part of key messaging, through senior management teams, to frontline staff and supervisors. This area of learning has also been incorporated into the training material that has been refreshed. Officers have access to mobile devices upon which contemporaneous notes can be made.”

Source location
Response from Derbyshire Constabulary
Page 5 · response
Published 1 December 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
Deliver investigative-mindset workshops and embed robust record-keeping requirements in the improvement strategy, with governance and QATT monitoring.

Verbatim wording from the response
“Building upon this, as mentioned above, the force’s Improving Investigations strategy has been reviewed and refocused for 2024, in which building an ‘investigative mindset’ is a key priority. A series of workshops are underway throughout January and February 2024, with senior leaders as well as frontline officers and staff, to understand the capabilities required and opportunities to improve the desired behaviour.”

Source location
Response from Derbyshire Constabulary
Page 5 · response
Published 1 December 2023
Open published response
18 Nov2020
Manchester South
Concerns raised1
1. Failure to routinely document police and CPS case discussions
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Re-issue guidance to CPS Direct prosecutors requiring MG3 records to include details of relevant police conversations.
  Stated by CPS North WestStated completed
Respondent positions 1
1. Position
  Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.
  Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibility
AI-generated summary

Alfie Gildea · 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

Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

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 routinely document police and CPS case discussions
Wider context from the report
“10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information. ”
Source location
Alfie Gildea · 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
Re-issue guidance to CPS Direct prosecutors requiring MG3 records to include details of relevant police conversations.

Verbatim wording from the response
“We also take on board the importance of a consistent and transparent approach to recording whether there has been a telephone call with the police as part of the charging decision. Senior managers within CPS Direct have confirmed that guidance has been re-issued to all of their prosecutors on the need to include within the MG3 details of any conversation relevant to an issue in the case, where it is not already included within the documentation submitted.”

Source location
2020-0242-Response-from-CPS-Redacted.pdf
Page 3 · response
Published 24 December 2020
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 named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.

Verbatim wording from the response
“I have noted that your Regulation 28 letter has also been sent to Greater Manchester Police, Trafford Metropolitan Borough Council, Greater Manchester Mental Health NHS Foundation Trust, Pennine Care NHS Foundation Trust, The Crown Prosecution Service, the Home Office and the Department of Health and Social Care and I will leave it to the named respondents to address the concerns which you have expressed. My letter therefore addresses the issues that fall within the remit of GMHSCP more widely around how we can share the learning from this case.”

Source location
2020-0242-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted.pdf
Page 1 · response
Published 24 December 2020
Open published response
13 Oct2014
Inner South London
Concerns raised1
1. Failure to document investigative decisions sufficiently to inform others
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Strengthen sergeant and detective-supervisor capability through mandatory training, probationary evidence workbooks, investigative skills courses and documented supervision requirements.
  Stated by Metropolitan Police ServiceStated completed
AI-generated summary

Arsema Dawit · 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

Arsema Dawit, aged 15, died on 2 June 2008 after being stabbed by a former friend who had been stalking her; the inquest jury concluded that the death was unlawful killing. Concerns included the recording and classification of the initial police report, inadequate and untimely investigation, insufficient supervision and communication with the family, gaps in investigative procedures, and reluctance to use interpreting services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to document investigative decisions sufficiently to inform others
Wider context from the report
“(2) The court was told that most serious crime reported should be the principal offence, but the threat to kill was not entered as the principle offence, when at some stage it was reviewed by senior supervising officers, nor was a linked crime report made. The entry of the second Inspector was insufficient to properly inform others of his decisions. Two inspectors were involved and that gave false reassurance to more junior officers, who did not question the appropriateness of the principal offence, despite contrary evidence. It was not clear whether this was a series of misunderstandings or a systemic or cultural failure to properly document and ensure flexibility in investigations. ”
Source location
Arsema Dawit · 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
Strengthen sergeant and detective-supervisor capability through mandatory training, probationary evidence workbooks, investigative skills courses and documented supervision requirements.

Verbatim wording from the response
“Since 2008, considerable work has been undertaken nationally and within the MPS on these fronts, beginning with a number of significant changes nationally and within the MPS in the training and support of all newly promoted and serving uniformed and detective officers.”

Source location
2014-0442-Response-by-Metropolitan-Police
Page 5 · response
Published 13 October 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to maintain contemporaneous and sufficiently detailed investigation records

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to routinely document police and CPS case discussions

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to document investigative decisions sufficiently to inform others

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

Actions described in response 4

Actions described in response 1

Respondent positions 1

Actions described in response 1