Recurring concern

Unreliable placement and maintenance of police risk and vulnerability markers

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First reported 25 Jan 2019•Latest report 27 May 2021

Definition

What this concern includes

Includes failures of police processes for placing, updating, maintaining or assuring risk and vulnerability markers on vehicles or police information systems, including ACT markers during missing-from-home investigations and vulnerability markers on systems such as OPUS, where the marker is intended to support risk recognition, information sharing or operational response.

Not included

Excludes general police record-keeping, communications or information-system deficiencies where no risk or vulnerability marker control is identified.
Excludes missing-person response, safeguarding, vehicle tracking or incident-management failures that do not involve placing or maintaining a police risk or vulnerability marker.
Excludes failures to act on a correctly placed and current marker when the marker process itself was reliable.
Excludes generic risk information that is not represented through a dedicated police marker or flag.

Reports: 4
Individual concerns: 5
Date range: 2019–2021
Stated actions: 5

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.

Greater Manchester Police3

College of Policing1

East of England Ambulance Service NHS Trust1

Essex Partnership University NHS Foundation Trust1

Essex Police1

Home Office1

National Police Chiefs’ 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 May2021
Manchester North
Concerns raised2
1. Lack of GMP Officers’ knowledge and understanding of ACT marker levels and their implications for missing from home investigations
2. Delays in placing ACT markers on vehicles during missing from home investigations
This report raised 2 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 2
1. Action
  Communicate key changes and learning from relevant policies and guidance to operational officers and staff through a comprehensive communication plan.
  Stated by Greater Manchester PoliceStated planned
2. Action
  Review and update the GMP Missing From Home policy to specify ACT marker use, timely activation responses, and supervisory checks.
  Stated by Greater Manchester PoliceStated in progress
AI-generated summary

Zeyna Partington · 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

Zeyna Partington was reported missing on 8 August 2019 and was believed to be at risk of suicide. Her vehicle was detected by ANPR in Derbyshire, but GMP did not become aware of this until 10 August; she was then found deceased in a nearby field after taking an overdose of prescribed medication. The substantive concerns included inadequate understanding of ACT marker levels, delays or gaps in national ANPR notification, and the absence of a fully implemented national system across all forces.

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 GMP Officers’ knowledge and understanding of ACT marker levels and their implications for missing from home investigations
Wider context from the report
“1. There is a lack of knowledge and understanding by GMP Officers as to the different level of ACT markers and the implications the varying levels may have on investigations particularly missing from home investigations. ”
Source location
Zeyna Partington · 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
Delays in placing ACT markers on vehicles during missing from home investigations
Wider context from the report
“2. If the policy is not to place an ACT marker on a vehicle until the missing from home report is completed then this can mean a delay of several hours, particularly as the court heard it is often difficult to resource and allocate officers to grade 2 calls within an hour. In this case if the radio operator had not acted outside of policy then the hits on the 8th August in both Rochdale and Derbyshire would not have been known at all. ”
Source location
Zeyna Partington · 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
Communicate key changes and learning from relevant policies and guidance to operational officers and staff through a comprehensive communication plan.

Verbatim wording from the response
“Although the content of the College of Policing guidance document on the use of markers and the Missing From Home policy are known to specific practitioners, the evidence presented at the Inquest into Zeyna Partington's death indicates there is a need to ensure increased awareness of the content across operational staff; specifically uniform frontline officers and staff from the operational communications branch.”

Source location
2021-0181-Response-from-Greater-Manchester-Police_Published
Page 2 · response
Published 28 May 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 and update the GMP Missing From Home policy to specify ACT marker use, timely activation responses, and supervisory checks.

Verbatim wording from the response
“In addition to the above, internally we are in the process of reviewing and updating the GMP Missing From Home policy. Following your observations and recommendations and the changes to the national guidance, this will be updated to include more specific information on the use of ACT markers. This will include the expedient application of the correct level of marker in circumstances such as this case has highlighted. It will also include guidance on the use and review of markers and highlight expectations on the need for a timely response to activations.”

Source location
2021-0181-Response-from-Greater-Manchester-Police_Published
Page 2 · response
Published 28 May 2021
Open published response
24 Nov2020
Essex
Concerns raised1
1. Lack of sufficiently clear EEAS training on identifying relevant flag markers for appropriate police attendance at a property
This report raised 4 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sharon Louise Kelly · 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

Sharon Louise Kelly, who had a long history of mental health and alcohol problems and frequent suicide attempts, informed a family member that she would kill herself on the anniversary of her baby son’s death. On 27 June 2019, an ambulance attended her property but did not enter while awaiting delayed police attendance; when services eventually entered, Ms Kelly was deceased. The concerns included delays and communication between ambulance and police services, risk assessment and police response procedures, and arrangements for urgent mental health assessments.

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 sufficiently clear EEAS training on identifying relevant flag markers for appropriate police attendance at a property
Wider context from the report
“Whether there is sufficiently clear training at EEAS in relation to (1) identifying relevant flag markers to ensure police attendance at a property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019) ”
Source location
Sharon Louise Kelly · Prevention of Future Deaths report
Page 1 · concerns
Open source report
15 Aug2019
Manchester South
Concerns raised1
1. Failure to update OPUS with vulnerability markers
This report raised 6 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
  Implement an integrated operating system supporting warning-marker creation, updates, reviews, removal, provenance, accountability, mandatory review notifications, and cautionary prompts.
  Stated by Greater Manchester PoliceStated in progress
Respondent positions 2
1. Position
  Operational and procedural concerns about police practice are for the police to address.
  Stated by Home OfficeRedirects responsibility
1. Position
  A warning-marker policy cannot yet be completed pending assessment of the new system and anticipated inquiry requirements.
  Stated by Greater Manchester PoliceUnable to act
AI-generated summary

Dane Lee Pearson · 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

Dane Lee Pearson, who had a history of mental health problems and amphetamine use, was found suspended from a ligature at his home on 13 December 2017. The investigation concluded that the death was suicide, with the medical cause recorded as hanging. Concerns included failures in the issuing and documentation of a Child Abduction Warning Notice, failure to assess or account for his vulnerability, inadequate recording of vulnerability markers, and failure to communicate that criminal proceedings had been discontinued.

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 update OPUS with vulnerability markers
Wider context from the report
“3. The inquest heard that OPUS the Police system did not appear to have been correctly updated with markers to flag his vulnerability. ”
Source location
Dane Lee Pearson · 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
Implement an integrated operating system supporting warning-marker creation, updates, reviews, removal, provenance, accountability, mandatory review notifications, and cautionary prompts.

Verbatim wording from the response
“As a Force, we are currently in the process of implementing a new, integrated operating system which will replace many of our existing systems. ████████ has worked closely alongside the iOPS team to ensure that all requirements for safely managing intelligence are met. GMP have provided the following as essential functions in relation to markers;”

Source location
2019-0056-Responses
Page 8 · response
Published 6 June 2019
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 procedural concerns about police practice are for the police to address.

Verbatim wording from the response
“The matters of concern that you raised are primarily operational and procedural matters for the police who, I understand, will be responding to you separately.”

Source location
2019-0056-Responses
Page 3 · response
Published 6 June 2019
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
A warning-marker policy cannot yet be completed pending assessment of the new system and anticipated inquiry requirements.

Verbatim wording from the response
“████████ of the Force Intelligence Bureau (FIB) is tasked with writing GMP’s first Force policy and guidance document on the use of WM. This will be completed”

Source location
2019-0056-Responses
Page 7 · response
Published 6 June 2019
Open published response
25 Jan2019
Manchester North
Concerns raised1
1. Failure to place risk and vulnerability markers on police systems
This report raised 8 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 2
1. Action
  Implement iOPS warning-marker functionality, including marker management, review notifications, provenance recording and audit details.
  Stated by Greater Manchester PoliceStated in progress
2. Action
  Develop GMP’s first force policy and guidance on using warning markers.
  Stated by Greater Manchester PoliceStated planned
Respondent positions 1
1. Position
  The first warning-marker policy and guidance document awaits assessment of the new system and mandatory public-inquiry reforms.
  Stated by Greater Manchester PoliceUnable to act
AI-generated summary

Anne-Marie Nield · 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

Anne-Marie Nield was a repeat victim of domestic violence who died from multiple injuries after her partner inflicted a violent and sustained attack at her home on 8 May 2016. The report identifies concerns about inadequate police risk assessment, delays, failures to provide support and information, and insufficient understanding and application of domestic abuse policies. It also notes that not all recommendations addressing these shortcomings had been implemented two and a half years after her death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to place risk and vulnerability markers on police systems
Wider context from the report
“2. Markers are not being placed on police systems (e.g. OPUS) in line with policy and procedure. Markers are all the more important where resources are finite and demands placed upon the Police Service are increasing. Markers help in identifying/conveying risk and vulnerability. ”
Source location
Anne-Marie Nield · 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
Implement iOPS warning-marker functionality, including marker management, review notifications, provenance recording and audit details.

Verbatim wording from the response
“As a force, we are currently in the process of implementing a new, integrated operating system which will replace many of our existing systems. ████████ has worked closely alongside the iOPS team to ensure that all requirements for safely managing intelligence are met.”

Source location
2019-0477-Response-from-Greater-Manchester-Police-Redacted
Page 2 · response
Published 25 January 2019
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 GMP’s first force policy and guidance on using warning markers.

Verbatim wording from the response
“There is not currently a force policy or guidance document on warning markers. The decision whether to add a warning marker (WM) to an individual’s nominal profile (OPUS profile) depends solely on the professional judgement of officers.”

Source location
2019-0477-Response-from-Greater-Manchester-Police-Redacted
Page 2 · response
Published 25 January 2019
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 first warning-marker policy and guidance document awaits assessment of the new system and mandatory public-inquiry reforms.

Verbatim wording from the response
“████████ of the Force Intelligence Bureau (FIB) is tasked with writing GMP’s first force policy and guidance document on the use of WMs. This will be completed when several key factors can be fully considered. This includes seeing the capability of our new iOPS system and awaiting mandatory reform requirements from the Anthony Granger Public Inquiry (which is likely to include necessary actions required around WMs). Part of this policy will be that officers and staff are actively encouraged to place appropriate WMs on police records to help manage risk.”

Source location
2019-0477-Response-from-Greater-Manchester-Police-Redacted
Page 2 · response
Published 25 January 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of GMP Officers’ knowledge and understanding of ACT marker levels and their implications for missing from home investigations

Delays in placing ACT markers on vehicles during missing from home investigations

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.2

Concerns raised1

Lack of sufficiently clear EEAS training on identifying relevant flag markers for appropriate police attendance at a property

Concerns raised1

Failure to update OPUS with vulnerability markers

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

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

Concerns raised1

Failure to place risk and vulnerability markers on police systems

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.2

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

Actions described in response 2

Actions described in response 1

Respondent positions 2

Actions described in response 2

Respondent positions 1