Recurring concern

Unreliable Merlin safety-critical risk information

First to latest report 15 Jul 2015 — 27 Nov 2020

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
3

What this concern includes

Includes failures of the Merlin database and directly associated Merlin workflows to record, update, retrieve, cross-check, highlight or make safety-critical vulnerability and risk information available to authorised police or emergency-response personnel, including inaccessible or non-prominent risk details, failure to recheck records after new identifying information, and failure to create required vulnerability records.

What is not included
  • Excludes generic police information-sharing, database-access or record-keeping deficiencies where Merlin is not the deficient system.
  • Excludes failures to act on complete and clearly presented Merlin information when Merlin access, visibility and recording controls operated reliably.
  • Excludes unrelated police systems, including PNC, NOMIS and other databases, unless the assertion explicitly concerns Merlin or its direct integration.
  • Excludes generic training, workload or communication deficiencies unless they directly impair the safety-critical operation or use of Merlin.
  • Excludes downstream missing-person, safeguarding or emergency-response failures where Merlin information was reliably available and used.

Reports and published responses 3 reports

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

  1. Inner North London

    AI-generated summary

    Agnès Blandine Marthe MARCHESSOU · 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

    Agnès Marchessou had experienced fragile mental health for four or five years before her death. After her arrest on 4 July 2020, she was knocked over by a bus on 8 July and taken to hospital. The principal concerns were that police did not pass key information about the incident and her stated reasons for stepping into the road to ambulance or hospital staff, did not promptly make relevant enquiries or record her potential vulnerability, and showed confusion about the required process.

    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 create a Merlin record of potential vulnerability and need for assistance

    Wider context from the report

    “4. When the police officers returned to the police station, they did make a search themselves and discovered that she had been arrested for domestic violence. However, they did not make a Merlin record of her potential vulnerability and need for assistance. ”

    Source location

    Agnès Blandine Marthe MARCHESSOU · 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

    Introduce a Merlin Toolkit advising officers when to complete reports and requiring Vulnerability Assessment Framework-based risk assessment.

    Verbatim wording from the response

    “The MPS will shortly be introducing a Merlin Toolkit, which will provide advice and guidance on the circumstances in which reports should be completed. This also references the Vulnerability Assessment Framework (VAF) which should be used as the basis for assessment for all officers. This assessment is based on appearance, behaviour, communication/capacity of the victim and whether the victim is in danger and the environment/circumstances they are in. The MPS considers that this action will support officers in making appropriate decisions in respect of completing Merlin Reports for vulnerable people.”

    Source location

    2020-0255-Letter-from-Metropolitan-Police-Redacted.pdf
    Page 3 · response
    Published 30 December 2020

    Open published response

  2. Inner North London

    AI-generated summary

    Rosario CORDERO-SANZ · 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

    Rosario (known as Charo) Cordero-Sanz died after jumping in front of a train at Bethnal Green Underground Station on 14 July 2018. The concerns included gaps in special police officers’ access to information, understanding of missing-person and mental-health procedures, communication with a non-native English-speaking friend, and the failure to identify her as a high-risk missing person.

    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 actively listen and recheck Merlin records when new identifying information is obtained

    Wider context from the report

    “3. The three special police officers who attended late that Friday evening / early Saturday morning were described as kind, and clearly demonstrated concern, but ultimately they did not know that they were dealing with a high risk missing person. Without tablets or a mobile data terminal, they had no means of checking this themselves. The jury found that the special sergeant and the CAD operator did not actively listen to one another. This meant that the Merlin system was not checked again after officers had obtained Ms Cordero-Sanz’s full name, missing the opportunity to match her details with those reported earlier and to identify her as a high risk misper. ”

    Source location

    Rosario CORDERO-SANZ · 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

    Provide local learning addressing communication and active-listening failures involving Metropolitan Special Constabulary officers and the CAD operator.

    Verbatim wording from the response

    “• The second CAD operator’s (call despatch) mistake was not related to wild card searches either. His error was not to check Ms Cordero-Sanz’s name and its phonetic spelling with the officers at the scene. However it is acknowledged that CAD operators have numerous demands placed on them at any one time and are generally dealing with multiple calls. This was a failure of communication and active listening, and has been dealt with by way of local learning for the MSC officers and the second CAD operator.”

    Source location

    2018-0307-Response-by-Metropolitan-Police
    Page 4 · response
    Published 17 February 2019

    Open published response

  3. London (East)

    AI-generated summary

    PAULS RICARDS KALNINS · 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

    PAULS RICARDS KALNINS, who had a history of depression and had expressed suicidal thoughts, was found hanging in a shed after leaving a location where police had spoken to him. The principal concerns were that the Merlin database did not clearly display key risk information, was difficult to navigate, and that communications officers needed more familiarisation and refresher training.

    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 Merlin database to present key risk information prominently and accessibly

    Wider context from the report

    “(1) The communications officer confirmed that he had worked in his role for 15 years, but had little need to obtain data from the Merlin database. Whilst he therefore had access to it, he was not familiar with it. He confirmed that he had last had training in 2011, in relation to the database. (2) The communications officer said that he did not know where to look for the required details. He explained that the database is complex to navigate. The front screen does not contain any key information relating to risk. (3) An investigation was carried out by the Directorate of Professional Standards and they found that the communications officer had accessed the correct pages of the database but had failed to see the relevant pieces of information. (4) The line manager for the communications officer concerned, confirmed that it would “100% assist if key risks come up automatically on the front screen of the Merlin database”. (5) She confirmed that the communications officers are under a lot of pressure when they provide information to officers on the ground; they do not need to access the Merlin database regularly and have to go through a lot of detail in the database. She agreed that refresher training for communications officers would also be useful. (6) The investigator from the Directorate of Professional Standards, ████████ also agreed that the Merlin database is a piece of software which could be improved and could be more user-friendly. He agreed that Merlin is an important database and it would be useful to have refresher training. (7) It was considered that the identification of the grade of risk (low, medium or high) on the front page, together with a brief explanation as to the type of risk posed, is likely to assist in prompting the communications officer to undertake a more detailed search of key parts of the database. ████████ suggested that the warning could be in red. Having heard all of the above evidence, I consider that if the key risks could be highlighted on the front screen of the Merlin database, this would greatly assist communications officers and reduce risk to vulnerable persons in the future. Mandatory refresher training for communications officers, may also reduce risk. ”

    Source location

    PAULS RICARDS KALNINS · 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 mandatory Merlin refresher training covering warning flags, unflagged incident details, and compliance monitoring for all current MET CC communications staff.

    Verbatim wording from the response

    “In relation to this area of concern, the Metropolitan Police Service does not intend to make changes to the Merlin database because the functionality identified already exists. However, the importance of this functionality will be part of the training that is set out below, with an intended completion date of 31 March 2016.”

    Source location

    2015-0278-Response-by-Metropolitan-Police
    Page 2 · response
    Published 15 July 2015

    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 Merlin database changes are intended because the recommended warning functionality already exists in the system.

    Verbatim wording from the response

    “████████ states that if information is correctly input onto the system in the first place, the suggested functionality is already present on the system, and would result in a red warning triangle being prominently visible on the top right of every page of the database entry. Clicking on this triangle takes one directly to the relevant warning text. An internal briefing document with screen shots taken from Mr Kalnins’ real Merlin record has been prepared to illustrate this, but as this contains sensitive personal data which should not be circulated to third parties without permission, it has not been included here. If you wish to have sight of this document, please advise, and we will facilitate this separately.”

    Source location

    2015-0278-Response-by-Metropolitan-Police
    Page 2 · response
    Published 15 July 2015

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026