Recurring concern

Unreliable gathering of witness evidence for formal investigations

First to latest report 29 May 2014 — 6 Feb 2026

Reports that mention this concern
17
Times this concern has been raised
19
Stated actions linked to this concern
34

What this concern includes

Includes failures to identify relevant witnesses and obtain, document or provide their statements or accounts in time for formal coronial, inquest, service, disciplinary, prosecution or comparable safety investigations.

What is not included
  • Excludes general investigation delays or incomplete investigations where no witness-evidence gathering failure is identified.
  • Excludes disclosure failures occurring after witness statements or accounts have been reliably obtained, unless the assertion also concerns obtaining the witness evidence itself.
  • Excludes failures to obtain non-witness documentary, digital or physical evidence unless the assertion also concerns the gathering of witness statements or accounts.
  • Excludes ordinary clinical, care or employment documentation failures that are not part of gathering evidence for a formal investigation or proceeding.

Reports and published responses 17 reports

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

  1. Manchester City

    AI-generated summary

    Jude Daryl Lloyd · 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

    Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.

    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 obtain crucial witness evidence, learn lessons, and adequately oversee SUI report sign-off

    Wider context from the report

    “h. The GMMH SUI investigation report contained several factual errors and misinterpretations. The CMHT Responsible Clinician did not provide a statement or was interviewed despite him being a crucial witness. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off. ”

    Source location

    Jude Daryl Lloyd · Prevention of Future Deaths report
    Page 4 · 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

    Share the Trust review findings with inpatient and CMHT teams through a learning event.

    Verbatim wording from the response

    “The findings of the Trust’s review were presented to the Inpatient and CMHT Teams in a learning event on 28 September 2021.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 13 October 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

    Update the serious-incident information-gathering process to obtain staff statements early and use them in investigations.

    Verbatim wording from the response

    “The Trust process for obtaining information from staff involved in an SI has been updated to ensure we gather statements from staff at an early stage following the SI and use these statements in the SI review.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 6 · response
    Published 13 October 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

    Assign a Patient Safety Practitioner to support and advise serious-incident review teams.

    Verbatim wording from the response

    “When a team of clinical staff are allocated to complete a review following a serious incident, they are allocated a Patient Safety Practitioner to support and advise the review team throughout the review process. The Patient Safety Practitioner is an experienced professionally qualified member of staff who has additional knowledge and skills in incident management.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 6 · response
    Published 13 October 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 omission of the Responsible Clinician’s interview would not have changed the Serious Incident investigation’s findings.

    Verbatim wording from the response

    “We apologise if there were factual errors within the Trust Serious Incident (SI) investigation report. We acknowledge that the CMHT RC could have been interviewed as part of the review, although this would not have changed the findings of the review.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 6 · response
    Published 13 October 2021

    Open published response

  2. Inner North London

    AI-generated summary

    Agnes Stephanie LAMBERT · 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

    Agnes Stephanie Lambert was a mental health nurse who died after an investigation into allegations concerning her contact with a patient who was fixated on her. The inquest determined that her death was suicide, with the medical cause recorded as suspension by ligature. Concerns included the failure to move her to another ward despite recognising the patient’s fixation, and an allegedly unacceptable delay in progressing the disciplinary investigation.

    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

    Delays in interviewing witnesses to progress disciplinary hearings

    Wider context from the report

    “2. Following the allegations, it then took the trust four months (rather than the expected four weeks) to interview eight witnesses in order to progress to a disciplinary hearing. This was a distressing time for Ms Lambert and she finally went on sick leave. The service manager who gave evidence in court agreed that this was an unacceptable delay. ”

    Source location

    Agnes Stephanie LAMBERT · 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

    Roll out Vital Conversations training for line managers as a professional requirement, initially prioritising nursing managers.

    Verbatim wording from the response

    “To support this, we are in the process of rolling out ‘vital conversations’ training which will form part of the professional requirements for all line managers in the Trust, though nursing managers will initially be prioritised.”

    Source location

    2018-0410-Response-by-Camden-and-Islington-NHS-Trust
    Page 2 · response
    Published 17 December 2018

    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 the disciplinary policy to clarify which matters warrant full investigation and complete the refreshed policy.

    Verbatim wording from the response

    “We absolutely recognise that unnecessary and lengthy disciplinary processes can have a serious detrimental impact on staff mental health and wellbeing. With this in mind, the disciplinary policy is currently being reviewed to include clearer criteria as to what does or does not warrant a full investigation. We also have an added step in our disciplinary process whereby a specially-trained lay member of staff reviews cases to gain assurance or indeed challenge that a formal hearing is required. It is expected that this change along with the”

    Source location

    2018-0410-Response-by-Camden-and-Islington-NHS-Trust
    Page 2 · response
    Published 17 December 2018

    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 a specially trained lay staff member to review disciplinary cases and provide assurance or challenge whether a formal hearing is required.

    Verbatim wording from the response

    “We absolutely recognise that unnecessary and lengthy disciplinary processes can have a serious detrimental impact on staff mental health and wellbeing. With this in mind, the disciplinary policy is currently being reviewed to include clearer criteria as to what does or does not warrant a full investigation. We also have an added step in our disciplinary process whereby a specially-trained lay member of staff reviews cases to gain assurance or indeed challenge that a formal hearing is required. It is expected that this change along with the”

    Source location

    2018-0410-Response-by-Camden-and-Islington-NHS-Trust
    Page 2 · response
    Published 17 December 2018

    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

    Strengthen formal disciplinary investigations by emphasising managers’ responsibility to minimise delays and monitoring occupational health and Employee Assist referrals.

    Verbatim wording from the response

    “Vital Conversations training, will facilitate more issues being resolved informally through the supervision process. For those investigations that do proceed formally, there will be a greater focus on managers’ responsibility to minimise delay/keep to timeframes, and monitoring to ensure that managers have offered/referred staff to occupational health for support and also made them aware of our Employee Assist Programme. The refreshed policy is expected to complete in March 2019.”

    Source location

    2018-0410-Response-by-Camden-and-Islington-NHS-Trust
    Page 3 · response
    Published 17 December 2018

    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

    Add the risks of unnecessary and lengthy disciplinary processes to the HR and OD department risk register and monitor progress.

    Verbatim wording from the response

    “The risks posed by unnecessary and lengthy disciplinary processes have been added to the HR & OD department risk register to monitor and ensure progress is made.”

    Source location

    2018-0410-Response-by-Camden-and-Islington-NHS-Trust
    Page 3 · response
    Published 17 December 2018

    Open published response

  3. Inner North London

    AI-generated summary

    Jeroen ENSINK · 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

    Dr Jeroen Ensink was stabbed to death in a wholly unprovoked attack on 29 December 2015. The report identified multiple concerns involving police recording and information-sharing failures, including failures to identify and communicate possible mental health problems and issues in the handling of evidence and custody records.

    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 obtain statements from available witnesses

    Wider context from the report

    “3. Only one statement was taken, though there were other witnesses on scene. ”

    Source location

    Jeroen ENSINK · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Sunderland

    AI-generated summary

    Patricia Ann Heslop · 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

    Patricia Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.

    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 obtain timely witness statements after falls

    Wider context from the report

    “5. Despite Patricia having fallen sometime in the early part of November no attempts were made at that time to take statements from various witnesses about the fall while events were fresh in their memories. Instead that had to be done as part of the Inquest process. That said, if there was a reluctance to be frank and candid then it was unlikely to manifest itself at the Inquest. It was deeply disappointing that vital information was not to hand about a resident having fallen or being found or assisted after a fall, especially when Patricia had a known history of falls. ”

    Source location

    Patricia Ann Heslop · 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

    Monitor incident-investigation reporting quality and provide refreshed investigation-management training to Home Managers and Area Team Managers.

    Verbatim wording from the response

    “5.2 HC-One has a clear incident investigation process in place as detailed in ████████ statement and above. Since this incident action has been undertaken to ensure the quality of incident investigation reporting is monitored, which has lead in turn to refreshed investigation management training. This has been provided at both Home Manager level and also as part of an 8 day intensive and practice focussed induction for Area Team Managers. This was conducted by the Head of Standards and Compliance and Leadership Development Manager for the company during March and April 2018.”

    Source location

    2018-0102-Response-by-HC-One
    Page 6 · response
    Published 17 June 2018

    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

    Contrary to the report, witness information was obtained during the initial and subsequent internal investigations.

    Verbatim wording from the response

    “5.1 It is stated in the Regulation 28 Report that no attempts were made to take statements from individual witnesses immediately after the fall in November 2016. Immediately following the incident in November 2016, an investigation was undertaken by the then Home Manager, BJ and completed on 26 November 2016. As part of this investigation, witness information was obtained from 8 witnesses. A further investigation was undertaken by HC-One by LL, Area Director dated 7 February 2017. For the purposes of this second internal investigation 12 witnesses were re-interviewed and additional information obtained. Further witness statements were obtained for the purposes of the inquest investigation to re-examine the information and provide more comprehensive statements. It is acknowledged that none of these witness statements identified any evidence of when or how Mrs.”

    Source location

    2018-0102-Response-by-HC-One
    Page 6 · response
    Published 17 June 2018

    Open published response

  5. Buckinghamshire

    AI-generated summary

    JACK OLIVER PORTLAND · 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

    Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

    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

    Delays in identifying relevant witnesses and providing witness statements for coronial investigations

    Wider context from the report

    “(4) In relation to the coronial investigation and the inquest itself, there were significant concerns surrounding the co-ordination of disclosure by HMP Woodhill, initially by volume disclosure direct to the coroner, and subsequently in a piecemeal, partial fashion via Government Legal Department. Emails in which prison staff and/or healthcare staff were participants and which were very relevant to issues raised in the inquest became identifiable only through production records and there was a concern that relevant communications should have formed part of the specific prisoner records and been part of the HMP Woodhill disclosure. Whilst significant urgent work was undertaken by Government Legal Department during the inquest itself to assist the court with additional and correct documentation, these concerns, together with late identification of relevant witnesses and provision of witness statements caused delays to the coronial investigation which may have also have delayed the overall learning process and compromised the ability of HMP Woodhill to implement change in a manner specific to the issues and concerns identified, rather than in the broader terms described during the inquest. ”

    Source location

    JACK OLIVER PORTLAND · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Derby and Derbyshire

    AI-generated summary

    Sheila Johnson · 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

    Sheila Johnson died on 15 May 2013 from catastrophic haemorrhage from a femoral graft wound, less than 24 hours after discharge from hospital with an open left groin wound. The report identified failures in responding to recognised bleeding before discharge and concerns about the inadequacy of the Trust’s investigation, including the omission of key witnesses, limited review of clinical documentation, factual inaccuracies, and the lack of an urgent recall system for patients discharged with potentially life-threatening conditions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to interview key witnesses during investigations

    Wider context from the report

    “(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report. (2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths. (3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod. (4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed. (5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature. No consideration was given to the clinical content of those entries and as to whether or not they were appropriate. (6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made. (7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future. (8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions. ”

    Source location

    Sheila Johnson · 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 serious incident processes provide significant assurance that appropriate systems and processes are in place.

    Verbatim wording from the response

    “The auditors concluded in their report dated 10th March 2015 that the serious incident processes provided significant assurance to the Trust that systems and processes were in place.”

    Source location

    2015-0238-Response-by-Tameside-Hospital-NHS-Trust
    Page 3 · response
    Published 19 May 2015

    Open published response

  7. London (North)

    AI-generated summary

    Mark Duggan · 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 4 August 2011, Mark Duggan was shot by an armed police officer during an enforced vehicle stop in London and was pronounced dead at the scene. The report raises concerns about intelligence sharing and operational decisions before the shooting, the investigation and preservation of evidence at the scene, the recording of the operation, and the coordination and access to intelligence during the investigation and inquest.

    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 obtain prompt comprehensive statements from all police witnesses to fatal shootings

    Wider context from the report

    “Concern 2: Comprehensive accounts were not taken from police witnesses at the first possible opportunity I am concerned that fatal police shootings are not as rigorously examined as they could be and that doubts about the accuracy of police accounts are not minimised. Lessons learned after a death should be as complete as possible. My concern is that not all witnesses to a fatal shooting are asked to give full statements as soon as possible after the event, giving a detailed account of what they saw. I am also concerned about whether there is any purpose in seeking to distinguish between “principal officers” and other police officers save that, where there is any reason to caution an officer, then of course that must be done. I am concerned that witnesses who perceived a threat from the person who was shot did not set that out in their statements. I therefore invite ACPO and the MPS to deal with what I have said when they respond to the IPCC consultation. ”

    Source location

    Mark Duggan · Prevention of Future Deaths report
    Page 22 · 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

    Issue draft statutory guidance on obtaining best evidence in death or serious injury matters for consultation.

    Verbatim wording from the response

    “7. The Coroner makes reference to the IPCC consultation on post incident procedures. On 5 March 2014 the IPCC issued for consultation draft statutory guidance to the police service on achieving best evidence in death or serious injury matters (the draft statutory guidance is enclosed with this response). Paragraphs 21–24 of the draft statutory guidance set out the IPCC’s preliminary position on acquiring ‘detailed individual factual accounts’ and addresses a number of the concerns raised by the Coroner in his Report.”

    Source location

    2014-0182-Response-by-IPPC
    Page 3 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review consultation responses and produce a revised statutory guidance document for submission to the Secretary of State.

    Verbatim wording from the response

    “8. The consultation period for the draft statutory guidance closed on 27 May 2014 and the IPCC is reviewing the many consultation responses received. The IPCC will then, taking account of the consultation responses, produce a revised document that will require the approval of the Secretary of State before being issued. Police officers will then be under a duty to have regard to”

    Source location

    2014-0182-Response-by-IPPC
    Page 3 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review post-incident procedures in light of issues arising from Mark Duggan’s death.

    Verbatim wording from the response

    “The National Policing portfolios are currently undertaking a further review of these procedures, in part at least as a direct result of the issues arising from the death of Mark Duggan. We have already taken steps to ensure that as part of immediate post incident procedures, a senior officer is present when officers are preparing initial accounts. This senior officer will be in a position to confirm and reassure that either conferring did not take place or, if it did, it was for a necessary purpose as provided by the APP, which sets out in clear terms that an officer should not confer about any honestly held belief relating to the use of force. In addition, we have made clear the post incident process can and should be more transparent to both a host force’s initial investigating officers and to the IPCC’s investigators.”

    Source location

    2014-0182-Response-by-ACPO
    Page 3 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ensure a senior officer is present while officers prepare initial accounts after a death or serious injury incident.

    Verbatim wording from the response

    “The National Policing portfolios are currently undertaking a further review of these procedures, in part at least as a direct result of the issues arising from the death of Mark Duggan. We have already taken steps to ensure that as part of immediate post incident procedures, a senior officer is present when officers are preparing initial accounts. This senior officer will be in a position to confirm and reassure that either conferring did not take place or, if it did, it was for a necessary purpose as provided by the APP, which sets out in clear terms that an officer should not confer about any honestly held belief relating to the use of force. In addition, we have made clear the post incident process can and should be more transparent to both a host force’s initial investigating officers and to the IPCC’s investigators.”

    Source location

    2014-0182-Response-by-ACPO
    Page 3 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Commission an expert review of research underpinning delayed formal accounts after traumatic firearms incidents.

    Verbatim wording from the response

    “In paragraph 66 you make specific reference to the apparent inconsistencies in findings between earlier Home Office Study Papers (which lends some support to the practice of allowing a period between a traumatic event and a statement being given) and a more recent paper by Dr William Lewinski. As part of the National Policing response to the earlier IPCC consultation, we recently commissioned Professor Gudjonsson, Emeritus Professor of Forensic Psychology at King’s College, London to conduct a review of the conclusions of Home Office Study Papers of 1986 and 1993, taking into account subsequent relevant studies.”

    Source location

    2014-0182-Response-by-ACPO
    Page 6 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise the APP to restrict staff association representatives’ pre-account intervention to welfare considerations, working with the College of Policing.

    Verbatim wording from the response

    “Many police forces in England and Wales quite properly and responsibly ensure staff association representatives receive accredited training in post incident management. Whilst such representative play a crucial part in these post incident procedures under the direction and control of the post incident manager, it is equally important that such representatives do not duplicate or intrude into the provision of legal advice.”

    Source location

    2014-0182-Response-by-ACPO
    Page 9 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require a senior officer to attend the Post Incident Management suite while officers produce statements, ensuring accounts contain sufficient detail.

    Verbatim wording from the response

    “The MPS understands the need to prevent any perception that the systems employed lack integrity. The MPS can and does in striving to achieve best practice adopt and implement procedures which go beyond but are consistent with national practice and guidance. Thus, for example, a senior officer must now be present in the Post Incident Management [‘PIM’] suite whilst officers produce witness statements, with a view to ensuring the openness and transparency of the process. The MPS agrees that the current Post Incident Procedure (PIP) does not attract public confidence and needs to be made more transparent.”

    Source location

    2014-0182-Response-by-Metropolitan-Police-Service
    Page 4 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with law firms representing firearms officers to clarify expectations for detailed post-incident accounts.

    Verbatim wording from the response

    “a. The MPS agrees that ‘bland and uninformative’ accounts, if and whenever provided, are not acceptable. The MPS now requires a senior officer to be present in the PIM suite, whose functions include ensuring the inclusion of sufficient detail in initial and subsequent accounts. Sufficient detail includes the presence or absence of any perceived threat and the officer’s response thereto. The MPS is working with law firms who represent firearms officers to ensure that its expectations are clearly understood. The success of these measures was demonstrated by the post incident processes adopted following the events of May 2013 in Woolwich and the quality of the witness statements produced through those processes.”

    Source location

    2014-0182-Response-by-Metropolitan-Police-Service
    Page 4 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Further comment on police witness accounts was deferred because statutory guidance had not been finalised and consultation responses were still under review.

    Verbatim wording from the response

    “9. However, bearing in mind that the IPCC has not issued the final version of this statutory guidance, the IPCC does not consider it appropriate to comment further on this issue until it has completed the consultation exercise and submitted its final position to the Secretary of State.”

    Source location

    2014-0182-Response-by-IPPC
    Page 4 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The existing APP’s flexible, balanced approach is considered sufficient; wholesale separation of officers is not supported as fit for purpose.

    Verbatim wording from the response

    “The IPCC’s draft guidance promotes the third factor at the expense of the first, second and fourth factors. The National Policing portfolios’ view is that post incident procedures should strike an appropriate balance between all four factors, a position that Module 7 of the APP seeks to achieve.”

    Source location

    2014-0182-Response-by-ACPO
    Page 10 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Separating officers may be operationally, logistically and practically impractical, particularly where numerous witnesses and operational imperatives are involved.

    Verbatim wording from the response

    “Seeking to ensure the separation of officers engaged and involved in a critical incident for what may prove to be a significant period of time before an opportunity to rationally collect thoughts and compose an initial account – no matter how brief - is of course a legitimate and laudable aim but one that has to be set into context. Where officers have been together at the time of such an incident, as is in the case of many armed policing operations, the separation of officers may prove operationally or logistically impractical, as there are often large numbers of officers who will fall into the definition of a key policing witness. Such officers may have been together for a substantial period of time before it is practical to separate them, negating the rationale for separation.”

    Source location

    2014-0182-Response-by-ACPO
    Page 10 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Taking full statements immediately from officers affected by shock, distress or extreme fatigue was considered counterproductive and of limited forensic value.

    Verbatim wording from the response

    “d. Officers involved in a fatal shooting are under intense scrutiny. A decision about criminal or disciplinary proceedings may not be made for months or years after such a shooting. Such officers are required to carry out difficult and/or dangerous tasks, at not infrequently, great personal risk. Any witness may speak to a solicitor prior to giving information to police. The same is true of any suspect. A witness is entitled to provide their account in the manner of their choosing. Officers involved in a fatal shooting should be entitled to no lesser protections and support than any other member of the public who is a witness. This is codified in the Ministry of Justice 2011 guidance for Achieving Best Evidence [‘ABE’] regarding the timing of any interview and the provision of a full and detailed account.”

    Source location

    2014-0182-Response-by-Metropolitan-Police-Service
    Page 5 · response
    Published 29 May 2014

    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