Recurring concern

Failure to obtain critical information during initial police incident responses

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First reported 4 Jun 2015•Latest report 19 Jul 2019

Definition

What this concern includes

Includes only assertions that directly instantiate the manually reviewed condition ‘Failure to obtain critical information during initial police incident responses’ and satisfy this evidence boundary: Two distinct reports directly support failures to question relevant people and obtain information during initial police responses, including domestic-abuse incidents. Excludes the separate harassment assertion, which concerns failure to act or take reports seriously rather than information gathering.

Not included

  • Excludes evidence gathering during formal investigations after the initial incident response, including general witness-statement or prosecution-evidence failures, unless the assertion specifically concerns the initial police response.
  • Excludes generic police communication, record-keeping or information-sharing deficiencies where failure to obtain or verify critical incident information is not the unsafe condition.
  • Excludes clinical assessment or treatment failures after relevant information has been reliably obtained and communicated.
  • Excludes non-police information-gathering processes and factual incidents without an asserted continuing deficiency in police response information gathering.
  • Excludes manifestations outside the manually reviewed boundary: Two distinct reports directly support failures to question relevant people and obtain information during initial police responses, including domestic-abuse incidents. Excludes the separate harassment assertion, which concerns failure to act or take reports seriously rather than information gathering.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2015–2019

First to latest report issue date

Stated actions
2

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.

Cumbria Constabulary1
HM Prison and Probation Service1
Lancashire Constabulary1
Metropolitan Police Service1
Ministry of Justice1
North Cumbria Integrated Care NHS Foundation Trust1

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. Lancashire and Blackburn with Darwen

    AI-generated summary

    Cherylee Yvette Shennan · 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

    Cherylee Yvette Shennan, a 40-year-old woman, was murdered on 17 March 2014 by a former offender who had subjected her to domestic abuse, including serious violence. The report raised concerns about inadequate inter-agency communication and management of the perpetrator, including the absence of a mandatory process for sharing information when an offender with a known history of domestic abuse was managed at MAPPA Level 1.

    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 information during initial attendances on reported domestic abuse incidents

    Wider context from the report

    “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses, the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment. Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not, and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken. In particular reference was made to, but unsupported by documentation, or any other form of evidence: • Policies reflecting recommended changes; • Information sharing agreements between agencies; • MARAC emergency policy or notes; • DASH Training or policy regarding obtaining GP details; and • Audits of Grade 2 ‘Ethical fails’ and reasons for such fails. ”

    Source location

    Cherylee Yvette Shennan · 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

    Adopt a force-wide Safeguarding, Investigation and Prevention model and embed it in vulnerability training and frontline coaching.

    Verbatim wording from the response

    “The constabulary through its Public Protection Unit has adopted a force-wide model of “SIP” – Safeguarding, Investigation & Prevention which is for officers/staff to apply to all incidents they deal with and will help appreciate wider vulnerabilities of the individuals, families, groups and environments they come into contact with and instil ‘professional curiosity’ in dealing with vulnerability, not least domestic abuse. SIP is incorporated into vulnerability training in all related courses/inputs and has recently been delivered at ‘Vulnerability Coach lunch sessions to over 250 frontline police officers/staff which has seen the recruitment of over 100 Vulnerability coaches in these roles to support, guide and coach their colleagues.”

    Source location

    2019-0244-Response-by-Lancashire-Constabulary_Redacted
    Page 5 · response
    Published 9 September 2019

    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 use language support to obtain information from non-native English speakers

    Wider context from the report

    “2. In addition, the jury heard as follows. - The three police officers did not appear to have an in depth understanding of the misper process. - They did not (save for one who had attended such calls before) appear to have an in depth understanding of the s136 Mental Health Act / mental health potential issues. - They did not consider using language line to assist them in obtaining information from the non native English speaking friend, with whom they spoke outside the building where Ms Cordero-Sanz was staying with a friend. Being able to speak in his native language might have facilitated the informant to give fuller details, such as the fact that Ms Cordero-Sanz was by now hearing voices. - Having been told that she would be upset by their uniforms, they did not insist on seeing Ms Cordero-Sanz to assess her for themselves, or call for the assistance of a plain clothes colleague, or suggest that they speak to the friend who was sitting inside with her. - Nobody thought of calling an ambulance that night, save for the CAD (computer aided despatch) operator who took the call in the first place, but he did not mention he had done so to anyone else. I wonder whether this suggests a training need, and/or whether, given the difficulties in maintaining skills on only 15 hours a month, consideration could be given to teaming special officers with regulars? ”

    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

    Recirculate Language Line access instructions and information about its benefits to Metropolitan Special Constabulary officers.

    Verbatim wording from the response

    “Language Line can be accessed via police Airwave radios at any time and full instructions on how to access this service is readily available on the MPS intranet. Instructions on how to use this and its benefits have been recirculated to the MSC via the duty sheet messaging system. The failures identified within this matter of concern represent individual failings which have been addressed directly with the officers concerned.”

    Source location

    2018-0307-Response-by-Metropolitan-Police
    Page 2 · response
    Published 17 February 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

    Suggested scene-assessment actions will not be made mandatory because they may be impracticable or inappropriate in some circumstances.

    Verbatim wording from the response

    “It has been established that the MSC officers who attended the address were not provided with the full details of the call. The informants whom they spoke to did not indicate that Ms Cordero-Sanz was in immediate danger. However it is recognised that if they had obtained more information at the scene utilising Language Line they may have altered their risk assessment and seen her in person. Whilst the suggested considerations have merit, we would not seek to make them mandatory actions as they may not be appropriate or practicable in all circumstances. Had the MSC officers known Ms Cordero-Sanz was a high risk missing person, MPS policy would have required them to physically see her and ensure she was safe and of no danger to herself or others.”

    Source location

    2018-0307-Response-by-Metropolitan-Police
    Page 3 · response
    Published 17 February 2019

    Open published response

  3. Cumbria

    AI-generated summary

    Alice Anne McMeekin · 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

    Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

    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 and verify critical information about reported threats

    Wider context from the report

    “1.The Police The evidence revealed that on the 6th June 2013 the perpetrator made remarks to a member of the public to the effect that he “would not kill his mother”. This information was passed to the Officers who attended the area. Some 2 hours later the same officers attended a call about a man behaving strangely and covered in blood. An ambulance was called. The officers had not spoken to the original caller, who subsequently gave evidence that the remarks were that the perpetrator said he “would kill his mother”. “Common sense” told the officers that the person was one and the same and they did a welfare check on his mother. At no stage did they question the perpetrator about his originally reported remarks. Also, citing confidentiality they did not pass those remarks onto the Ambulance Team. This meant that when later seen by psychiatric nurse the latter was in ignorance of this significant statement. It is possible that had the nurse been aware this may have altered the outcome of the perpetrator’s initial assessment and how he was dealt with. ”

    Source location

    Alice Anne McMeekin · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026