Recurring concern

Failure to preserve and document fatal incident scenes for investigation

First to latest report 29 May 2014 — 15 May 2022

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
5

What this concern includes

Includes failures in dedicated arrangements for preserving, recording, documenting or controlling access to fatal incident scenes and their material evidence until relevant investigators have completed their examinations, including scene video recording and prevention of premature removal or alteration of evidence.

What is not included
  • Excludes ordinary crime-scene investigation quality, evidence analysis or investigative decision-making where preservation or documentation of the fatal scene is not the deficient control.
  • Excludes post-scene disclosure, reporting or learning failures after the scene and evidence have been reliably preserved and documented.
  • Excludes non-fatal incident scenes unless the assertion explicitly supports the same fatal-incident scene-preservation process.
  • Excludes generic police, fire-service or coronial governance deficiencies without a direct failure to preserve or document a fatal incident scene.

Reports and published responses 2 reports

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

  1. Surrey

    AI-generated summary

    Connor Samuel Timothy Wellsted · 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

    Connor Samuel Timothy Wellsted, a five-year-old boy with significant neuro-disabilities, was found deceased in his cot on 17 May 2017 during a residential neuro-rehabilitation stay. The investigation determined that he died following entrapment by a loose cot bumper causing airway obstruction. Concerns included inadequate cot maintenance and securing, lack of regular direct visual night-time supervision, and failures to preserve the scene, inform relevant bodies, and investigate the circumstances openly and transparently.

    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 preserve the scene and fully inform police and coronial investigators after a death

    Wider context from the report

    “3. Probity and Investigation by the Children’s Trust, Tadworth The Police and the coroner’s service attending the Trust shortly after being informed of Connor’s death were not fully informed of the circumstances of his death. The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed. Connor’s death was sudden and unexpected, and the senior management of the Trust (chief nurse and medical director) were concerned at the time the role the padded board may have played in Connor’s death. However, they did not keep a copy of Connor’s medical records, nor did they undertake their own initial internal enquiries, or inform the relevant statutory bodies of their concerns. Furthermore, they arguably misled the CQC as to the circumstances of Connor’s death. Likewise, the pathologist who undertook the autopsy on Connor was not informed of the circumstances of his death thereby preventing a forensic post-mortem to have taken place to establish the role the cot bumper may have played in his death. In addition, the Trust engaged an expert opinion from a forensic pathologist without fully informing him of the position the cot bumper may have played in Connor’s death. The Trust undertook several Serious Investigation reports, the first of which was six months after Connor’s death. These reports did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant. ”

    Source location

    Connor Samuel Timothy Wellsted · 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

    Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.

    Verbatim wording from the response

    “I note that you also sent your Report to the Chief Executive and Medical Director of the Children’s Trust, Tadworth, and I have had sight of their response as referred to above. On 15 July 2022, representatives from the South East Region attended upon the Trust and carried out a comprehensive review of all of the points that you made in your Report. They concluded that there were no current quality concerns, however there was room for improvement. The outstanding actions for improvement will continue to be monitored by NHS England South East. I am assured that the Children’s Trust, Tadworth, have addressed all of the concerns raised in your Report.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 17 May 2022

    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 clear protocols and training for unexpected child deaths using relevant national and local guidance.

    Verbatim wording from the response

    “In addition to this, we have reviewed The Royal College of Pathologists guidelines on ‘Sudden unexpected death in infancy and childhood: Multi-agency guidelines for care and investigation’, 2016, and guidance produced by the Surrey Child Death Review Partnership. We are further developing a clear protocol and training for our nursing and medical staff in the event of an unexpected child death. We accept that our training has historically focussed on basic life support and actively assessing and supporting children who we do not anticipate will die unexpectedly. Whilst our staff will continue to receive their basic life support training, we will have clear guidelines on processes and actions to be taken in the event of a sudden unexpected death. We are also planning to expand our existing simulation training beyond medical emergencies and basic life support, to cover unexpected deaths.”

    Source location

    Response from The Children's Trust
    Page 8 · response
    Published 17 May 2022

    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 police were informed of the cot bumper’s position and the relevant timing and circumstances of death were recorded in investigative materials.

    Verbatim wording from the response

    “Information provided to the police and coroner’s service We willingly complied with all external investigations that took place and also carried out our own detailed review. The evidence before the coroner at the inquest was that the police officer attending the scene following Connor’s death had been informed of the position in which the cot bumper had been found. This was reflected in the contemporaneous notes taken by the officer in their police-issued pocket notebook. The officer in question gave evidence at the inquest that he had been informed of the positioning of the bumper.”

    Source location

    Response from The Children's Trust
    Page 7 · response
    Published 17 May 2022

    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

    Connor’s equipment and room remained sealed after staff repositioned him for clinical assessment, contrary to the concern that the scene was not preserved.

    Verbatim wording from the response

    “airway, check for breathing, and check circulation. Accordingly, when our staff first found Connor unresponsive in his cot, they moved him into a horizontal, supine position in order to assess his vital signs. The police then performed their own independent physical examination. All of Connor’s equipment remained in the room with him, and the room (including the bed and bumpers) remained sealed until the findings of the post-mortem were released.”

    Source location

    Response from The Children's Trust
    Page 8 · response
    Published 17 May 2022

    Open published response

  2. 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 video record fatal police shooting scenes

    Wider context from the report

    “Concern 4: The scene of the fatal police shooting was not video recorded I believe that it is important to minimise distrust in the police in connection with fatal shootings, as that distrust can then permeate the entire investigation which follows and may mean that civilian witnesses will not come forward. That plainly has the capacity to prevent lessons being learned which could prevent deaths in the future. This concern is addressed to the MPS, the IPCC and ACPO. ”

    Source location

    Mark Duggan · Prevention of Future Deaths report
    Page 28 · 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

    Consider including scene video recording requirements in the statutory guidance.

    Verbatim wording from the response

    “21. The IPCC can see the benefit of early video recording a scene as part of the process of evidencing where items have been found. Therefore, the IPCC will be considering whether reference to video recording scenes should be included in the statutory guidance. The IPCC anticipates being able to submit finalised statutory guidance to the Secretary of State for her approval by the end of March 2015.”

    Source location

    2014-0182-Response-by-IPPC
    Page 7 · 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

    Consider how to reflect earliest-possible scene video recording in College of Policing APP post-incident procedures.

    Verbatim wording from the response

    “The National Policing portfolios concur with your view that is important to minimise distrust in the police in connection with fatal shootings, and notwithstanding any development over the use of body worn video (BWV), will consider how best to reflect changes in the College of Policing’s APP on post incident procedures to ensure standard operational procedures encompass the benefits of the earliest possible commencement of the video recording of scenes, subject of course to ongoing operational imperatives to protect public and individual safety and to continue to mitigate any risk of harm.”

    Source location

    2014-0182-Response-by-ACPO
    Page 12 · 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

    Conduct a feasibility study on assigning an operations team officer to record pre-planned shooting scenes until specialist investigators or support services arrive.

    Verbatim wording from the response

    “Another option that is currently being explored by the MPS in the case of pre-planned operations is to assign this role to an operations team officer. This officer’s primary responsibility would be to record the scene in the event of a police shooting until such time that either a police helicopter (if available or able to deploy), independent investigators (DPS/IPCC) or any specialist support services deployed by them (for example, Crime Scene Managers or the Computer Aided Modelling Bureau - see below) arrive on scene. A feasibility study is currently being conducted to ensure that any issues associated with this option can be considered.”

    Source location

    2014-0182-Response-by-Metropolitan-Police-Service
    Page 7 · 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 IPCC, through its senior investigating officer, holds ultimate responsibility for recording the scene of a fatal police shooting.

    Verbatim wording from the response

    “The MPS acknowledges that the recording of the scene of a fatal police shooting is a desirable aspect of crime scene management and recognises the importance of securing best evidence in the immediate aftermath and ongoing investigation of a police shooting. This is the ultimate responsibility of the senior investigating officer (SIO); in the case of a fatal police shooting; that”

    Source location

    2014-0182-Response-by-Metropolitan-Police-Service
    Page 6 · 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

    Firearms officers’ priorities of saving life, protecting the public and securing the scene were treated as limiting the feasibility of comprehensively recording every aspect.

    Verbatim wording from the response

    “In the immediate aftermath of a police shooting, it is inevitable that only the officers on scene will be available to carry out an immediate video or photographic capture. The convoy of cars on 4th August 2011 was equipped with both video and still cameras. The primary purpose for which that equipment is provided is to capture images of locations and environments to assist in tactical planning. Armed officers are not currently trained or equipped to record scenes to an evidential standard. On 4th August 2011, officers were able to and did, as an incidence of individual decision making and availability in the circumstances of the particular case of resources, use both cameras to record some parts of the scene, in particular, the provision of first aid.”

    Source location

    2014-0182-Response-by-Metropolitan-Police-Service
    Page 7 · 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

    Firearms officers should not be responsible for recording post-incident scene preservation; responsibility should fall to investigators or an assigned operations team officer.

    Verbatim wording from the response

    “It is the view of the MPS that firearms officers should not be responsible for recording post incident scene preservation. MPS firearms officers are due to commence the piloting of Body Worn Cameras (see Concern 6, below). This may provide some level of recording of the actions taken to preserve the scene in the immediate aftermath but they have limitations in that they will only capture a certain camera angle. In a spontaneous incident, it is likely that this will be the only method of immediately recording the scene.”

    Source location

    2014-0182-Response-by-Metropolitan-Police-Service
    Page 7 · 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