Recurring concern

Unreliable management and control of emergency incident scenes

First to latest report 7 Jul 2015 — 24 May 2016

Reports that mention this concern: 4
Times this concern has been raised: 5
Stated actions linked to this concern: 2

What this concern includes

Includes failures in the operational management of an emergency incident scene, including timely scene control, securing the area, managing access or unauthorised personnel, coordinating attending responders, and protecting or appropriately managing injured or vulnerable people at the scene.

What is not included

Excludes formal crime-scene investigation, forensic evidence collection and post-incident investigative processes where operational scene control is not the deficient condition.
Excludes ambulance dispatch, police attendance or emergency-service response delays after the scene-management issue has been resolved.
Excludes generic inter-agency communication or notification failures unless they directly leave the incident scene or people at it without appropriate professional management.
Excludes routine site security, crowd control or premises access concerns without an emergency incident-scene context.

Trends

Reports over time

Reports mentioning this concern, 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 Police2

Department of Health and Social Care1

Devon & Cornwall Police1

Metropolitan Police Service1

NHS England1

North West Ambulance Service NHS Trust1

South Western Ambulance Service NHS Foundation Trust1

Reports and published responses 4 reports

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

24 May2016
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to appropriately manage the incident scene and patient safety and dignity
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

William Robert Raymond Nute · 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

William Robert Raymond Nute fell while a car was reversing near a shop on 30 June 2015 and sustained a fractured neck of femur. He later developed pneumonia and died on 2 July 2015. Concerns included delays in ambulance attendance and transfer to hospital, inappropriate triage of emergency calls, and delayed notification of the police, leaving him without effective emergency management while lying on a public highway.

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 appropriately manage the incident scene and patient safety and dignity
Wider context from the report
“That South Western Ambulance did not inform the police of a road traffic accident in a timely fashion resulting in the scene of the incident/patient and late arrival of the ambulance not being managed appropriately. For example the witnesses to the road traffic accident were left waiting a good number of hours for the police to arrive to provide their details to them and there was no one to professionally manage the safety/dignity of Mr Nute who was lying on the highway. ”
Source location
William Robert Raymond Nute · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 May2016
Manchester South
Concerns raised1
1. Failure to safeguard an injured or intoxicated vulnerable person before police departure
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Ian Hopkins QPM., MBA
Stated actions 1
1. Ian Hopkins QPM., MBA
  Complete wider vulnerability work incorporating lessons learned from this case.
Respondent positions 2
1. Ian Hopkins QPM., MBA
  Specific waiting times cannot be formalised because circumstances vary and fixed timescales would be impractical.
  Unable to act
1. Ian Hopkins QPM., MBA
  The National Decision Making Model is considered sufficient for officers to assess risks and decide whether to remain at a scene.
  Existing arrangements considered sufficient
AI-generated summary

Christopher Philip Fields · 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

Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red response.

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 safeguard an injured or intoxicated vulnerable person before police departure
Wider context from the report
“1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived. Sometime later, the assailant re-entered the flat and beat the deceased to his death. Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner, why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated, why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found? Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE) ”
Source location
Christopher Philip Fields · 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
Complete wider vulnerability work incorporating lessons learned from this case.

Verbatim wording from the response
“It is proposed that we will be able to report back to the Coroners. In October 2016 in terms of the wider work we are completing around vulnerability, including the lessons learnt from this case.”

Source location
2016-0194-Response-by-Greater-Manchester-Police
Page 3 · response
Published 18 May 2016
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
Specific waiting times cannot be formalised because circumstances vary and fixed timescales would be impractical.

Verbatim wording from the response
“No policy or guidance exists that formalises how long officers should wait in such cases and it would be impractical to set down specific timescales for officers to adhere to. Officers are given guidance in the use of the National Decision Making Model (‘NDMM’). The NDMM allows officers to make decisions based on the following principles:”

Source location
2016-0194-Response-by-Greater-Manchester-Police
Page 1 · response
Published 18 May 2016
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 National Decision Making Model is considered sufficient for officers to assess risks and decide whether to remain at a scene.

Verbatim wording from the response
“No policy or guidance exists that formalises how long officers should wait in such cases and it would be impractical to set down specific timescales for officers to adhere to. Officers are given guidance in the use of the National Decision Making Model (‘NDMM’). The NDMM allows officers to make decisions based on the following principles:”

Source location
2016-0194-Response-by-Greater-Manchester-Police
Page 1 · response
Published 18 May 2016
Open published response
13 Jul2015
Inner South London
Concerns raised1
1. Failure to provide adequate initial regard, enquiry and ambulance response to injured third parties at pursuit scenes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Metropolitan Police Service
Stated actions 1
1. Metropolitan Police Service
  Embed the National Decision Model in recruit and refresher training, pursuit procedures, and online reference toolkits.
Respondent positions 1
1. Metropolitan Police Service
  The available evidence does not show officers knowingly prioritised suspect capture over preserving life; their decisions reflected the information available at the time.
  Disputes the concern
AI-generated summary

Viktoria Was · 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

Viktoria Was died on 6 January 2013, aged 13, after being injured in a road traffic collision while travelling as a rear-seat passenger in a Volkswagen Polo. The concerns included insufficient regard for injured third parties at the scene, inadequate evidence that lessons had been learned from police pursuits, and insufficient refresher training for police officers.

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 provide adequate initial regard, enquiry and ambulance response to injured third parties at pursuit scenes
Wider context from the report
“(1) At the point of impact and for an unsatisfactory period of time thereafter, there was insufficient regard to Viktoria Was and her family. There were a number of officers immediately at the scene, and all focus appears to have been on the wanted suspect to the exclusion of injured third parties. A call for an ambulance, without further initial enquiry to third parties, whilst the pursuit continued for a number of hours was inadequate. ”
Source location
Viktoria Was · 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
Embed the National Decision Model in recruit and refresher training, pursuit procedures, and online reference toolkits.

Verbatim wording from the response
“A simple mnemonic - ‘COW’ - Casualties, Obstructions, Witnesses - has long been a cornerstone of officer training in the handling of road traffic incidents, reminding first responders of their priorities as they arrive on scene. However, since the tragic death of Ms WAS, further steps have been taken by the MPS to better equip our officers, firstly with the cognitive tools to structure their choices in such difficult circumstances, and subsequently to better evidence these choices in a way which can make their rationale more readily apparent to others. For example, the Metropolitan Police now subscribes to the National Decision Model (NDM), developed by the College Of Policing.”

Source location
2015-0271-Response-by-Metropolitan-Police
Page 3 · response
Published 13 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
The available evidence does not show officers knowingly prioritised suspect capture over preserving life; their decisions reflected the information available at the time.

Verbatim wording from the response
““This is not a situation where disciplinary proceedings would be suitable. In summary, it would appear that none of the officers saw the VW Polo on their immediate arrival at the scene. ████████ did immediately request an ambulance with regards to the crash. On the arrival at the crash by ████████ immediately started to make off from the scene and ████████ chose to give chase. ████████ had information that the driver of the Peugeot was wanted for a serious assault and may be armed. ████████ chose to also chase ████████ to assist ████████ and based on the increased risk that came with this information. The officers had not seen the VW Polo and their decision making is in line with the National Decision Model.”

Source location
2015-0271-Response-by-Metropolitan-Police
Page 11 · response
Published 13 July 2015
Open published response
7 Jul2015
Manchester South
Concerns raised2
1. Failure of attending officers to secure the scene and remove an off-duty colleague
2. Failure of an off-duty police officer to withdraw from a forensic scene
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Yvonne Davies and Andrew Francis Davies · 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

Yvonne Davies was stabbed in the neck by her husband, Andrew Davies, who then hanged himself. The report raised concerns that an off-duty police officer entered and moved around the scene, potentially contaminating it, and was not removed by the first attending officers.

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 attending officers to secure the scene and remove an off-duty colleague
Wider context from the report
“3. Neither of the first two attending officers secured the scene and removed their off-duty colleague from the house. ”
Source location
Yvonne Davies and Andrew Francis Davies · Prevention of Future Deaths report
Page 1 · 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
Failure of an off-duty police officer to withdraw from a forensic scene
Wider context from the report
“2. Even when the first two on-duty police officers arrived, he did not remove himself from the property but continued moving around and entered the kitchen area where the body of the wife lay. ”
Source location
Yvonne Davies and Andrew Francis Davies · Prevention of Future Deaths report
Page 1 · concerns
Open source report

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to appropriately manage the incident scene and patient safety and dignity

Concerns raised1

Failure to safeguard an injured or intoxicated vulnerable person before police departure

Linked response

Stated actions 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 provide adequate initial regard, enquiry and ambulance response to injured third parties at pursuit scenes

Linked response

Stated actions 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.1

Concerns raised2

Failure of attending officers to secure the scene and remove an off-duty colleague

Failure of an off-duty police officer to withdraw from a forensic scene

Stated actions 1

Respondent positions 2

Stated actions 1

Respondent positions 1