25 Apr 2024 Dr Jonathan Harvey Shaw · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1
Lack of a legal requirement to request a welfare check before releasing consignments View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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
Home Office
Explore legislative and policy options to control the substance and address ethical frontline responses to welfare concerns.
View source
×
AI-generated summary
Dr Jonathan Harvey Shaw · 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 Jonathan Harvey Shaw took his own life by intentionally ingesting the contents of a package purchased online from a Malaysian company. The package had been stopped by UK Border Force but was released without consultation with Greater Manchester Police, after which Dr Shaw used its contents to end his life. The report identifies concerns about the 30-day limit on holding the consignment and the absence of national guidance or training for police and UK Border Force on managing such consignments and coordinating welfare checks or safe destruction.
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 Lack of a legal requirement to request a welfare check before releasing consignments
Wider context from the report “There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force .
” Source location Dr Jonathan Harvey Shaw · Prevention of Future Deaths report
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 Explore legislative and policy options to control the substance and address ethical frontline responses to welfare concerns.
Verbatim wording from the response “I am determined that we must ensure that all reasonable steps to prevent further loss of life are taken and the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and similar substances) including how to ensure front line officers respond ethically to circumstances where the welfare of individuals is concerned.” Source location Response from Home Office
Open published response
21 Jul 2022 Gaia Kima Pope-Sutherland · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1
Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Dorset Police
Embed the adopted missing-person policy changes into working practice.
View source
Dorset Police
Review the concern-for-welfare policy to incorporate current physical and mental ill-health trends and professional guidance.
View source
Dorset Police
Implement revised call-handling, deployment and grading policies with risk assessment and performance monitoring.
View source
Dorset Police
Evaluate how revised policies affect deployment decisions and complete the commissioned external audit.
View source See 1 more action
×
AI-generated summary
Gaia Kima Pope-Sutherland · 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
Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.
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 Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy.
” Source location Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
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 adopted missing-person policy changes into working practice.
Verbatim wording from the response “The latest review of the missing person policy was in the process of being finalised during Gaia’s inquest. I enclose a copy of the finalised policy, which is now adopted, and work is ongoing to embed the changes in working practice. I highlight a few aspects of the updated policy that were relevant to the matters explored in the course of Gaia’s inquest:” Source location Response from Dorset Police
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 concern-for-welfare policy to incorporate current physical and mental ill-health trends and professional guidance.
Verbatim wording from the response “The Dorset Police concern for welfare policy is designed, in consultation with partner agencies, to ensure that the public get the right service to meet their specific needs at the first point of contact. The current version is subject to a review led by the Prevention Department to capture the latest physical and mental ill health trends and guidance from key professionals. The initial draft of the policy is close to completion.” Source location Response from Dorset Police
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 Implement revised call-handling, deployment and grading policies with risk assessment and performance monitoring.
Verbatim wording from the response “The Organisation reviewed and updated the call handling, deployment and grading policy in 2021 and implemented changes in March 2022. The Deployment Policy has been recently reviewed in line with national guidance to ensure that each public contact is risk assessed to inform the appropriate police response. The revised grading of incidents is now a key performance measure with regular reviews and evaluation to ensure compliance. As part of the implementation process, we have now moved to the evaluation stage to understand how the changes in the policy have translated into deployment decision making. The Organisation has commissioned an external audit conducted by the South West Audit Partnership which has been taking place over the summer. A full report is due this Autumn which will inform ongoing developments.” Source location Response from Dorset Police
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 Evaluate how revised policies affect deployment decisions and complete the commissioned external audit.
Verbatim wording from the response “The Organisation reviewed and updated the call handling, deployment and grading policy in 2021 and implemented changes in March 2022. The Deployment Policy has been recently reviewed in line with national guidance to ensure that each public contact is risk assessed to inform the appropriate police response. The revised grading of incidents is now a key performance measure with regular reviews and evaluation to ensure compliance. As part of the implementation process, we have now moved to the evaluation stage to understand how the changes in the policy have translated into deployment decision making. The Organisation has commissioned an external audit conducted by the South West Audit Partnership which has been taking place over the summer. A full report is due this Autumn which will inform ongoing developments.” Source location Response from Dorset Police
Open published response
6 Jul 2021 Levi Craig Don Pettit · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1
Lack of officer awareness of the Concern for Welfare Policy Document View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Lincolnshire Police
Recirculate the Concern for Welfare policy among Force Control Room staff and embed it in incident decision-making.
View source
Lincolnshire Police
Recirculate relevant guidance to Force Control Room officers and staff to reinforce policy awareness.
View source
×
AI-generated summary
Levi Craig Don Pettit · 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
Levi Craig Don Pettit was reported to police as having suicidal ideations on 8 December 2019. Four days later, he died by suicide; concerns included the handling of the police response, including the failure to complete or make required referrals and uncertainty about relevant policy and 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 Lack of officer awareness of the Concern for Welfare Policy Document
Wider context from the report “(I) PC ████████ was not aware of the Lincolnshire Police Concern for Welfare Policy Document PD238
” Source location Levi Craig Don Pettit · Prevention of Future Deaths report
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 the Concern for Welfare policy among Force Control Room staff and embed it in incident decision-making.
Verbatim wording from the response “To reassure ourselves that our guidance to officers and staff in the FCR is being adhered to, I have ensured that the relevant policy document is recirculated among our FCR staff, and informs our decision making process when receiving, allocating, reviewing and closing incidents of this nature.” Source location 2021-0231-Response-from-Lincolnshire-Police_Published
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 Recirculate relevant guidance to Force Control Room officers and staff to reinforce policy awareness.
Verbatim wording from the response “As mentioned in my answer to question 1, above, I will ensure that the relevant guidance is recirculated to officers and staff in the FCR to remind them of the importance of the relevant policies in place.” Source location 2021-0231-Response-from-Lincolnshire-Police_Published
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 Frontline officers need not know the Concern for Welfare Policy because it governs Force Control Room processes, not frontline guidance.
Verbatim wording from the response “I am in agreement with you that PC ████████ “...did act appropriately” and, “...went the extra mile” with regards to his actions on the evening with Levi. I would not expect frontline officers to know the detail, nor even the existence of a “Concern for Welfare Policy”. The Policy is designed to document our approach to calls for service through the Force Control Room, rather than as guidance for frontline officers. You will note that Document PD238 was written by Force Control Room (FCR) Inspector ████████ and is annually reviewed by the FCR inspector to ensure that it is still legislatively and ethically compliant. It is not a guidance document for frontline officers.” Source location 2021-0231-Response-from-Lincolnshire-Police_Published
Open published response
28 Dec 2018 Mr Gregory Rekowski · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1
Unclear and delayed police-to-ambulance referral process for welfare concerns View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Mr Gregory Rekowski · 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
Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.
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 Unclear and delayed police-to-ambulance referral process for welfare concerns
Wider context from the report “In this case GMP did not call NWAS and asked the nurses to contact NWAS . The Court heard evidence from the Deputy Sector manager for NWAS as to how GMP will contact them to attend concerns for welfare. This was not a process PCT staff were familiar with . This also led to a delay in the call being made .
” Source location Mr Gregory Rekowski · Prevention of Future Deaths report
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 Review, revise and enhance multi-agency procedures through sessions involving all named partner organisations.
Verbatim wording from the response “Several distinct sessions were convened to review, revise and enhance our existing procedures from multiple perspectives. These sessions each included insight and oversight from all partner organisations named in this letter.” Source location 2018-0411-Response-by-GMCA
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 a pan-Greater Manchester response protocol defining roles, responsibilities, shared risk assessment, communication and escalation arrangements.
Verbatim wording from the response “We have now drawn together a pan-GM protocol for response, developed specifically in order to achieve a common understanding of roles and responsibilities; to ensure a shared view of risk; and to promote communication and escalation at the first point that a common understanding may falter.” Source location 2018-0411-Response-by-GMCA
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 Embed the response protocols within partner agencies and cascade them across their workforces through the Responding to Crisis Board.
Verbatim wording from the response “Clearly, it is one thing to develop protocols, and quite another to embed them across the workforce. For this reason, we will now seek to embed these protocols within their respective agencies. I will ask them to agree to do so at a coming meeting of a new GM Responding to Crisis Board – a meeting I have convened in part in response to a common desire all partners have to enhance our broader offer around members of the community confronted with such risk. This Board will hold responsibility as part of its work programme for ensuring that these protocols are cascaded, rooted, and delivered upon.” Source location 2018-0411-Response-by-GMCA
Open published response
4 Aug 2015 Mr Warren · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Failure to equip social work staff with knowledge and training about police welfare-check criteria and appropriateness View source
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
Mr Warren · 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
Mr Warren, an elderly and deaf tenant with no known family or friends, was found deceased at home on 29 January 2015 after apparently falling around 24 January and suffering broken ribs, bronchopneumonia and signs of hypothermia. Concerns included the failure to address a hazardous electric heater, the use of a non-urgent police welfare check, insufficient guidance and training for social-work staff, and the absence of a formal review by the relevant councils.
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 equip social work staff with knowledge and training about police welfare-check criteria and appropriateness
Wider context from the report “(4) That WSCC Social Work staff are not aware of, given any training regarding or provided with any information about the criteria likely to be applied by police for conducting welfare checks and/or the circumstances in which it is or is not appropriate to ask the police to conduct a welfare check .
” Source location Mr Warren · Prevention of Future Deaths report
Open source report
21 Jul 2015 Anne Wilson · Prevention of Future Deaths report South London
View report summary
Concerns raised 5
Failure to share the final MPS Welfare Check policy with the London Ambulance Service View source Unclear version control for the MPS Welfare Check policy View source Failure of the MPS and LAS to meet to discuss joint working under the welfare checks policy View source
Failure to share welfare check policy changes with the London Ambulance Service View source Lack of training for staff handling welfare check requests in the new policy View source See 2 more concerns
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
London Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
London Ambulance Service NHS Trust
Provide the current Metropolitan Police welfare-check briefing note to address uncertainty about the policy version in force.
View source
London Ambulance Service NHS Trust
Discuss the welfare-check policy and its impact for ambulance services at the next LAS/MPS Joint Working Group meeting.
View source
London Ambulance Service NHS Trust
Review and clarify joint LAS/MPS meeting arrangements to strengthen governance and ensure appropriate LAS representation.
View source
London Ambulance Service NHS Trust
Incorporate the March 2015 Metropolitan Police welfare-check policy into the LAS/MPS Joint Memorandum of Understanding through the annual review process.
View source See 1 more action
×
AI-generated summary
Anne Wilson · 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
Anne Wilson had a history of depression, had recently been discharged from psychiatric hospital, and was found deceased in her flat after failing to attend appointments and following concerns raised to the police. The principal concerns were the downgrading of the welfare-check request without informing her GP, inadequate training and guidance under the Metropolitan Police Service welfare-check policy, and failures in communication and joint working between the Metropolitan Police Service and London Ambulance Service.
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 share the final MPS Welfare Check policy with the London Ambulance Service
Wider context from the report “(6) It is unclear what version of the MPS Welfare Check policy is currently in force and a final version has not yet been shared with the LAS despite requests to do so .
” Source location Anne Wilson · Prevention of Future Deaths report
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 Unclear version control for the MPS Welfare Check policy
Wider context from the report “(6) It is unclear what version of the MPS Welfare Check policy is currently in force and a final version has not yet been shared with the LAS despite requests to do so.
” Source location Anne Wilson · Prevention of Future Deaths report
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 the MPS and LAS to meet to discuss joint working under the welfare checks policy
Wider context from the report “(7) The MPS and LAS have joint working arrangements but have yet to meet to discuss joint working arrangements under the MPS Welfare checks policy .
” Source location Anne Wilson · Prevention of Future Deaths report
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 to share welfare check policy changes with the London Ambulance Service
Wider context from the report “(1) In 2014 the Metropolitan Police Service (MPS) introduced a new policy for dealing with requests for and attending welfare checks. The precise date of the implementation of the new policy could not be established at inquest. The MPS and the London Ambulance Service (LAS) have joint working arrangements however the changes made concerning the future handling of welfare checks was not shared with the LAS at that time .
” Source location Anne Wilson · Prevention of Future Deaths report
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 Lack of training for staff handling welfare check requests in the new policy
Wider context from the report “(2) MPS staff responsible for dealing with requests for welfare checks were not given training in the new policy and the power-point guidance circulated did not contain:
(a) A checklist or examples of questions that should be asked to elicit sufficient information about the concern being raised
(b) an example of how to manage a request for a welfare check concerning the mental health of an individual
(c) how to manage additional information received once a welfare check request had been closed.
(d) The importance of updating those involved in the change in actions being taken by the MPS
” Source location Anne Wilson · Prevention of Future Deaths report
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 the current Metropolitan Police welfare-check briefing note to address uncertainty about the policy version in force.
Verbatim wording from the response “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.” Source location 2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
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 Discuss the welfare-check policy and its impact for ambulance services at the next LAS/MPS Joint Working Group meeting.
Verbatim wording from the response “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.” Source location 2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
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 and clarify joint LAS/MPS meeting arrangements to strengthen governance and ensure appropriate LAS representation.
Verbatim wording from the response “Following this Regulation 28 Report, the Director of Operations, who is the Trust's strategic operational lead for joint LAS and MPS working and the Director of Nursing and Quality, who is responsible for strategic policy and liaison regarding mental health and safeguarding with the MPS, have asked for our joint meeting arrangements to be reviewed and clarified to ensure that the governance arrangements are robust and that the LAS is represented at an appropriate level in the future.” Source location 2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
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 Incorporate the March 2015 Metropolitan Police welfare-check policy into the LAS/MPS Joint Memorandum of Understanding through the annual review process.
Verbatim wording from the response “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.” Source location 2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
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 March 2015 Metropolitan Police welfare-check briefing is understood to be the current version in force.
Verbatim wording from the response “A copy of the Metropolitan Police “External Briefing Note – welfare checks dated March 2014 – updated March 2015 V.1” has been provided following the inquest. No fundamental changes were identified with the previous version (March 2014 – updated December 2014 V.1). We understand the document updated in March 2015 to be the current version in force and is to be incorporated into the LAS/MPS Joint Memorandum of Understanding by end December 2015, in accordance with the annual review process. Nevertheless the Deputy Director of Operations, Control Services and Deputy Director of Nursing and Quality will discuss the policy and its impact for the LAS at the next quarterly meeting of the LAS / MPS Joint Working Group on 13 November 2015.” Source location 2015-0293-Response-by-London-Ambulance-Service-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.