Recurring concern

Unreliable sharing of safety-critical information between police forces

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First reported 28 Jul 2014•Latest report 20 Oct 2025

Definition

What this concern includes

Includes failures in arrangements for identifying, disseminating, transferring, receiving, clarifying or confirming safety-critical information between police forces, including cross-force safety learning, offender information and known suicide-risk information.

Not included

Excludes information sharing within a single police force where no cross-force interface is identified.
Excludes generic police communications, operational radio or control-room failures where information sharing between police forces is not the bounded concern.
Excludes case-transfer failures limited to formal transfer of ownership between forces when no broader safety-critical information-sharing deficiency is asserted.
Excludes failures involving non-police recipients or cross-border information systems unless the assertion specifically concerns sharing safety-critical information between UK police forces.

Reports: 8
Individual concerns: 8
Date range: 2014–2025
Stated actions: 15

Reports 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.

National Police Chiefs’ Council5

Home Office3

Department of Health and Social Care2

College of Policing1

Devon & Cornwall Police1

Gloucestershire Constabulary1

Greater Manchester Police1

Lancashire Constabulary1

Ministry of Justice1

National Probation Service1

NHS England1

Probation Service1

Somerset NHS Foundation Trust1

Yeovil District Hospital1

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.

20 Oct2025
Black Country
Concerns raised1
1. Failure to share known suicide risk between police forces
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Brief CRC supervisors and staff on sharing information with other forces to mitigate risks and safeguard vulnerable people.
  Stated by Devon & Cornwall PoliceStated completed
2. Action
  Amend Force Policy DCP-P-051 to require sharing information with relevant forces when risks or vulnerabilities affect people outside Devon and Cornwall.
  Stated by Devon & Cornwall PoliceStated in progress
Respondent positions 1
1. Position
  The lack of information sharing was not considered to have contributed to the death, although learning and recommendations were accepted.
  Stated by Devon & Cornwall PoliceDisputes the concern
AI-generated summary

STUART MARTIN FOWKES · 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

STUART MARTIN FOWKES died at his home on 26 May 2025 after travelling from the West Midlands to Cornwall and back while reportedly suicidal and likely under the influence of alcohol. The principal concern was that Devon and Cornwall Police recorded information about a known risk to his life, but this risk was not shared with West Midlands Police; by the time concerns for his safety were raised locally, he was likely already deceased.

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 known suicide risk between police forces
Wider context from the report
“(1) DCP had a recorded log entry ref ████████ of a domestic and suicidal report made to DCP by Mr Fowkes’s Mother on 26/5/25 timed at 00:52. Coronerial enquiries elicited a response from a PC ████████ who confirmed the details of that report being from ████████ (Mother of the deceased) who lives in Devon and Cornwall area. She reported her adult son Stuart Fowkes, born 17/6/89 had left her property in a vehicle whilst in drink and suicidal. Prior to leaving, Fowkes had been shouting and swearing at his mum ████████ and whilst close to her, threatened to put his fist in her face. She said she couldn’t stop him leaving as she thought he was going to hurt her. He had told her that if he hadn’t come down to see her tonight, he would have gone to B and O and ████████ harm himself. He had told her that if he hadn’t come down to see her tonight, he would have gone to B and O and ████████ harm himself. (2) DCP recorded a second reference to Mr Fowkes being suicidal under the same reference ████████ at 00:56 and 01:17 including further information that Mr Fowkes is suicidal and that his father committed suicide 8 years ago in Birmingham. (3) DCP had recorded a known risk to Mr Fowke’s life. (4) DCP appear to have been aware of Mr Fowke’s risk of suicide in the early hours of 26 May 2025. (5) WMP conducted an internal investigation which revealed that no risk to Mr Fowke’s life was shared with West Midlands Police by Devon and Cornwall Police. WMP reported that based on information from DCP, Mr Fowkes was wanted for drink driving and domestic abuse offences. By the time Mr Fowke’s ex-partner raised a concern for his safety and made reference to suicide it is likely Mr Fowkes was already deceased. ”
Source location
STUART MARTIN FOWKES · 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
Brief CRC supervisors and staff on sharing information with other forces to mitigate risks and safeguard vulnerable people.

Verbatim wording from the response
“Upon receipt of the PSD Report referred to above, the Devon & Cornwall Police Contact and Resolution Centre (‘CRC’), who are responsible for the contact centre and dispatching to incidents, have taken the following steps to address the learning raised in this matter:”

Source location
Response from Devon & Cornwall Police
Page 3 · response
Published 23 October 2025
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
Amend Force Policy DCP-P-051 to require sharing information with relevant forces when risks or vulnerabilities affect people outside Devon and Cornwall.

Verbatim wording from the response
“2. In addition, a review of Force Policy has been undertaken and Policy DCP-P-051 referring to grading and deployment is also in the process of being amended, with the addition of the below new section as follows:”

Source location
Response from Devon & Cornwall Police
Page 3 · response
Published 23 October 2025
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 lack of information sharing was not considered to have contributed to the death, although learning and recommendations were accepted.

Verbatim wording from the response
“It is accepted that information regarding Mr Fowkes was not shared by Devon & Cornwall Police with West Midlands Police in this case. It is not suggested, I understand, that the lack of information sharing in this case contributed towards the tragic outcome. However, it is recognised there were recommendations made, and learning taken from this incident to ensure the high level of public service we strive for within this force are met and, where necessary, improved upon.”

Source location
Response from Devon & Cornwall Police
Page 3 · response
Published 23 October 2025
Open published response
10 Jul2025
Dorset
Concerns raised1
1. Lack of inter-force sharing and flagging of information about shotgun licence holders and shotgun locations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Develop proposed changes with the Home Office to require declaration of second-home firearm storage in statutory guidance and application forms.
  Stated by College of Policing and National Police Chiefs’ CouncilStated planned
2. Action
  Develop the National Firearms Licensing Management System to provide consistent national licensing processes and enable second-home firearm notifications to local force systems.
  Stated by College of Policing and National Police Chiefs’ CouncilStated in progress
3. Action
  Amend firearm and shotgun applications to capture additional residences and update NFLMS to record those locations.
  Stated by Home OfficeStated planned
AI-generated summary

Jairus Joshua Timothy Earl · 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

Jairus Joshua Timothy Earl, aged 15, died by suicide on 14 April 2024 after using one of his father’s shotguns at the family’s Dorset property. The concerns relate to gaps in the regulation of shotgun licences, including the lack of requirements to notify police about additional properties, inadequate information-sharing and address flagging between police forces, and limited access to medical information about other people living at a licence holder’s property.

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 inter-force sharing and flagging of information about shotgun licence holders and shotgun locations
Wider context from the report
“(1) I have concerns in relation to gaps in the regulation of shotgun licences especially when a licence holder has more than one property where the guns may be used or stored. The Firearms Act 1968 (The Act) is the primary legislation that governs the possession and handling of firearms. This is supported by statutory guidance, Firearms Licensing: Statutory Guidance for Chief Officers of Police and non statutory Home Office guidance, Guide on firearms Licensing Law. Section 2 of the Act deals with the requirement of certificate for possession of shotguns. Evidence was given at the Inquest by Acting Chief Inspector ████████ of Dorset Police who works within the Dorset Firearms and Explosive Licensing Unit and also works with the College of Policing and the national Firearms & Explosive Licencing Working Group to review and update the Home Office statutory guidance and support the national training effort in response to the Prevention of Future Deaths report from the Inquest touching upon the deaths in Keyham on 12th August 2021. He gave evidence that the regulation for shotguns is different to the regulations for firearms which is governed by Section 1 of The Act. There seems to be a great deal of difference in the regulation of firearms and the regulation of shotguns, however both can equally cause death. I am concerned that the lack of regulation around shotguns could lead to future deaths. For example, he explained that there is no obligation on a licence holder of a shotgun licence to notify the approving force they are moving to or visiting another property In his written evidence to the Court, which was further expanded on orally at the Inquest, he explained: “Under section 26B(1) of the 1968 Act, an application for the grant of a shotgun shall be made to the chief officer of police where the applicant resides, there is nothing within the firearms act to define a residence or when applicants have properties in different force areas, the non-statutory guide tells me that where an applicant has a residences in different force areas, it is for the individual to decide which force issues their certificate. Shotgun certificates are issued by individual forces’ and will display the force crest and signature of the chief officer of the issuing force, however they are valid throughout England and Wales, and allows the holder to travel with their shotguns anywhere in the United Kingdom. … Shotgun certificates differ from firearm certificates in a number of ways, for firearms, possession of each and every gun must satisfy individual good reason, whereas a good reason for a shotgun is a collective term, and more relaxed, for example a request for a firearms certificate for target shooting will require that the applicant is a member of a Home Office approved club and shoots regularly, whereas a mere intention to undertake clay pigeon shooting would satisfy good reason for a shotgun certificate. A shotgun certificate also will also authorise a person to have in their possession, purchase or acquire and unlimited number of shotguns without the need for approval in respect of individual guns, that is to say that so long as the shotguns are stored securely a person may have as many as they want. Another nuance of the shotgun certificate is the ’72-hour rule’ that it will allow a certificate holder to borrow a shotgun for up to 72 hours without the need to have to record the shotgun on the certificate or notify the police of the transfer. … Section 28(2)(a) of the 1968 Act provides that a shotgun certificate is granted subject to any prescribed conditions, and no others, that is that these conditions must be applied to the certificate, but the chief officer cannot add additional conditions. … There is no onus on an applicant to notify another force area where they hold a certificate and have another address in that force area, this is only the case if the certificate holder changes their permanent address that this would be captured by the third condition. There is also no obligation on a certificate holder to notify a chief officer of police when they intent to visit another force area in possession of their shotguns. Acting Chief Inspector ████████ explained that on the Tuesday following Jairus’ death he briefed the national coordinator from the Firearms & Explosive Licencing Working Group to raise matters arising from the circumstances of Jairus’ death so there is awareness of the issues relating to second homes, however, there is no legal requirement for second homes to be declared by licence holders. He further told the Court that in 2015, HM Inspection of Firearms Licencing recommended that forces must have a notification system on their local records to identify addresses and people where firearms are held. He explained that these systems are local rather than national and his recommendation to the Firearms & Explosive Licencing Working Group following Jairus’s death was that where an applicant declares a second home, the force where that home is located should be notified. Dorset Police have taken action and put a system in place that when they are notified of the above, they will create a record on their system to flag the address as if that were a Dorset certificate holder, however it is not a legal requirement for forces to do this, and it is unknown if other forces nationally are doing this. I therefore have concerns there is a lack of a system of sharing and flagging information between Police forces regarding shotgun licence holders and the location of shotguns, which could lead to future deaths. Accordingly, emergency services may attend an address where shotguns are held without knowledge of that fact due to the lack of a marker being placed on the address. This causes a risk to all those attending unmarked addresses as they would potentially be ill prepared for what they could face which could lead to future deaths. Additionally failing to have such markers on additional homes means that if the police are called to the address for other reasons such as a concern for welfare, they may miss the opportunity to put in place additional security measures ,or even revoke the licences, as required for the safety of the occupants at the address, and others. Evidence was heard that Dorset Police were called to Jairus’s family address in Dorset on the 28th March 2024 following a report that Jairus was missing. It was not apparent from the Police system at the time that there would be shotguns at the address. Jairus’s mental health was discussed during the report of this incident. Had the flag system been in place then, consideration could have been given to the continued possession of the shotgun in a property where Jairus could access them. ”
Source location
Jairus Joshua Timothy Earl · 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
Develop proposed changes with the Home Office to require declaration of second-home firearm storage in statutory guidance and application forms.

Verbatim wording from the response
“would become too complicated for example if new rules were created for licence holders without second homes to inform policing every time their firearms are temporarily away from home when attending shooting locations. We would not have the capacity to check and authorise such short-term arrangements.”

Source location
Response from National Police Chief's Council
Page 2 · response
Published 16 July 2025
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 the National Firearms Licensing Management System to provide consistent national licensing processes and enable second-home firearm notifications to local force systems.

Verbatim wording from the response
“In addition to the above there is a significant programme of works underway chaired by the NPCC Firearms Licensing Lead and project managed by Police Digital Services (PDS) to develop a brand-new National Firearms Licensing Management System (NFLMS). Of the various aspirations with this new system, it will deliver the much-needed consistency required as all firearms licensing teams, licence holders and applicants will use it. It will align with many systems already used by policing and in relation to this tragic incident there would be opportunities for second homes to subsequently alert local force systems that firearms may be present on those premises.”

Source location
Response from National Police Chief's Council
Page 2 · response
Published 16 July 2025
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
Amend firearm and shotgun applications to capture additional residences and update NFLMS to record those locations.

Verbatim wording from the response
“light of your Regulation 28 Report, we will be amending the firearm and shotgun application form as soon as is practicable to request details of any second (or additional) residences where guns may be held, so that police are aware of where firearms are being stored, including where guns are being stored in different police force areas. This change to the application form will be implemented via Statutory Instrument and will also require a change to the NFLMS to ensure such details are recorded. We are therefore adding this change to planned adjustments to the system, which we expect to be completed in early 2026. In the meantime, this issue will be addressed by the police when undertaking suitability interviews with applicants or certificate holders.”

Source location
Response from Home Office
Page 2 · response
Published 16 July 2025
Open published response
23 Feb2023
Suffolk
Concerns raised1
1. Lack of standardised information-sharing requirements or protocols for cross-border missing-person investigations
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Develop and consult forces on NPCC advice for requesting missing-person enquiries in another force and transferring investigations.
  Stated by National Police Chiefs’ CouncilStated in progress
2. Action
  Update the National Transfer form to capture requests for enquiries in another force, including direct telephone or video communication of risk and urgency.
  Stated by National Police Chiefs’ CouncilStated in progress
AI-generated summary

Anthony John Raymond INGRAM · 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

Anthony Ingram was found deceased at his second home in Suffolk on 29 March 2022, having died by hanging. The report identified poor communication between the Metropolitan Police and Suffolk Constabulary, including failure to share information that he had a rope and a collapsible bicycle, resulting in a missed opportunity to find him earlier. The principal concern was the lack of standardised information-sharing requirements or protocols for cross-border missing-person investigations, including cases involving suicidal missing people.

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 standardised information-sharing requirements or protocols for cross-border missing-person investigations
Wider context from the report
“It was clear that crucial information (that Anthony had a rope in his possession, and a collapsible bicycle providing a secondary form of transport) was not passed between the Metropolitan Police and Suffolk Constabulary. It was heard that there was no set format, or prescribed information requirements to be shared by officers reporting missing persons between one force and another. Investigating officers in the Metropolitan police spoke to the Suffolk Constabulary control room, whose staff logged what they were told onto the CAD record. This information was then relayed to the officers on the ground. Witnesses in this case stated that there is no standardised information sharing requirement or protocol for cross border missing persons investigations (including missing persons with suicidal ideation). I am concerned that, as there is no standardised information sharing requirements or protocols in such cases, in the future a force receiving details of a suicidal missing person may also not be informed that an individual has taken a means of suicide with them. In addition, other important information that may assist in the search for that person may also not be passed. ”
Source location
Anthony John Raymond INGRAM · 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
Develop and consult forces on NPCC advice for requesting missing-person enquiries in another force and transferring investigations.

Verbatim wording from the response
“Further to the APP guidance a Task and Finishing Group has been initiated focusing on the very issue you have outlined. Draft NPCC advice on ‘Requesting Missing Person Enquiries in Another Force and Transfers of Investigations’ has been developed and has now been circulated to all forces for consultation.”

Source location
Response from National Police Chiefs' Council
Page 2 · response
Published 28 February 2023
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 National Transfer form to capture requests for enquiries in another force, including direct telephone or video communication of risk and urgency.

Verbatim wording from the response
“In addition to the above The National Transfer form is being updated to include a section to be used for requesting enquiries in another force. One of the new recommendations is to require the officer requesting the enquiries or transfer to contact by telephone or video call the key decision-maker in the other force so that the level of risk and urgency of enquiries can be effectively communicated, rather than rely on what is written on an email or the incident log. We are still waiting for the new form to be completed, but there is a working party completing that task and it is anticipated that it will be available in the next few weeks when the new processes will go live.”

Source location
Response from National Police Chiefs' Council
Page 2 · response
Published 28 February 2023
Open published response
26 Nov2021
Dorset
Concerns raised1
1. Lack of access by other police forces to information held on individual police force systems
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Increase operational use of the Police National Database, including uploading safeguarding information and searching for information about vulnerable people.
  Stated by Home OfficeStated planned
2. Action
  Actively consider referrals to safeguarding hubs or control-room triage services and recording relevant information on the Police National Database.
  Stated by Home OfficeStated planned
3. Action
  Consider developing a safeguarding capability within the Police National Database transformation to improve operational effectiveness across safeguarding agencies.
  Stated by Home OfficeStated planned
1. Action
  Use IMORCC working groups to deliver national information-sharing agreements, provide national-system and mobile-device data, and share data with partners where appropriate.
  Stated by National Police Chiefs’ CouncilStated planned
2. Action
  Continue work to enable sharing of each police force’s records-management-system data across policing.
  Stated by National Police Chiefs’ CouncilStated in progress
Respondent positions 2
1. Position
  The exchange of information between police forces is outside NHS England’s remit for comment.
  Stated by NHS EnglandOutside remit
1. Position
  Each police force is responsible for its own budget, systems, staffing, and data management as its Chief Constable’s responsibility.
  Stated by National Police Chiefs’ CouncilRedirects responsibility
AI-generated summary

Felicity Jane Clough · 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

Felicity Jane Clough was taken to hospital on 24 November 2019 after being prescribed Tramadol, discharged during the early morning, and later found collapsed and unresponsive in a field. The concerns included limited information-sharing between healthcare trusts and police forces, and the failure to consistently review paramedic records containing potentially critical information at Yeovil District Hospital.

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 access by other police forces to information held on individual police force systems
Wider context from the report
“ii. I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces, especially neighbouring forces who may both have contact with individuals. Whilst I understand there is some work being done on a regional basis to address this, I would request that the issue is considered nationally as to how information held on all Police systems, not just the Police National Database, can be shared to assist in the management and assessment of individuals and the risk they pose to themselves or others. ”
Source location
Felicity Jane Clough · 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
Increase operational use of the Police National Database, including uploading safeguarding information and searching for information about vulnerable people.

Verbatim wording from the response
“Action 1: For Operational Police Officers/Police Staff to ensure greater utilisation of the Police National Database (PND). This would include encouraging uploading safeguarding information to PND, to ensure it is accessible country wide, as well as Officers asking for the PND to be searched against any vulnerable individuals when encountering seemingly vulnerable persons.”

Source location
Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
Page 5 · response
Published 29 November 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
Actively consider referrals to safeguarding hubs or control-room triage services and recording relevant information on the Police National Database.

Verbatim wording from the response
“Action 2: For Operational Police Officers/Police Staff to actively consider making referrals into the Multi-Agency Safeguarding Hubs and/or Control Room Triage services, which should in turn record any relevant information determined through these collaborated units onto PND. This will ensure greater information sharing around vulnerability across all UK Police Forces.”

Source location
Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
Page 5 · response
Published 29 November 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
Consider developing a safeguarding capability within the Police National Database transformation to improve operational effectiveness across safeguarding agencies.

Verbatim wording from the response
“Action 3: For Chief Officers and Home Office Officials involved in the design and delivery of the PND transformation, to consider the development of a safeguarding capability and how it can add greater operational effectiveness across safeguarding agencies/authorities.”

Source location
Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
Page 5 · response
Published 29 November 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
Use IMORCC working groups to deliver national information-sharing agreements, provide national-system and mobile-device data, and share data with partners where appropriate.

Verbatim wording from the response
“The National Police Chiefs Council (NPCC) Information Management and Operational Coordination Committee (IMORCC), aims to ensure that information is shared to reduce harm, make the public safe and reduce crime. The committee oversees several working groups that will deliver national information sharing agreements, provide data that is needed from national systems and on mobile devices and share data with partners where appropriate. IMORCC has recently set up a Data Board”

Source location
Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
Page 9 · response
Published 29 November 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
Continue work to enable sharing of each police force’s records-management-system data across policing.

Verbatim wording from the response
“The Police Digital Service (PDS) was created in April 2021, with the ambition of delivering the Digital, Data and Technology Strategy 2020-2030. Part of the PDS is the creation of a new NPCC National Data Office and proposed Data Strategy (LEARN), that will look at the opportunities for better use of data including that of other agencies. Work has already commenced to try to address data issues to enable sharing of each forces RMS data across policing.”

Source location
Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
Page 11 · response
Published 29 November 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 exchange of information between police forces is outside NHS England’s remit for comment.

Verbatim wording from the response
“The initial focus is on sharing within the boundaries of the Integrated Care Systems – in this case within Dorset and within Somerset – and 41 of the 42 Integrated Care Systems have already implemented a basic solution. There is a commitment to get these to interwork and this was set out in the most recent NHS Priorities and Operational Planning Guidance for 2022/23. The intention is for this to work regionally by the end of 2022/23 and nationally no later than 2023/24. Details of the Dorset Care Record are at https://www.dorsetccg.nhs.uk/project/dorset-care-record/ and the Somerset Integrated Care Record at https://www.somersetccg.nhs.uk/about-us/digital-projects/sider/ The exchange of information between police forces is not a matter NHS England can comment on.”

Source location
Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
Page 7 · response
Published 29 November 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
Each police force is responsible for its own budget, systems, staffing, and data management as its Chief Constable’s responsibility.

Verbatim wording from the response
“Each force is responsible for their own budget and how they allocate this will depend on their individual needs. This is reflected in their ICT infrastructure with regards to systems and staffing which equates to the capabilities across each force being significantly different. This can also be seen in the Records Management Systems (RMS) each force holds and as such there are several different suppliers and systems in use throughout the country that do not communicate easily with each other. Each Chief Constable is the Data Controller for their force and has ultimate responsibility for the management and use of data and information as defined by the Data Protection Act 2018.”

Source location
Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
Page 10 · response
Published 29 November 2021
Open published response
15 Mar2021
Manchester South
Concerns raised1
1. Failure to share and embed lessons about policing plans across other Force Areas
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Joe Peter Robinson · 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

Joe Peter Robinson became unwell and collapsed near Ashton Canal in the early hours of 14 June 2020, and attempts to resuscitate him were unsuccessful. The post-mortem examination found that he died from a combination of MDMA and ketamine. The concerns included the absence of first-aid or paramedic facilities at a large unlicensed gathering, and uncertainty about whether lessons concerning policing plans had been shared and embedded across other force areas.

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 and embed lessons about policing plans across other Force Areas
Wider context from the report
“The evidence before the inquest was that Greater Manchester Police became aware of the event but felt unable to prevent it from continuing. The inquest was told that at the time GMP did not have a clear plan to deal with such a situation. However, since this event at Daisy Nook and a similar one that same night also in South Manchester they have developed a robust plan and there have not been similar large scale illegal gatherings. What was not clear from the inquest was whether the lessons learnt of the need for policing plans to prevent such events occurring and reduce the risk of future deaths occurring had been shared and embedded in other Force Areas. ”
Source location
Joe Peter Robinson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Aug2019
Manchester North
Concerns raised1
1. Failure to accurately share information about offenders between police forces
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Produce and distribute a Greater Manchester custody briefing on responsibilities for detainees subject to licence or supervision and accurate information sharing.
  Stated by Greater Manchester PoliceStated completed
2. Action
  Publish and update the Intelligence Collection, Analysis and Dissemination Policy Framework to standardise intelligence handling and sharing within HMPPS and with partner agencies.
  Stated by HM Prison and Probation Service and Ministry of Justice and Probation ServiceStated completed
Respondent positions 4
1. Position
  Operational matters within each force, including the concerns raised, are the responsibility of the respective chief constable.
  Stated by National Police Chiefs’ CouncilRedirects responsibility
1. Position
  The NPCC lacks authority to direct chief constables to take or refrain from specific operational action.
  Stated by National Police Chiefs’ CouncilOutside remit
2. Position
  The uncertainty about information sharing was isolated and did not indicate systemic failures.
  Stated by Lancashire ConstabularyDisputes the concern
3. Position
  The information-sharing failure in this case does not amount to a systemic issue requiring broader systemic action.
  Stated by Greater Manchester PoliceDisputes the concern
AI-generated summary

Michael Hoolickin · 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

Michael Hoolickin was attacked and stabbed in an unprovoked assault on 14 October 2016 and died at Manchester Royal Infirmary on 17 October 2016. The report identifies organisational and management failures in supervising the perpetrator, including failures concerning drug testing, information sharing and provision of relevant information, which resulted in a missed opportunity to initiate recall to prison. The Inquest found that this probably contributed to Michael Hoolickin’s death, although it was not causative of the attack.

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 accurately share information about offenders between police forces
Wider context from the report
“There was a complete breakdown of communication and information sharing between GMP and Lancashire Constabulary which lead to only information about one of the two offenders being passed on. More importantly there was confusion between the forces as to which offender was being discussed. ”
Source location
Michael Hoolickin · Prevention of Future Deaths report
Page 5 · 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
Produce and distribute a Greater Manchester custody briefing on responsibilities for detainees subject to licence or supervision and accurate information sharing.

Verbatim wording from the response
“Custody suites are a conduit for sharing information between forces for out of area arrests including those in breach of licence conditions.This type of contact is daily business and there isn’t any specific guidance for custody staff in relation to how to pass information between police forces. This approach to sharing information about the arrest of a person who is subject to licence conditions meets the requirements for initial notification of arrest to the team responsible for managing that offender. It is appropriate and proportionate to remind all staff working within custody offices of the importance of paying attention to detail when sharing information.”

Source location
2019-0292-Response-from-Greater-Manchester-Police-Redacted
Page 4 · response
Published 25 October 2019
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
Publish and update the Intelligence Collection, Analysis and Dissemination Policy Framework to standardise intelligence handling and sharing within HMPPS and with partner agencies.

Verbatim wording from the response
“Questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders. In addition, whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team.”

Source location
2019-0292-Response-from-HM-Prison-and-Probation-Service-Redacted.pdf
Page 3 · response
Published 25 October 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
Operational matters within each force, including the concerns raised, are the responsibility of the respective chief constable.

Verbatim wording from the response
“I was not previously aware of this incident, and I am very sorry to learn of the tragic circumstances surrounding the death of Mr Hoolickin. You will appreciate that I am unable to comment on the specific facts of this case, but I can address your concerns regarding policing practice more generally. I understand that you have made contact with the chief constables of Greater Manchester Police and Lancashire Constabulary, both whom will no doubt wish to respond separately in addressing the issues you have raised with specific reference to the actions of their respective forces.”

Source location
2019-0292-Response-from-the-National-Police-Chiefs-Council-1
Page 1 · response
Published 25 October 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
The NPCC lacks authority to direct chief constables to take or refrain from specific operational action.

Verbatim wording from the response
“It is important to understand the distinct role of the National Police Chiefs’ Council (NPCC). As you know, each chief constable is ultimately responsible for operational matters within their own force area, which includes all of those issues referred to within the matters of concern you have raised. Whilst the NPCC seeks to encourage chief constables to work collaboratively in the national interest (for example, the way in which forces implement policies or practice), the NPCC does not have the authority to direct a chief constable to take (or not to take) a specific course of action. That said, we do recognise the need for consistency across forces whenever possible, which we know can lead to better outcomes for the public. The way the NPCC”

Source location
2019-0292-Response-from-the-National-Police-Chiefs-Council-1
Page 1 · response
Published 25 October 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
The uncertainty about information sharing was isolated and did not indicate systemic failures.

Verbatim wording from the response
“The lack of certainty as to what information was being shared was an isolated incident and was not demonstrative of any systemic failing(s). We have detailed below how Lancashire Constabulary operates in practice in this area.”

Source location
2019-0292-Response-from-Lancashire-Constabulary.-Redactedf
Page 1 · response
Published 25 October 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
The information-sharing failure in this case does not amount to a systemic issue requiring broader systemic action.

Verbatim wording from the response
“Response: Whilst it is accepted that the exchange of information in this case between police officers from Lancashire Constabulary and GMP could and should have been more effective it is respectfully submitted that evidence from this single incident does not amount to a systemic issue.”

Source location
2019-0292-Response-from-Greater-Manchester-Police-Redacted
Page 4 · response
Published 25 October 2019
Open published response
1 Mar2017
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Shortcomings in cascading safety information across police forces
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Darran Hunt · 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 8 February 2015, Darran Hunt was involved in a struggle with police after attempting to evade detention and placing a package in his mouth. He choked on the package and died despite efforts to clear his airway and provide life support. The report raises concerns about police training and guidance on using PAVA spray, forced searches of a detainee’s mouth, and control and restraint where a detainee has placed something in their mouth.

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
Shortcomings in cascading safety information across police forces
Wider context from the report
“It is of concern that there is a 2006 case with no too dissimilar facts in the South Wales Police Force area. In that case, the lack of training in relation to the forced search of the mouth of a detainee and control and restrain where a detainee has been seen to put something in their mouth were issues highlighted by the Inquest. One of the recommendations of the Preventing Future Death’s Report in that case was that officers should be trained in the technique of forced searching of the mouth. There is an apparent shortcoming in the cascading of information across the different police forces. ”
Source location
Darran Hunt · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Jul2014
Oxfordshire
Concerns raised1
1. Failure to pass high-risk information between police forces and control rooms
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Complete a thorough review of the information-sharing concern, consulting senior colleagues across relevant departments.
  Stated by Thames Valley PoliceStated completed
Respondent positions 2
1. Position
  Thames Valley Police disputes that it failed to inform Gloucestershire Police of the relevant welfare concerns.
  Stated by Thames Valley PoliceDisputes the concern
1. Position
  Gloucestershire Police was responsible for assessing whether the shared information required a different intervention.
  Stated by Thames Valley PoliceRedirects responsibility
AI-generated summary

Suzanne Cammell · 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

Suzanne Cammell died on 3 October 2013 after lying beneath the wheels of a lorry in a layby near Burford Golf Club; she sustained severe blunt head injuries when the lorry drove away. The principal concern was that high-risk information about the incident and a previous similar incident may not have been communicated by Thames Valley Police to Gloucestershire Constabulary or made available to the officer conducting a welfare check.

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 pass high-risk information between police forces and control rooms
Wider context from the report
“(1) There was also an incident on 23 September 2013 in Gloucestershire when Ms Cammell had been sectioned under Section 136 of the MHA because she had been seen placing her head under the wheels of a recycling lorry where she lived. She was seen by neighbours and/or the driver in time. This information about the incident on 23 September 2013 was held on the Police National Database which, presumably, Gloucestershire control and ████████ would have had access to. The concern therefore is in relation to communication between TVP and Gloucestershire Constabulary and, in turn, communication between Gloucestershire Control and its Officers. At Inquest, I did not have available to me details of the specific information passed by TVP control to Gloucestershire control in the early hours which subsequently led to ████████ and his colleague carrying out the welfare check at approximately 03.30. The evidence of ████████ at Inquest was that he did not know that she had been found lying underneath the wheels of the lorry earlier in the morning. He gave evidence that, if he had known this, he would have put in hand arrangements for a MHA assessment. ████████ also gave evidence that he did not know about the previous similar incident on 23 September despite the fact that it was on the PND and, furthermore, on Gloucestershire’s “Unified” Intelligence database. The issue of concern therefore is the fact that specific information, of a high risk nature, was not or may not have been passed by TVP to Gloucestershire Constabulary or, if it was, it may not have been available to ████████. I appreciate that ████████ carried out a prompt welfare check and that Ms Cammell’s presentation was such that ████████ did not consider her to be at risk but it appears he did not have available crucial information. ”
Source location
Suzanne Cammell · 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
Complete a thorough review of the information-sharing concern, consulting senior colleagues across relevant departments.

Verbatim wording from the response
“████████ of our Professional Standards Department has carried out a thorough review of this matter, in the course of which he has consulted with senior colleagues from the Control Room & Enquiries Department, the Force Intelligence Bureau and the Partnership Team (which covers mental health).”

Source location
2014-0579-Response-by-Thames-Valley-Police
Page 1 · response
Published 28 July 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
Thames Valley Police disputes that it failed to inform Gloucestershire Police of the relevant welfare concerns.

Verbatim wording from the response
“In summary, it would seem that TVP informed Gloucestershire Police of the concerns as reported by ████████ insofar as he had found Ms Cammell in a confused state and that she had been trying to get underneath a lorry. Admittedly, the information shared did not go into quite the detail reported by ████████, who said that he actually woke Ms Cammell while she was under a lorry and not simply that she was trying to get under one. I am not sure whether this would have made a material difference to ████████ risk assessment when he visited Ms Cammell at home. This would seem to be a matter for Gloucestershire but I hope I have at least been able to clarify the information that was shared.”

Source location
2014-0579-Response-by-Thames-Valley-Police
Page 4 · response
Published 28 July 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
Gloucestershire Police was responsible for assessing whether the shared information required a different intervention.

Verbatim wording from the response
“In summary, it would seem that TVP informed Gloucestershire Police of the concerns as reported by ████████ insofar as he had found Ms Cammell in a confused state and that she had been trying to get underneath a lorry. Admittedly, the information shared did not go into quite the detail reported by ████████, who said that he actually woke Ms Cammell while she was under a lorry and not simply that she was trying to get under one. I am not sure whether this would have made a material difference to ████████ risk assessment when he visited Ms Cammell at home. This would seem to be a matter for Gloucestershire but I hope I have at least been able to clarify the information that was shared.”

Source location
2014-0579-Response-by-Thames-Valley-Police
Page 4 · response
Published 28 July 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to share known suicide risk between police forces

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of inter-force sharing and flagging of information about shotgun licence holders and shotgun locations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Lack of standardised information-sharing requirements or protocols for cross-border missing-person investigations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Lack of access by other police forces to information held on individual police force systems

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

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 share and embed lessons about policing plans across other Force Areas

Concerns raised1

Failure to accurately share information about offenders between police forces

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Actions described in response 2

Respondent positions 1

Actions described in response 3

Actions described in response 2

Actions described in response 5

Respondent positions 2

Actions described in response 2

Respondent positions 4