10 Jun 2025 Amy Anne Levy · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of general guidance on when to leave voicemail messages in non-domestic-abuse cases View source Unclear applicability of voicemail guidance to police officers and control-room staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Amy Anne Levy · 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
Amy Anne Levy, a 22-year-old student, took an overdose of prescription drugs on 18 June 2023 and later died in hospital on 22 June 2023. Police and ambulance services did not know her address for over two hours despite knowing that her condition was deteriorating and that the case required an immediate response. The principal concern was that police officers and call handlers did not leave voicemail messages when attempting to contact her parents, potentially delaying the discovery of her location; the inquest jury identified a catalogue of missed opportunities to obtain her correct address.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of general guidance on when to leave voicemail messages in non-domestic-abuse cases
Wider context from the report “As I have outlined above, this was an ‘immediate’ priority search to obtain the address of a young woman who whose life was believed to be at risk.
It is hard to understand the decision (made by more than one police caller) not to leave any voicemail/message.
We heard evidence from two police Inspectors (one from Avon and Somerset Constabulary and one from Surrey Police) that although there is guidance in Avon not to leave voicemails when the incident in question concerns domestic abuse, there is no general guidance about when to leave a voicemail message in other cases (ie, it is neither encouraged not discouraged by any policy or standard operating procedure) .
I was subsequently provided with an updated ‘Deployment of Resources Procedure’ from Surrey Police, which indicates that ‘call takers and dispatchers must consider whether it is appropriate to leave a voicemail, unless there is a compelling operational reason not to do so’. It is not clear from the title of the document or the wording of the guidance whether this is intended to affect police officers, or only the actions of those in Surrey’s contact centre and force control room.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Unclear applicability of voicemail guidance to police officers and control-room staff
Wider context from the report “As I have outlined above, this was an ‘immediate’ priority search to obtain the address of a young woman who whose life was believed to be at risk.
It is hard to understand the decision (made by more than one police caller) not to leave any voicemail/message.
We heard evidence from two police Inspectors (one from Avon and Somerset Constabulary and one from Surrey Police) that although there is guidance in Avon not to leave voicemails when the incident in question concerns domestic abuse, there is no general guidance about when to leave a voicemail message in other cases (ie, it is neither encouraged not discouraged by any policy or standard operating procedure).
I was subsequently provided with an updated ‘Deployment of Resources Procedure’ from Surrey Police, which indicates that ‘call takers and dispatchers must consider whether it is appropriate to leave a voicemail, unless there is a compelling operational reason not to do so’. It is not clear from the title of the document or the wording of the guidance whether this is intended to affect police officers, or only the actions of those in Surrey’s contact centre and force control room .
” Open source report
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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 Missing Person policy and publish an updated version containing the revised voicemail wording.
Verbatim wording from the response “2) The Concern for Safety and Missing Person policies have been updated to include specific wording around the leaving of voicemails, as follows:” Source location Response from Avon & Somerset Constabulary
Open published response
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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 review of voicemail guidance and related improvements.
Verbatim wording from the response “ASC accept the findings that there was limited training and policy in place which provided clear guidance to police and staff about when a voicemail should be left when attempting to make contact with a member of the public. ASC are committed to ensuring that changes to our training and policies reduce any ambiguity around this, and a full review has been carried out by our Professional Standards and Communications departments to consider improvements.” Source location Response from Avon & Somerset Constabulary
Open published response
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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 updated Concern for Safety policy wording requiring voicemail or text messages, logging and continued contact attempts.
Verbatim wording from the response “2) The Concern for Safety and Missing Person policies have been updated to include specific wording around the leaving of voicemails, as follows:” Source location Response from Avon & Somerset Constabulary
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Maxine Betty Davison and 4 others · 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 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to condition firearms licensing delegation on adequate training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training .
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training .
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of a mandatory requirement for role-specific firearms licensing training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training . I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular .
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff ;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
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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 Firearms Licensing Team training requirements against the latest statutory guidance.
Verbatim wording from the response “Avon and Somerset Police comply with the Authorised Professional Practice (APP) and the Firearms Licensing: Statutory Guidance for Chief Officers of Police, February 2023. The Firearms Licensing Team are presently using the latest publication to establish further areas for additional improvement.” Source location Response from Avon and Somerset Police
Open published response
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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 dedicated senior Firearms Enquiry Officer training, coaching, and mentoring for new officers.
Verbatim wording from the response “Our Firearms Licensing Team have a dedicated senior Firearms Enquiry Officer who trains, coaches, and mentors all new Firearms Enquiry Officers in line with the College of Policing Assessment Guidance for Firearms Licensing (See Appendix B), ensuring consistency in the operational approaches that staff take.” Source location Response from Avon and Somerset Police
Open published response
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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 PiP Level 1 training for the Firearms Licensing Manager and Firearms Licensing Officers on decision-making, risk management, and investigation supervision.
Verbatim wording from the response “• Completion, by the Firearms Licensing Manager and Firearms Licensing Officers, of the Professionalising Investigations Programme (PiP) Level 1 training, focussing on decision making, managing risk, and supervising investigations. This course will mirror the input that is given to all police supervisors of investigations.” Source location Response from Avon and Somerset Police
Open published response
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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 Deliver the South Yorkshire Police three-day Firearms Enquiry Officer course to all Firearms Enquiry Officers.
Verbatim wording from the response “All Firearms Enquiry Officers in Avon and Somerset complete the South Yorkshire Police three-day Firearms Enquiry Officer course (see Appendix B).” Source location Response from Avon and Somerset Police
Open published response
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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 Train all Firearms Licensing Team staff in the National Decision Model.
Verbatim wording from the response “• Completion, by all staff in the team, of training on the National Decision Model; to further enable effective decision making that is justifiable, proportionate, lawful, accountable, necessary, and ethical.” Source location Response from Avon and Somerset Police
Open published response
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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 Deliver specific training for Firearms Licensing Administrators and maintain staff continuing professional development through regional events.
Verbatim wording from the response “Specific training courses for Firearms Licensing Administrators are delivered through Mowbray Partners. Staff from the department also maintain their own continuous professional development by participating in regional events which involve inputs from national shooting bodies, the British Association for Shooting and Conservation (BASC), and the National Gamekeepers Organisation.” Source location Response from Avon and Somerset Police
Open published response
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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 additional mandatory training for all Firearms Licensing Team staff.
Verbatim wording from the response “In response to the publication of the aforementioned guidance, and in recognition of the learning from the deaths in Keyham, the Firearms Licensing Team are reviewing their training requirements and will be implementing additional mandatory training for all staff working in the team.” Source location Response from Avon and Somerset Police
Open published response
23 Sep 2021 Hamish John Cameron HOWITT · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Absence of directives in police training material and national policy on referral of apparently intoxicated injured people View source Alcohol-appearing effects masking serious underlying medical conditions View source Insufficient police training to identify and refer apparently intoxicated people complaining of injury View source Failure to recommend hospital or ambulance assessment for apparently intoxicated people complaining of injury View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Hamish John Cameron HOWITT · 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
Hamish John Cameron HOWITT, a 20-year-old university student, died unexpectedly overnight in Frome on 1 July 2016 after an evening involving alcohol, a traumatic brain injury and self-administered ketamine. The concerns were that police did not recommend hospital assessment after he reported being injured, and that police training and national policy should address the risk of serious underlying conditions being masked by apparent intoxication.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of directives in police training material and national policy on referral of apparently intoxicated injured people
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Alcohol-appearing effects masking serious underlying medical conditions
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient police training to identify and refer apparently intoxicated people complaining of injury
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to recommend hospital or ambulance assessment for apparently intoxicated people complaining of injury
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report
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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 Add essential head-injury guidance to Modules 3 and 4 head-injury training.
Verbatim wording from the response “iv. The Module 3 and 4 first aid training on head injuries has been amended to incorporate the same essential guidance on head injuries.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
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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 head-injury response guidance into Taser, Personal Safety and Public Order training programmes.
Verbatim wording from the response “v. Avon and Somerset Constabulary officers with responsibility for leading force training in relation to Taser, Personal Safety Training and Public Order training have also been made aware of the Report and of the first aid guidance on head injuries, which have been incorporated into their training programmes.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Open published response
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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 Send this response and relevant updated force guidance and training documents to the CoP and NPCC for consideration in national guidance and training decisions.
Verbatim wording from the response “19. A copy of this response, and relevant updated force guidance and training documents, will also be sent to the CoP and the NPCC so that they are aware of all of the changes that have been made internally by Avon and Somerset Constabulary, and can take these into consideration when determining whether any additional national guidance, or amendments to training provision are required.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Open published response
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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 Circulate essential head-injury guidance to all officers, requiring medical assistance to be requested or facilitated where a head injury is suspected.
Verbatim wording from the response “i. An internal communications bulletin has been sent to all officers which identified head injuries as a matter of concern, and provided a link to “essential guidance” on head injuries. This was included in the “Must know” section of the bulletin, which all officers are required to read. The linked guidance states that if an officer or staff member has any suspicion, or is told in good faith, that a person may have a head injury, they should treat the person as such in the absence of clear evidence to dispel that suspicion. The guidance makes clear that no visible marking is not an acceptable level of evidence that a head injury has not been sustained.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Open published response
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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 first-aid training, policy or guidance when revised CoP or NPCC requirements are received.
Verbatim wording from the response “18. Avon and Somerset Constabulary will update its training provision immediately on receipt of any updated guidance from the CoP and / or NPCC.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Open published response
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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 reviewing the concerns and working with the CoP and NPCC to implement recommended changes to training, policy and guidance.
Verbatim wording from the response “17. It is understood that all matters of concern identified at Part 5 of your Report will be reviewed by the NPCC and CoP, including provision of training on head injury, the potential impact of alcohol in masking other underlying conditions, and your recommendations in relation to training material and national policy setting.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Open published response
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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 Add essential head-injury guidance to Modules 1, 2 and 4 casualty-assessment training.
Verbatim wording from the response “iii. The lesson plan for Modules 1, 2 and 4 for “Assess a Casualty (Primary and Secondary survey)” has been amended to require this training to provide the same essential guidance on head injuries.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Open published response
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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 Send essential head-injury guidance to all first-aid trainers.
Verbatim wording from the response “ii. All first aid trainers have been sent the essential guidance on head injuries.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Open published response
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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 Officers cannot always require members of the public to remain or engage with medical intervention.
Verbatim wording from the response “i. An internal communications bulletin has been sent to all officers which identified head injuries as a matter of concern, and provided a link to “essential guidance” on head injuries. This was included in the “Must know” section of the bulletin, which all officers are required to read. The linked guidance states that if an officer or staff member has any suspicion, or is told in good faith, that a person may have a head injury, they should treat the person as such in the absence of clear evidence to dispel that suspicion. The guidance makes clear that no visible marking is not an acceptable level of evidence that a head injury has not been sustained.” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Open published response
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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 CoP and NPCC are responsible for determining national FALP training and policy changes; the Constabulary will follow their updated guidance.
Verbatim wording from the response “ii. The CoP is working with clinical leads to review the high level learning outcomes with the aim of placing greater emphasis on the training elements that preserve life, and is presently considering:” Source location 2021-0320-Response-from-Avon-and-Somerset-Constabulary_Published
Open published response
23 Mar 2020 Lewis Charles Francis · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum View source Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lewis Charles Francis · 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
Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.
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. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
Wider context from the report “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies.
” Open source report
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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 liaising with South West Provider Collaborative partners to help develop the regional Memorandum of Understanding.
Verbatim wording from the response “Action 2: Further evidence at the inquest suggested that an initiative was underway through the good offices at Avon and Somerset Police to cooperate with the South West Provider Collaborative in the development of the Memorandum of Understanding detailed above. Confirmation on behalf of the named police forces is required that they are willing to work towards the development of such a Memorandum of Understanding.” Source location 2020-0074-Response-from-Avon-and-Somerset-Police_Redacted
Open published response
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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 Training on autistic prisoners’ needs is directed solely to the Prison Service and does not require a response from the Chief Constable.
Verbatim wording from the response “Action 3: It appeared desirable that training with regards to the special needs and susceptibilities of those prisoners within the autistic spectrum be provided for prison officers, support staff and newly appointed prison officers undergoing training both in the form of face to face training and the provision of information through prison intranet systems.” Source location 2020-0074-Response-from-Avon-and-Somerset-Police_Redacted
Open published response
22 Feb 2017 Mrs. Margaret Joyce Jones · Prevention of Future Deaths report Avon
View report summary
Concerns raised 5 Failure to maintain the high-friction road surface in the vicinity of the junction View source Inadequate or unrepaired carriageway markings warning drivers of the junction risk View source Failure to set an appropriately safe speed limit on the A36 either side of Branch Road View source Inadequate road signs warning drivers of the risk from the junction View source Repeated road traffic collisions at the junction involving drivers emerging onto the A36 View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs. Margaret Joyce Jones · 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
Mrs. Margaret Joyce Jones died at the scene after her car collided with a northbound articulated lorry while she was turning onto the A36 from Branch Road on 5 September 2016. The report identified repeated collisions at the junction and raised concerns about the speed limit, road signs, carriageway markings, and the condition of the high-friction surface.
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. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the high-friction road surface in the vicinity of the junction
Wider context from the report “(3) The road signs including carriageway markings should be reviewed and improved so as to provide greater warning to drivers as to the risk from this junction.
(4) Whilst not factors in this collision appropriate repairs should be made to the high friction surface and road markings in the vicinity of the junction .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Inadequate or unrepaired carriageway markings warning drivers of the junction risk
Wider context from the report “(3) The road signs including carriageway markings should be reviewed and improved so as to provide greater warning to drivers as to the risk from this junction .
(4) Whilst not factors in this collision appropriate repairs should be made to the high friction surface and road markings in the vicinity of the junction .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to set an appropriately safe speed limit on the A36 either side of Branch Road
Wider context from the report “(2)The speed limit in the section of the A36 either side of Branch Road should be reduced so as to improve the safety of drivers both those on A36 and those emerging from Branch Road .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Inadequate road signs warning drivers of the risk from the junction
Wider context from the report “(3) The road signs including carriageway markings should be reviewed and improved so as to provide greater warning to drivers as to the risk from this junction .
(4) Whilst not factors in this collision appropriate repairs should be made to the high friction surface and road markings in the vicinity of the junction.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Repeated road traffic collisions at the junction involving drivers emerging onto the A36
Wider context from the report “(1) Notwithstanding the contribution made to this collision by the factors described above there have been a number of road traffic collisions at this junction involving drivers emerging on to the A36 .
” Open source report
13 Feb 2015 Christopher David TAYLOR · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure of dispatch staff to continuously see incoming incidents View source High-risk stretch of river View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Christopher David TAYLOR · 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 David TAYLOR fell into the River Avon in Bath after being out drinking with friends and was unable to get out. He went under the water despite efforts by emergency services to rescue him. Concerns included a delay in dispatching the emergency response, inadequate visibility of immediate incidents, and the absence of life buoy rings and suitable fencing along a high-risk stretch of riverbank.
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. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure of dispatch staff to continuously see incoming incidents
Wider context from the report “1. In this particular case it appears that the team in dispatch were not aware of the immediate incident which resulted in a delay in it being actioned by them . Staff need to be able to see at all times a screen which displays incoming incidents for them to be able to action in an appropriate manner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation High-risk stretch of river
Wider context from the report “2. I appreciate that Sainsburys were not represented at the inquest and I do not have any evidence from them in relation to their plans for the bank next to the River Avon in Bath however I would ask that they consider their responsibility as land owner along this stretch of river in question which falls within the high risk area . Specifically I would ask that they liaise with Bath and North East Somerset Local Authority in relation to potentially the provision of a vandal proof life buoy station along that stretch of river .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt a call-scripting system with flags, tags and alerts to support dynamic assessment of call needs and priority.
Verbatim wording from the response “Finally, and perhaps most fundamental to the redesigning of our communication services, from April 2015 the Constabulary will adopt a new call scripting system which is designed with flags, tags and alerts for the benefit of the Call Handler/Dispatch team’s ability to dynamically and continually assess of needs/priority of any one call.” Source location 2015-0055-Response-by-Avon-Somerset-Constabulary
Open published response
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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 Commence co-location of Call Handlers and Dispatchers under a single supervisor.
Verbatim wording from the response “As per Inspector ████████ statement, once the call has been ‘taken’ it is transferred to from FSC to Dispatch, which is sited in another location away from FSC. The disparity between the call taker’s actions and the period of approximately 5 minutes during which no recorded action appears to have been taken is the first area the Constabulary has sought to address.” Source location 2015-0055-Response-by-Avon-Somerset-Constabulary
Open published response
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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 concern that staff must always see an incoming-incidents screen is not fully accepted because combined measures reduce reliance on any specific screen.
Verbatim wording from the response “If taken in isolation, none of the above steps comprehensively addresses the specific concern in your report that staff may not be able to ‘see at all-times a screen which displays incoming incidents.’ However, I hope you would share my view that when put into operation in concert with each other, the cumulative effect is such that staff no-longer rely solely upon visual access to any specific screen.” Source location 2015-0055-Response-by-Avon-Somerset-Constabulary
Open published response
30 Apr 2013 Jack William PAYTON · Prevention of Future Deaths report West Somerset
View report summary
Concerns raised 1 Failure to ensure control room staff workloads do not impair judgement and case handling View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jack William PAYTON · 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
Jack William PAYTON was found down an embankment after his car left the A38 while he was driving home from dialysis on 17 October 2012. The report raised concern about the handling of the incident by Portishead control room staff, including the downgrading of the initial report and the delay in locating him; the post-mortem found ischaemic heart disease, but could not confirm whether earlier discovery would have changed the outcome.
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. The report was sent to Avon and Somerset Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure control room staff workloads do not impair judgement and case handling
Wider context from the report “At the Inquest two members of the control room staff at Portishead namely ████████
████████ by their replies to my questions and demeanour conveyed to me the distinct impression that the hours they worked together with their case load had a detrimental affect on their judgement and subsequent handling of this matter .
” Open source report
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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 Commission an independent assessment of Communications Department shift patterns and their effects on staff.
Verbatim wording from the response “1. I am commissioning an independent assessment of the current shift pattern and its effects on staff. I currently anticipate this will be completed by ████████, a Human Scientist with Qinetiq who will be working in conjunction with ████████, the Force Medical Advisor from our Occupational Health Department who, as a specialist consultant physician, authored a dissertation on driving fatigue and shift work. It is anticipated this work will commence in January 2014, due to the availability of ████████” Source location 2013-0220-Response-by-Avon-Somerset-Constabulary
Open published response
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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 the recommendations at Force level and decide whether to implement them or progress other options.
Verbatim wording from the response “3. These recommendations will then be considered at Force level by an appropriate group to decide whether they should be implemented or whether any other options should be progressed. Should a decision be taken to amend shift patterns there are specific timescales set out with staff associations involving consultation and notice periods. The impact of these could mean that the timescales for full implementation could take until July 2014.” Source location 2013-0220-Response-by-Avon-Somerset-Constabulary
Open published response
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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 independent assessment and develop recommendations balancing fatigue findings with service demand, resources and business impacts.
Verbatim wording from the response “2. Their report will be presented for initial consideration to Chief Superintendent ████████
████████ who heads the Communications Department, together with representatives from the HR Department who will review the findings and develop recommendations balancing the findings of the independent report with the demand profiles the organisation experiences, the resources we have available, our need to provide a 24 hour/365 day service, and any other business impacts.” Source location 2013-0220-Response-by-Avon-Somerset-Constabulary
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations