4 May 2026 Suseel RANA · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Failure to recognise anxiety indicating the need for further safety planning View source Lack of clarity in DVDS Guidance about progression after intelligence checks and before disclosure decisions View source Failure to correctly understand Clare's Law applicability to previous partners View source Failure to progress Clare's Law applications through the DVDS decision-making stage and associated multi-agency referral 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
Suseel RANA · 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
Suseel RANA, who had mental health conditions and was experiencing anxiety and fear linked to domestic abuse, died by suicide after ingesting an excess of a substance. Concerns included the failure to progress her Clare’s Law application, a misunderstanding about its use for a previous partner, and the failure to recognise her anxiety as requiring further safety planning and multi-agency support.
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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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise anxiety indicating the need for further safety planning
Wider context from the report “1) In seeking some reassurance as to her safety, the Deceased had made a Clare's Law application under the Domestic Violence Disclosure Scheme (DVDS) prior to her death; however, this was had not been progressed by Police.
2) The reason for the lack of progression of the Deceased's Clare's Law application appear to have been based on a misunderstanding by the investigating officer that Clare's law could not be used in respect of a previous partner.
3) Neither the investigating officer nor the supervising officer appeared to recognise the Deceased's level of anxiety , as indicated by her Clare's Law application, required further safety planning .
4) The lack of progression of the Deceased's Clare's Law application to the actual decision making stage meant that the steps envisaged by the DVDS Guidance, which include a referral to a multi-agency forum (as illustrated by Figure 1 on page 8 of the Guidance), were not taken. Had such steps been taken, it is likely that the Deceased would have been more supported.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in DVDS Guidance about progression after intelligence checks and before disclosure decisions
Wider context from the report “5) Whilst paragraph 76 of the DVDS Guidance states: "The police may make the decision not to progress the disclosure following the completion of intelligence checks" - it is not currently clear whether the intention of the Guidance is for Police still to proceed to the decision making stage as to whether to make any disclosure or not (which would involve the multi-agency referral referenced above) or, whether, in that situation no further steps at all are required (as occurred in respect of the Deceased's application).
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly understand Clare's Law applicability to previous partners
Wider context from the report “1) In seeking some reassurance as to her safety, the Deceased had made a Clare's Law application under the Domestic Violence Disclosure Scheme (DVDS) prior to her death; however, this was had not been progressed by Police.
2) The reason for the lack of progression of the Deceased's Clare's Law application appear to have been based on a misunderstanding by the investigating officer that Clare's law could not be used in respect of a previous partner .
3) Neither the investigating officer nor the supervising officer appeared to recognise the Deceased's level of anxiety, as indicated by her Clare's Law application, required further safety planning.
4) The lack of progression of the Deceased's Clare's Law application to the actual decision making stage meant that the steps envisaged by the DVDS Guidance, which include a referral to a multi-agency forum (as illustrated by Figure 1 on page 8 of the Guidance), were not taken. Had such steps been taken, it is likely that the Deceased would have been more supported.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to progress Clare's Law applications through the DVDS decision-making stage and associated multi-agency referral
Wider context from the report “1) In seeking some reassurance as to her safety, the Deceased had made a Clare's Law application under the Domestic Violence Disclosure Scheme (DVDS) prior to her death; however, this was had not been progressed by Police .
2) The reason for the lack of progression of the Deceased's Clare's Law application appear to have been based on a misunderstanding by the investigating officer that Clare's law could not be used in respect of a previous partner.
3) Neither the investigating officer nor the supervising officer appeared to recognise the Deceased's level of anxiety, as indicated by her Clare's Law application, required further safety planning.
4) The lack of progression of the Deceased's Clare's Law application to the actual decision making stage meant that the steps envisaged by the DVDS Guidance, which include a referral to a multi-agency forum (as illustrated by Figure 1 on page 8 of the Guidance), were not taken . Had such steps been taken, it is likely that the Deceased would have been more supported.
” Open source report
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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 former-partner DVDS application was assessed under the applicable framework, and non-disclosure resulted from intelligence findings and proportionality considerations, not misunderstanding.
Verbatim wording from the response “The DVDS applies to both current and former partners. This is clearly reflected in Bedfordshire Police policy and practice.” Source location Response from Bedfordshire Police
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 Existing mental-health, safeguarding and Victim Engagement Officer support, alongside professional assessments, provided sufficient safeguarding for the deceased.
Verbatim wording from the response “Officers and Staff working within Domestic Abuse Investigations Teams are trained and experienced in recognising the impact of anxiety and vulnerability on victims. In this case, the Deceased was already engaged with mental health services, and two Victim Engagement Officers were in regular contact, and additional support options, including counselling referrals were provided.” Source location Response from Bedfordshire Police
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 DVDS applications were progressed through intelligence checks, supervisory review and formal decision-making, contrary to the concern that progression failed.
Verbatim wording from the response “Both applications were accepted, progressed through all relevant stages, subject to intelligence checks and reviewed at supervisory level.” Source location Response from Bedfordshire Police
Open published response
25 Nov 2025 Andrew Thomas MCCLEARY · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Lack of awareness and training regarding the risks and effects of force and restraint View source Failure to undertake collaborative planning with attending ambulance staff before using force or restraint View source Lack of knowledge and/or concern regarding Mental Capacity Act requirements for using force and restraint View source Failure to provide adequate attention and monitoring during and after restraint 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
Andrew Thomas MCCLEARY · 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
Andrew Thomas MCCLEARY died after cocaine use and the physiological and psychological effects of restraint, with his death confirmed at Bedford Hospital on 30 May 2021. The report identified concerns about failures to establish his capacity under the Mental Capacity Act, collaborative planning before restraint, monitoring of his physical and psychological wellbeing, and responding when he said he could not breathe.
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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness and training regarding the risks and effects of force and restraint
Wider context from the report “1) There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain Andrew.
2) There was an evident lack of awareness on the part of the attending officers of the risks/effects of using force against and restraining Andrew and of the need for collaborative planning with attending ambulance staff before doing so.
3) There was an evident lack of attention to and/or concern for Andrew on the part of the attending officers both during and after the restraint.
The above matters were of particular concern in view of the previous Regulation 28 Report made on 21 October 2021, following the Inquest into the death of Leon Briggs in 2013, which highlighted a lack of training regarding the effects of restraint as well as inadequate monitoring of a detainee subject to restraint on the part of Bedfordshire Police Officers.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake collaborative planning with attending ambulance staff before using force or restraint
Wider context from the report “1) There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain Andrew.
2) There was an evident lack of awareness on the part of the attending officers of the risks/effects of using force against and restraining Andrew and of the need for collaborative planning with attending ambulance staff before doing so .
3) There was an evident lack of attention to and/or concern for Andrew on the part of the attending officers both during and after the restraint.
The above matters were of particular concern in view of the previous Regulation 28 Report made on 21 October 2021, following the Inquest into the death of Leon Briggs in 2013, which highlighted a lack of training regarding the effects of restraint as well as inadequate monitoring of a detainee subject to restraint on the part of Bedfordshire Police Officers.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and/or concern regarding Mental Capacity Act requirements for using force and restraint
Wider context from the report “1) There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain Andrew.
2) There was an evident lack of awareness on the part of the attending officers of the risks/effects of using force against and restraining Andrew and of the need for collaborative planning with attending ambulance staff before doing so.
3) There was an evident lack of attention to and/or concern for Andrew on the part of the attending officers both during and after the restraint.
The above matters were of particular concern in view of the previous Regulation 28 Report made on 21 October 2021, following the Inquest into the death of Leon Briggs in 2013, which highlighted a lack of training regarding the effects of restraint as well as inadequate monitoring of a detainee subject to restraint on the part of Bedfordshire Police Officers.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate attention and monitoring during and after restraint
Wider context from the report “1) There was an evident lack of knowledge and/or concern on the part of the attending officers of the requirements of the Mental Capacity Act (MCA) 2005, particularly when it came to the decision to use force against and restrain Andrew.
2) There was an evident lack of awareness on the part of the attending officers of the risks/effects of using force against and restraining Andrew and of the need for collaborative planning with attending ambulance staff before doing so.
3) There was an evident lack of attention to and/or concern for Andrew on the part of the attending officers both during and after the restraint.
The above matters were of particular concern in view of the previous Regulation 28 Report made on 21 October 2021, following the Inquest into the death of Leon Briggs in 2013, which highlighted a lack of training regarding the effects of restraint as well as inadequate monitoring of a detainee subject to restraint on the part of Bedfordshire Police Officers .
” 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 Develop and launch joint police–ambulance scenario training for multi-agency incidents involving vulnerable patients.
Verbatim wording from the response “We have strengthened collaborative working with EEAST through the development and launch of joint scenario training which focusses on the ways in which Police and Ambulance personnel work together during multi-agency incidents, such as in the case of Mr McCleary. This improves communication, understanding of roles and responsibilities and importantly, maintains focus on the wellbeing of the patient.” Source location Response from Bedfordshire 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 mandatory Personal Safety Training incorporating the Acute Behavioural Disturbance programme and guidance on recognition, restraint risks, monitoring and multi-agency working.
Verbatim wording from the response “Since the death of Mr McCleary we have reviewed our use of force policies, processes and training. All Police Officers receive mandatory Personal Safety Training (“PST”) which includes a specific element on dealing with individuals suspected of being impaired by Acute Behavioural Disturbance (“ABD”).” Source location Response from Bedfordshire 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 Establish a joint Bedfordshire Police–EEAST memorandum of understanding defining roles for suspected Acute Behavioural Disturbance and access to rapid tranquilisation, pending EEAST sign-off.
Verbatim wording from the response “Additionally, Bedfordshire Police and EEAST have developed a Memorandum Of Understanding (“MOU”) to reinforce clear roles and responsibilities of both partner agencies in managing the needs of patients with suspected ABD and increasing the access to rapid tranquilisation at scene via appropriately trained paramedics. This MOU is awaiting imminent sign-off from EEAST Clinical Best Practice Group (already signed off by Bedfordshire Police). The MOU has been created in compliance with the CoP and Royal College of Emergency Medicine guidance.” Source location Response from Bedfordshire 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 mandatory Mental Capacity Act training to all frontline police officers, including capacity assessment, lawful restraint and recording requirements.
Verbatim wording from the response “I can confirm that all frontline Police Officers receive mandatory MCA training which includes, the statutory principles of the MCA (presumption of capacity, enabling decision-making, respect for unwise decisions, acting in best interests, and least restrictive option), capacity assessments, emergency interventions under Sections 5 and 6 MCA (including lawful authority for proportionate restraint), and the requirement to record decisions and rationale. Our MCA training is reinforced through scenario-based exercises and reference to case law, including R (Sessay) v South London and Maudsley NHS Foundation Trust.” Source location Response from Bedfordshire 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 Review use-of-force policies, processes and training following the death.
Verbatim wording from the response “Since the death of Mr McCleary we have reviewed our use of force policies, processes and training. All Police Officers receive mandatory Personal Safety Training (“PST”) which includes a specific element on dealing with individuals suspected of being impaired by Acute Behavioural Disturbance (“ABD”).” Source location Response from Bedfordshire Police
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 Police officers may defer to attending health professionals’ capacity assessments and rely on their advice when applying force.
Verbatim wording from the response “However, Police Officers are trained to defer to health professionals when making decisions regarding a person’s capacity status, with an assumption that the health professional has better training and experience than a Police Officer. Indeed, College of Policing national guidance states, “In situations where health or social care professionals are on the scene, police should defer to their expertise and provide support as appropriate and in accordance with local protocols”.” Source location Response from Bedfordshire Police
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 For health-related incidents, the agency with the appropriate skills and legal responsibility should lead rather than police.
Verbatim wording from the response “We acknowledge your reference to Mr Briggs’ PFD dated 21 October 2021 but note this post-dated Mr McCleary’s death. However, Bedfordshire Police and partners have worked together since 2024 to introduce and embed the national programme of Right Care, Right Person (RCRP). This is of particular relevance as the core principles are that Police should only respond where there is a clear policing purpose and the agency with the right skills and legal responsibility should lead.” Source location Response from Bedfordshire Police
Open published response
28 Feb 2024 Sylvia Dawn CROWTHER · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Failure to conduct an earlier discussion assessing dependence and considering alternative supportive options to criminal investigation View source Failure to obtain the alleged victim’s views on bail conditions and inform the custody officer View source Failure to follow important arrest procedures View source Failure to follow conditional pre-charge bail procedures 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
Sylvia Dawn CROWTHER · 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
Sylvia Dawn CROWTHER, who had physical disabilities, mental health issues and alcoholism, was found unresponsive at home on 6 January 2023 after expressing distress and requesting help while living alone following her husband's arrest and bail conditions. She had left notes indicating an intention to end her life and died despite resuscitation efforts. The Court identified concerns about police handling of the arrest and conditional pre-charge bail, including failure to seek and communicate her views about bail conditions and failure to identify her dependence on her husband and consider more supportive alternatives.
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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an earlier discussion assessing dependence and considering alternative supportive options to criminal investigation
Wider context from the report “(iii) An earlier discussion between Police and the Deceased might have highlighted the Deceased’s deep emotional and physical dependence on her husband and the need to consider alternative options to criminal investigation with potentially more supportive care attached to them , such as the use of a DVPN/DVPO as highlighted by the DHR.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain the alleged victim’s views on bail conditions and inform the custody officer
Wider context from the report “(ii) In particular, S47ZZA PACE 1984 requires the investigating officer to seek the views of the alleged victim on whether relevant conditions should be imposed on the person's bail and then to inform the custody officer of these views but this was not done in this case : the first time that the Deceased was made aware of the nature of her husband's bail conditions was when the Police brought him home after his release on bail to collect his belongings.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to follow important arrest procedures
Wider context from the report “(i) Whilst some officers carried out their tasks effectively and appropriately, overall important steps in the Deceased's husband's arrest and subsequent conditional pre-charge bail did not appear to have been followed .
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to follow conditional pre-charge bail procedures
Wider context from the report “(i) Whilst some officers carried out their tasks effectively and appropriately, overall important steps in the Deceased's husband's arrest and subsequent conditional pre-charge bail did not appear to have been followed .
” 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 Contact domestic-abuse victims after criminal interviews to discuss case status, proposed outcomes, bail conditions and investigation next steps.
Verbatim wording from the response “Nevertheless, reflective feedback has been provided to the individual Officer as well as to the wider Emerald Team in respect of the requirement for victim consultation regarding bail. To reassure you, a process is embedded across the force where upon the conclusion of the criminal interview, contact is made with the victims to discuss the status of the case, the proposed outcomes - including discussions regarding what bail conditions are appropriate (if bail is decided) - and next steps in the investigation. During these discussions, victims are encouraged to discuss any additional bail conditions they feel would be appropriate.” Source location Response from Bedfordshire 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 reflective feedback on victim consultation for bail conditions to the investigating officer and wider Emerald Team.
Verbatim wording from the response “Nevertheless, reflective feedback has been provided to the individual Officer as well as to the wider Emerald Team in respect of the requirement for victim consultation regarding bail. To reassure you, a process is embedded across the force where upon the conclusion of the criminal interview, contact is made with the victims to discuss the status of the case, the proposed outcomes - including discussions regarding what bail conditions are appropriate (if bail is decided) - and next steps in the investigation. During these discussions, victims are encouraged to discuss any additional bail conditions they feel would be appropriate.” Source location Response from Bedfordshire Police
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 delayed consultation was not considered materially capable of changing the bail decision given the safeguarding circumstances.
Verbatim wording from the response “I appreciate that on this occasion the investigating Officer overlooked the requirement for interaction with the victim regarding imposing bail conditions on her husband. This meant that engagement did not take place until after the bail conditions had been imposed. However, I believe the Officer and his supervisor felt bail was necessary due to serious safeguarding concerns and I cannot see that the consultation would have made a material impact on the decision in the circumstances as they presented on this occasion.” Source location Response from Bedfordshire Police
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 Existing procedures require victim engagement about bail conditions, including during evidence-led prosecutions, and are considered sufficient.
Verbatim wording from the response “Policing involves the identification, balance and mitigation or management of competing risks., a process that involves gathering information from multiple sources, including from victims. Having considered the concerns you raise, I am satisfied our force has necessary procedures in place to ensure victims of DA are involved in conversations regarding important decisions, such as police bail.” Source location Response from Bedfordshire Police
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.
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 Bedfordshire Police; 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 Bedfordshire Police; 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 Bedfordshire Police; 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
×
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 an annual schedule for continuing professional development of Firearms and Explosive Licensing Unit staff.
Verbatim wording from the response “Acknowledging a lack of nationally accredited training for Firearms Explosives Licensing Units, a review of our training has been conducted, with new role specific training currently being undertaken by all Firearms Explosives Licensing Unit staff. Continued professional development will be achieved through a planned annual training schedule, and we have purchased an external training package for all FELU staff dedicated to firearms licencing roles whilst a nationally accredited package is developed. Delegated decision maker authority is only given to those who have undertaken adequate training. Finally in January 2023 a full Change Team review of our Firearms and Explosive Licensing Unit commenced and is due to report in May.” Source location Response from Bedfordshire, Cambridgeshire and Hertfordshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver role-specific training to all Firearms and Explosive Licensing Unit staff.
Verbatim wording from the response “Acknowledging a lack of nationally accredited training for Firearms Explosives Licensing Units, a review of our training has been conducted, with new role specific training currently being undertaken by all Firearms Explosives Licensing Unit staff. Continued professional development will be achieved through a planned annual training schedule, and we have purchased an external training package for all FELU staff dedicated to firearms licencing roles whilst a nationally accredited package is developed. Delegated decision maker authority is only given to those who have undertaken adequate training. Finally in January 2023 a full Change Team review of our Firearms and Explosive Licensing Unit commenced and is due to report in May.” Source location Response from Bedfordshire, Cambridgeshire and Hertfordshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide an external firearms licensing training package for Firearms and Explosive Licensing Unit staff.
Verbatim wording from the response “Acknowledging a lack of nationally accredited training for Firearms Explosives Licensing Units, a review of our training has been conducted, with new role specific training currently being undertaken by all Firearms Explosives Licensing Unit staff. Continued professional development will be achieved through a planned annual training schedule, and we have purchased an external training package for all FELU staff dedicated to firearms licencing roles whilst a nationally accredited package is developed. Delegated decision maker authority is only given to those who have undertaken adequate training. Finally in January 2023 a full Change Team review of our Firearms and Explosive Licensing Unit commenced and is due to report in May.” Source location Response from Bedfordshire, Cambridgeshire and Hertfordshire Police
Open published response
16 Jan 2023 Sean DUIGNAN · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 5 Repeated failure of the armoury access-control system View source Lack of effective ongoing monitoring of the armoury access-control system View source Failure to communicate armoury access-system failures effectively View source Failure to restrict single-person armoury access View source Failure to keep the armoury override-key PIN confidential View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Work with ICT and JML to improve southern-base armoury hardware reliability and monitoring, tracking residual issues to resolution.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 January 2023. View source
Action
Control emergency armoury access through restricted code knowledge, two-officer confirmation, direct requests, and immediate code changes after use.
Stated completedThe respondent said that this action was complete when they made their response on 23 January 2023. View source
Action
Restrict single armoury access to authorised roles, communicate the restrictions, record them in procedures, and review access levels monthly.
Stated completedThe respondent said that this action was complete when they made their response on 23 January 2023. View source
Action
Record Chronicle access outages and operate an escalation process involving ICT and JML to monitor and resolve system failures.
Stated completedThe respondent said that this action was complete when they made their response on 23 January 2023. View source
Action
Implement a USB-related system fix to prevent associated armoury-access outages.
Stated completedThe respondent said that this action was complete when they made their response on 23 January 2023. View source
Action
Increase CCTV coverage across BCH armouries, monitor site connectivity, and improve officers', supervisors' and ICT staff's Chronicle knowledge.
Stated completedThe respondent said that this action was complete when they made their response on 23 January 2023. View source See 3 more actions
×
AI-generated summary
Sean DUIGNAN · 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
Sean DUIGNAN, a police sergeant, was found deceased at the Luton Airport policing unit after taking a handgun and ammunition from the armoury and shooting himself. The concerns included repeated failures of the armoury access system, inadequate monitoring, a universally known override PIN, and an incorrectly assigned single-access arrangement, which resulted in lax security and access to weapons.
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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Repeated failure of the armoury access-control system
Wider context from the report “There was a serious failure by senior management to effectively and safely manage the South Base Armoury. All the base officers who gave evidence before me told me the armoury system, which they referred to as Chronicle, repeatedly and randomly failed. These multiple failures were, according to ████████ not communicated effectively to her. She agreed that she did not herself make any further detailed enquiry instead relying on her Operational Inspector to manage the issue and/or to feed back as appropriate.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of effective ongoing monitoring of the armoury access-control system
Wider context from the report “The computerised system controlling the access to the armoury at South Base included a number of different parts including the server, the software, the Chronicle system itself, the card readers etc. The system as a whole repeatedly failed. There was no effective ongoing monitoring of the system. CI Rowley Smith agreed that the system did not work properly and the monitoring system did not work properly. As part of a fail safe to ensure that officers who needed weapons could obtain them if the computerised system failed, an armoury override key was kept in a locked box, secured by a PIN, in the equipment room. All officers giving evidence before me agreed that the PIN number was common knowledge.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate armoury access-system failures effectively
Wider context from the report “There was a serious failure by senior management to effectively and safely manage the South Base Armoury. All the base officers who gave evidence before me told me the armoury system, which they referred to as Chronicle, repeatedly and randomly failed. These multiple failures were, according to ████████ not communicated effectively to her. She agreed that she did not herself make any further detailed enquiry instead relying on her Operational Inspector to manage the issue and/or to feed back as appropriate.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict single-person armoury access
Wider context from the report “Sean, discovering his access to the override key was blocked asked one of the officers to second him into the armoury. By chance, it was ████████ who agreed and went with Sean to the armoury. She had been given single access by error following a Chronicle systems failure some time previously. Sean applied his armoury card to the reader and entered his PIN. It failed ████████ reasonably thought it was because Chronicle had failed again and used her card and PIN. Because she was allowed – incorrectly – single access, the door opened and she let Sean in where he retrieved a handgun and ammunition. Had ████████ any other officer at base known that Sean’s access had been restricted she would not, I am certain, have allowed him entry.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to keep the armoury override-key PIN confidential
Wider context from the report “The computerised system controlling the access to the armoury at South Base included a number of different parts including the server, the software, the Chronicle system itself, the card readers etc. The system as a whole repeatedly failed. There was no effective ongoing monitoring of the system. CI Rowley Smith agreed that the system did not work properly and the monitoring system did not work properly. As part of a fail safe to ensure that officers who needed weapons could obtain them if the computerised system failed, an armoury override key was kept in a locked box, secured by a PIN, in the equipment room. All officers giving evidence before me agreed that the PIN number was common knowledge.
” 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 Work with ICT and JML to improve southern-base armoury hardware reliability and monitoring, tracking residual issues to resolution.
Verbatim wording from the response “Whilst we do continue to have ICT challenges where officers are on occasion refused access to the armoury, we now have robust measures in place that ensure these are recorded, effectively managed, and follow an escalation process through to resolution. The backup armoury key safe code is only known to the Bedfordshire control room inspector and the Operations Superintendent, so whilst failures are frustrating for officers there is no risk to the public or workforce.” Source location Response from Bedfordshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Control emergency armoury access through restricted code knowledge, two-officer confirmation, direct requests, and immediate code changes after use.
Verbatim wording from the response “The access issue as detailed focused on single access as addressed in point 1 above. Access can also be granted via the emergency access function should either the door access fail or due to an overall power failure.” Source location Response from Bedfordshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Restrict single armoury access to authorised roles, communicate the restrictions, record them in procedures, and review access levels monthly.
Verbatim wording from the response “A review of armoury access was commissioned by the Operations Superintendent on 3 June 2021 which found that two officers within the unit had incorrect access, and this was rectified immediately. The IOPC report of 28 June 2021 also highlighted this (see appendix 1).” Source location Response from Bedfordshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record Chronicle access outages and operate an escalation process involving ICT and JML to monitor and resolve system failures.
Verbatim wording from the response “Following the death of Sgt Duignan, the access code for the emergency access at the southern base was reviewed and amended so that only the Force Incident Manager, stationed at Bedfordshire Police Headquarters, and the Superintendent of Specialist Operations were aware of the code. Any requirement for use would necessitate a request directly to the Force Incident Manager and confirmation of the presence of a second officer. Following use of the code, it would be changed immediately by the Superintendent or the Chief Superintendent in their absence. Since the introduction of the armoury access outage recording process on 11 November 2022 there have been 15 access issues identified.” Source location Response from Bedfordshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a USB-related system fix to prevent associated armoury-access outages.
Verbatim wording from the response “We have also introduced a specific escalation process should any difficulties be found in our use of Chronicle. This increases our ability to monitor the effective functioning of the systems and processes, including the escalation to ICT and JML. These have been reviewed, introduced and are now well-embedded across the unit to ensure that any impasses are easily identified and strictly monitored. As access failures referred to above identify, there are still problems with the computer hardware, specifically in relation to USB ports, these are being addressed by ICT and JML. A USB fix was implemented on the 24 February 2023, since that date there has been no related outages. Access failures do not result in any risk to the public or officers. Access to the armoury can be carried out via keys through the secure and managed process outlined above.” Source location Response from Bedfordshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase CCTV coverage across BCH armouries, monitor site connectivity, and improve officers', supervisors' and ICT staff's Chronicle knowledge.
Verbatim wording from the response “This escalation process was part of the work completed in conjunction with JML and BCH ICT following the inquest. This included:” Source location Response from Bedfordshire Police
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 Armoury access failures do not create a risk to the public or officers because secure key access remains available.
Verbatim wording from the response “We have also introduced a specific escalation process should any difficulties be found in our use of Chronicle. This increases our ability to monitor the effective functioning of the systems and processes, including the escalation to ICT and JML. These have been reviewed, introduced and are now well-embedded across the unit to ensure that any impasses are easily identified and strictly monitored. As access failures referred to above identify, there are still problems with the computer hardware, specifically in relation to USB ports, these are being addressed by ICT and JML. A USB fix was implemented on the 24 February 2023, since that date there has been no related outages. Access failures do not result in any risk to the public or officers. Access to the armoury can be carried out via keys through the secure and managed process outlined above.” Source location Response from Bedfordshire Police
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 Recorded access failures, escalation procedures and restricted backup key access are considered sufficient to manage armoury access problems.
Verbatim wording from the response “Whilst we do continue to have ICT challenges where officers are on occasion refused access to the armoury, we now have robust measures in place that ensure these are recorded, effectively managed, and follow an escalation process through to resolution. The backup armoury key safe code is only known to the Bedfordshire control room inspector and the Operations Superintendent, so whilst failures are frustrating for officers there is no risk to the public or workforce.” Source location Response from Bedfordshire Police
Open published response
4 Oct 2021 LEON BRIGGS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Failure of local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions View source Failure to provide continuous monitoring and risk assessment of detainees subject to restraint View source Insufficient training of police, ambulance crew and other front-line responders on medical emergencies and restraint risks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
LEON BRIGGS · 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
Leon Briggs was experiencing a psychotic disorder associated with exceptionally high amphetamine use when he was detained under section 136 of the Mental Health Act. Following restraint and conveyance to Luton Police station, he suffered cardiac arrest in the custody suite and later died in hospital. The principal concerns included poor communication, inappropriate restraint and use of force, inadequate medical assessment, unsatisfactory conveyance and supervision, and failures in risk assessment and monitoring that delayed recognition of his need for urgent medical attention.
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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions
Wider context from the report “1. Adequacy of the local S136 Multi-Agency Policy
Whilst the local S136 guidance has changed considerably since the death of Leon, in my view, it is still not fit for purpose for the following reasons:
(i) It requires streamlining and re-formatting (including the use of a larger font) to make it easier for all agencies to follow – it may assist to focus on multi-agency activities ONLY (leaving individual agencies to provide their own specific policies to support the multi-agency interaction)
(ii) Reference to other regulations might best be avoided (see for example 3.3) so that it can stand as freestanding guidance for those attending fast moving incidents to apply without delay ;
(iii) The guidance should closely follow the chronology of a relevant incident i.e. it should start with the decision to detain, followed by the relevant risk assessment, appropriate conveyance, place of safety etc. Information regarding permitted periods of detention and roles and responsibilities could be dealt with at the end.
N.B. Whilst it is reassuring to learn that a local ‘task and finish’ group has been set up within the Mental Health Crisis Concordat Strategic Group (MHCCG) to improve the current Policy and that reference is being made to College of Policing training packages, in effecting these improvements, the group might wish to consider engaging with a national expert in this field such as Inspector Michael Brown who provided expert evidence to the Inquest and has experience of effective mental health policy making.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuous monitoring and risk assessment of detainees subject to restraint
Wider context from the report “3. Adequacy of Monitoring of Detainees Subject to Restraint
The expert evidence of Dr ████████ (Consultant Intensivist). Professor ████████ (Consultant Cardiologist) and Dr ████████ (Forensic Pathologist) highlighted the effect that restraint has on detainees – not only in terms of the potential stress to the heart if the detainee struggles against such restraint but also in view of the continuing metabolic disturbance it creates which continues long after any restraint ceases or is removed. Indeed, they all agreed that metabolic disturbance from the restraint was one of the factors in causing Leon’s cardiac arrest and subsequent death. The evidence of Dr ████████ confirmed that the effects of the restraint would, however, have been treatable and that, if appropriate action had been taken, his cardiac arrest would likely have been avoided; indeed, he explained that even if action only had been taken at the point that Leon had become unconscious, the relatively simple steps of placing him in the recovery position in the cell and starting CPR, whilst awaiting emergency help, on the balance of probabilities, would have resulted in his survival.
The Jury through their answers to Questions 33-34 of the Jury Questionnaire not only determined that a failure to monitor Leon appropriately in the cell on 4 November 2013 more than minimally caused or contributed to his death but also concluded, in Box 3 of the Record of the Inquest, that “The inadequate continuous risk assessments and monitoring of Leon resulting in a failure to recognise when Leon became in need of urgent medical attention in the cell ” was one of the most serious failings by emergency services to provide Leon with adequate support.
Since the carrying out of even relatively basic first aid could have made a significant difference to the outcome in this case, it seems critical that the close monitoring of a detainee who has been subject to restraint should be guaranteed in all cases . As the Jury found there were specific failures by the Custody team in this case, consideration could perhaps be given to having additional monitoring in respect of such detainees independent of the Custody team.
The NHS England Patient Safety Alert (2015) gives guidance to NHS staff on post-restraint observations: https://www.england.nhs.uk/wp-content/uploads/2015/12/psa-vital-signs-restrictive-interventions-031115.pdf. Although this has been circulated to some police, it may not be widely known about and even though it may not cover all of the situations which the police will encounter in their work, something similar could be of potential benefit to all police forces across the country.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of police, ambulance crew and other front-line responders on medical emergencies and restraint risks
Wider context from the report “2. Lack of Sufficient Training for Police Officers, Ambulance Crew and other Front-Line Responders
Although, the MHCCG Strategic Group are progressing joint training for all first responders including hospital staff who might need to assess medical fitness and/or treat S136 detainees, it was clear from the evidence heard at the Inquest that there remains insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia . Consideration, therefore, needs to be given by National and Local Police and Ambulance services as to whether the current individual service training (including refresher training) is adequate (and of similar level to that provided to those working in Mental Health Units pursuant to the Mental Health Units (Use of Force) Act 2018) to ensure the welfare and safety of S136 detainees.
” 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 and sign off the revised local section 136 multi-agency policy.
Verbatim wording from the response “As you are aware from the evidence at the inquest, the policy which applied in 2013 had been superseded. The current policy is under a task and finish group. It was reviewed by the current National Lead for Mental Health, Deputy Chief Constable ████████, whose team stated they thought it was comprehensive. Additionally, officers met with partners on 13 October 2021 to review, update and confirm understanding, which took place with the benefit of the concerns you have identified. A revised policy is due to be signed-off this year. I will ask my legal services department to provide you with a final copy as soon as it has been signed off.” Source location 2021-0330-Response-from-Bedfordshire-Police_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Forward the signed-off revised multi-agency policy to the Coroner.
Verbatim wording from the response “As you are aware from the evidence at the inquest, the policy which applied in 2013 had been superseded. The current policy is under a task and finish group. It was reviewed by the current National Lead for Mental Health, Deputy Chief Constable ████████, whose team stated they thought it was comprehensive. Additionally, officers met with partners on 13 October 2021 to review, update and confirm understanding, which took place with the benefit of the concerns you have identified. A revised policy is due to be signed-off this year. I will ask my legal services department to provide you with a final copy as soon as it has been signed off.” Source location 2021-0330-Response-from-Bedfordshire-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A particular specialist level of additional detainee monitoring cannot be guaranteed in every case because circumstances and resources vary.
Verbatim wording from the response “I make clear that all officers involved in the provision of restraint and care to a detainee are required to monitor the detainee. That did not happen appropriately in Mr Briggs’ case. While we cannot guarantee a particular specialist level of additional monitoring in every case, due to the significant variety of circumstances and resourcing challenges, there is in the current training the concept of a ‘Safety Officer’, where possible a supervisor, who will not have a hands-on role in restraint of a detainee but will be observing them and looking for any signs of problems and can give advice to the officers performing restraint.” Source location 2021-0330-Response-from-Bedfordshire-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Medical assessments, monitoring and medical decisions should be led by ambulance staff and clinicians, not police officers.
Verbatim wording from the response “Significant learning came out of the Briggs Inquest and resulted in the local multi-agency Mental Health Hub being even more determined to form better working practices with our partner agencies. Despite good working relationships already, there are still challenges for front-line officers including medically-supervised transport; resourcing; making sure ambulance colleagues are leading medical assessments, monitoring and taking responsibility for medical situations brought to their attention; and ensuring there are routes into emergency departments.” Source location 2021-0330-Response-from-Bedfordshire-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police cannot undertake clinical vital-sign monitoring because officers are not trained or equipped for it.
Verbatim wording from the response “Bedfordshire Police highlighted, in light of your report, the ‘NHS Patient Safety Alert’ to the National Mental Health Lead. Their view was that this document reinforced the requirement for monitoring of ‘vital signs’ for patients post restraint. Monitoring of vital signs, as referred to in a clinical context, is not something officers are trained or equipped to do. However, officers do receive the modern training referred to above (including First Aid) and it was felt that a separate document adapting the” Source location 2021-0330-Response-from-Bedfordshire-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policing guidance and training are considered sufficient, so a separate document adapting the NHS Patient Safety Alert is unnecessary.
Verbatim wording from the response “The College of Policing has issued updated Authorised Professional Practice (APP), and provides ‘College Learn’ (formerly NCALT) with regards Officer Safety Training, First Aid and Mental Health Awareness. These packages have been updated significantly since 2013 to reflect learning with regards to awareness of Acute Behavioural Disturbance (ABD) and principles of detainee monitoring.” Source location 2021-0330-Response-from-Bedfordshire-Police_Published
Open published response
3 Jun 2019 David Bird · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Failure to explore potentially ironic or concerning detainee behaviour and demeanour View source Failure to formulate care plans that identify the need for pre-release health care assessment View source
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.
×
AI-generated summary
David Bird · 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
David Bird was arrested and held in police custody after concerns that he might take his own life, but was released without the medical assessment requested by police. He was found hanging in his bedroom on 21 August 2018. The principal concerns were the adequacy of custody officers’ training in interpreting detainee behaviour and in identifying when a detainee should see a healthcare practitioner before release.
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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to explore potentially ironic or concerning detainee behaviour and demeanour
Wider context from the report “(1) Adequacy of Training of Custody Officers in interpreting the behaviour/demeanour of detainees:
Although both Bedfordshire Police Custody Sergeants had received in their training (as evidenced by the Power-Point presentation exhibited as “EM02”) guidance on interpreting ‘Behaviour’ in the ABCDE of Vulnerability Assessments, both Sergeants had interpreted David’s response that he was ‘On Top of the World’ to the Question ‘How are you feeling?’ on being booked in, literally , - when, in fact, this might be interpreted as having an element of irony requiring further exploration ;
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate care plans that identify the need for pre-release health care assessment
Wider context from the report “(2) Adequacy of Training of Custody Officers in formulating a suitable care-plan for a detainee ; in particular, identifying the need in the Pre-Release Risk Assessment (PRRA) for Mr Bird to see a Health Care Practitioner (HCP) before release :
Although both Custody Sergeants had received in their training (as evidenced by the Power-Point presentation exhibited as “EM02”) guidance on formulating a Care-Plan and page 28 of that presentation gave the following example: “DP has been returned from interview from OIC, became tearful during interview and made comments that indicated possible self-harm risk on release. Obs level changed to L/30mins obs. PRRA considerations – DP to see HCP before release, DP has been told to see his GP about how he feels, he lives with his partner so there is someone at home to give support”, Mr Bird was released without a being seen by the HCP even though:
i. David had already been identified as a Vulnerable Adult (in term of a possible suicide risk) by Bedford Police on 18 August 2018 and a further concern for welfare had been raised in respect of him by Northamptonshire Police on 19 August 2018;
ii. He had been very tearful and distressed during his interview describing himself as ‘one with no home, no life, no job’.
iii. The IO and his colleague had requested a medical assessment for him prior to release 3 times
” Open source report
29 Oct 2018 KARL BRUNNER · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Defective and inappropriate mouth and face guards for high-risk suspects View source Lack of knowledge of choking risks during arrest or detention View source Failure to carry and use mouth and face guards in appropriate cases View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
KARL BRUNNER · 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
Karl Brunner died after choking on a package of drugs he swallowed while being arrested by police in Bedford on 11 May 2016. The report identified concerns that officers lacked knowledge of the risks of choking during arrest or detention and that the mouth and face guards provided to them were defective and inappropriate for high-risk suspects.
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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Defective and inappropriate mouth and face guards for high-risk suspects
Wider context from the report “Police Officers are provided with mouth and face guards which are so defective and inappropriate when dealing with high risk suspects who may have significant health issues that they are neither carried nor used in appropriate cases. This should be urgently addressed.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of choking risks during arrest or detention
Wider context from the report “The evidence before me showed that police officers were trained to deal with suspects who had swallowed drugs. The evidence however disclosed a complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained . This should urgently be addressed in the Officers’ training and the appropriate medical procedures should be adopted.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to carry and use mouth and face guards in appropriate cases
Wider context from the report “Police Officers are provided with mouth and face guards which are so defective and inappropriate when dealing with high risk suspects who may have significant health issues that they are neither carried nor used in appropriate cases . This should be urgently addressed.
” 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 Provide annual first-aid training, including choking management, to officers, special constables, detention officers and Police Community Support Officers.
Verbatim wording from the response “4. Across Bedfordshire, Cambridgeshire and Hertfordshire police forces all officers, special constables, detention officers and Police Community Support Officers receive First Aid training at least annually on a rolling programme. Student officers receive training more often as it is incorporated within their two year probationary period. Thus training is provided in accordance with the standards set down by the College of Policing, which remain under review.” Source location 2018-0310-Response-by-Bedfordshire-Police
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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 Give officers and custody staff instructions for managing detainees who place items in their mouths, swallow items or begin choking, including ambulance escalation and emergency life support.
Verbatim wording from the response “7. Officers and custody staff are given the following specific instructions in the event they are faced with a scenario similar to that which occurred during the detention of Mr Brunner. These are in line with the recommendations issued by the Independent Office for Police Conduct (“IOPC”) and state that:” Source location 2018-0310-Response-by-Bedfordshire-Police
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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 officers and students to use choking training aids and demonstrate front-position thrusts when rescuers cannot encircle a casualty.
Verbatim wording from the response “5. Included within the training is a module which deals specifically with persons who are choking. It sets out the appropriate manner in which a choking detainee should be managed, and specifically incorporates the comprehensive lesson plan produced by the College of Policing. In particular, this includes:” Source location 2018-0310-Response-by-Bedfordshire-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 Issue all officers personal Pocket Face Masks and instruct them in their correct use for mouth-to-mouth resuscitation.
Verbatim wording from the response “Mouth/face guards” Source location 2018-0310-Response-by-Bedfordshire-Police
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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 Regular choking training complies with IOPC recommendations and meets College of Policing standards.
Verbatim wording from the response “8. The regular training provided to all Bedfordshire Police officers complies with the recommendations of the IOPC and meets the standards set out by the College of Policing.” Source location 2018-0310-Response-by-Bedfordshire-Police
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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 personal Pocket Face Mask is adequate and appropriate for its required resuscitation use, alongside first-aid equipment in response vehicles.
Verbatim wording from the response “9. Prior to August 2016 all Bedfordshire Police officers were issued with a mouth/face guard which comprised a flat plastic sheet with either a hole or a piece of gauze in the middle which allowed the user to breathe into to give mouth to mouth resuscitation. Since August 2016, all officers are now issued with a personal Pocket Face Mask and instructed on its correct use in mouth to mouth resuscitation. The Personal Safety Team Leader for Bedfordshire, Cambridgeshire and Hertfordshire Police has stated that this piece of equipment is adequate and appropriate for its required use. In addition to the mouth/face guard issued to all officers during their training, all response vehicles contain first aid equipment.” Source location 2018-0310-Response-by-Bedfordshire-Police
Open published response
Concerns raised 3 Failure to retain proper records of decisions on operational ammunition View source Lack of a system ensuring alternative ammunition avoids excessive or unnecessary injury risks from bullet fragmentation View source Failure to treat NPCC/CAST ammunition recommendations as superseding previous recommendations 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
RICHARD THOMAS DAVIES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Thomas Davies was killed by a police firearms officer during an incident on 21 October 2015 after he threatened his children and fired a homemade firearm at armed police officers. The report raised concerns about the use of unbonded ammunition by the joint Bedfordshire, Cambridgeshire and Hertfordshire Armed Policing Unit, including the absence of safeguards against excessive injury from bullet fragmentation and inadequate records of ammunition decisions.
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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to retain proper records of decisions on operational ammunition
Wider context from the report “17. Accordingly, I am concerned that the Armed Policing Unit of Bedfordshire, Cambridgeshire and Hertfordshire police forces:
• Is or may be treating NPCC (previously ACPO)/CAST ammunition recommendations as not superseding previous recommendations contrary to the wording of those recommendations.
• Does not have in place a system to ensure that if NPCC/CAST recommendations on ammunition are not followed, the ammunition it adopts avoids the risk of excessive / unnecessary injury identified in the Nordic studies.
• Has not retained proper records of decisions made in respect of operational ammunition when it has decided in the past not to follow non-binding national guidance.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a system ensuring alternative ammunition avoids excessive or unnecessary injury risks from bullet fragmentation
Wider context from the report “17. Accordingly, I am concerned that the Armed Policing Unit of Bedfordshire, Cambridgeshire and Hertfordshire police forces:
• Is or may be treating NPCC (previously ACPO)/CAST ammunition recommendations as not superseding previous recommendations contrary to the wording of those recommendations.
• Does not have in place a system to ensure that if NPCC/CAST recommendations on ammunition are not followed, the ammunition it adopts avoids the risk of excessive / unnecessary injury identified in the Nordic studies.
• Has not retained proper records of decisions made in respect of operational ammunition when it has decided in the past not to follow non-binding national guidance.
” 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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to treat NPCC/CAST ammunition recommendations as superseding previous recommendations
Wider context from the report “17. Accordingly, I am concerned that the Armed Policing Unit of Bedfordshire, Cambridgeshire and Hertfordshire police forces:
• Is or may be treating NPCC (previously ACPO)/CAST ammunition recommendations as not superseding previous recommendations contrary to the wording of those recommendations.
• Does not have in place a system to ensure that if NPCC/CAST recommendations on ammunition are not followed, the ammunition it adopts avoids the risk of excessive / unnecessary injury identified in the Nordic studies.
• Has not retained proper records of decisions made in respect of operational ammunition when it has decided in the past not to follow non-binding national guidance.
” 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 Record ammunition-selection decisions and relevant circulars and correspondence in a central STRA electronic record.
Verbatim wording from the response “39. As a result of the inquest, an additional provision has been added to the BCH STRA (Appendix 10) to provide a central location for recording any decisions regarding the choice of ammunition and documents relevant to those decisions, including ACPO/NPCC circulars and any correspondence with CAST. The procedures outlined in this response (in particular paragraphs 24, 25, 32 to 34 and 38) are summarised in Appendix 10, a copy of which can be provided to the Coroner if required.” Source location 2017-0325-Response-by-Bedfordshire-Police
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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 Use 55-grain tactical bonded 5.56mm ammunition for all operational purposes instead of un-bonded ammunition.
Verbatim wording from the response “16. Following the most recent tender process in 2017, the BCH APU has, in conjunction with the Eastern Region Armed Policing area,¹¹ moved to using the 55 grain tactical bonded version of the 5.56 ammunition, as recommended in the May 2012 ACPO circular, for all operational purposes. The BCH APU is no longer using un-bonded 5.56mm 55 grain JSP ammunition operationally.” Source location 2017-0325-Response-by-Bedfordshire-Police
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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 Discuss national firearms circulars at quarterly Firearms Steering Group meetings, record discussions and decisions, and update the STRA action log where necessary.
Verbatim wording from the response “38. The STRA also includes an “action log” which is reviewed every three months at the FSG. If there are actions to be taken in response to a new circular, these will be discussed at the FSG and the STRA action log updated accordingly.” Source location 2017-0325-Response-by-Bedfordshire-Police
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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 APU relies on NPCC and CAST to disseminate ammunition-evaluation guidance and clarify whether new recommendations supersede earlier ones.
Verbatim wording from the response “45. The BCH APU is reliant on the NPCC and/or CAST to disseminate to local forces any guidance they produce on the evaluation of ammunition, and making clear whether any recommendations supersede or are to be read in conjunction with previous recommendations. All national circulars are now kept on the “POLKA” system, which is accessible to firearms departments throughout the country.” Source location 2017-0325-Response-by-Bedfordshire-Police
Open published response
9 Feb 2016 Eitvydas ZDANYS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1 Lack of basic life support training for Police Officers expected to act as first responders 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
Eitvydas ZDANYS · 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
Eitvydas ZDANYS, aged 19, died at the scene on 2 August 2015 after a motorcycle collision while intoxicated and carrying a pillion passenger. The report raised concerns that attending police officers were unable to assess his serious injuries or commence potentially life-saving resuscitation, although it concluded that the delay did not contribute to his death.
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 Bedfordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of basic life support training for Police Officers expected to act as first responders
Wider context from the report “During the course of the Investigation my attention was drawn to the video footage from the Officers who originally attended this road traffic incident. It would appear that these Officers were unable to assess a seriously injured motorcyclist and were unable to commence what could have been life-saving resuscitation . There perhaps needs to be a review of the training of all Police Officers to ensure that they have all received training in basic life support if they are at any time expected to take on the role of ‘first responder’ . One of the Officers who investigated the collision was of the opinion “….CPR should have been administered at a much earlier stage……” I am satisfied that the delay in attending to the deceased did not in any way contribute to his death.
” 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 Remind all officers during annual refresher training when it is necessary and appropriate to commence CPR.
Verbatim wording from the response “The abovementioned officers will shortly receive training on when and how to administer CPR so that they are better equipped to make the right decisions should such an emergency decision arise in the future. Furthermore all officers will be reminded during their annual refresher training of when it is necessary and appropriate to commence CPR.” Source location E-Zdanys-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 the two officers with training on when and how to administer CPR.
Verbatim wording from the response “The abovementioned officers will shortly receive training on when and how to administer CPR so that they are better equipped to make the right decisions should such an emergency decision arise in the future. Furthermore all officers will be reminded during their annual refresher training of when it is necessary and appropriate to commence CPR.” Source location E-Zdanys-Response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations