15 Apr 2026 Lisa Marie Elizabeth Beatrice TAYLOR-PENNY · Prevention of Future Deaths report Cheshire
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Concerns raised 1 Failure to provide sufficient scope for call handlers to escalate RCRP calls for senior professional judgment 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
Lisa Marie Elizabeth Beatrice TAYLOR-PENNY · 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
Lisa Marie Elizabeth Beatrice Taylor-Penny was found deceased at home on 11 July 2025 after carers and social workers spent nearly seven hours trying to obtain emergency assistance to enter the property. The principal concern was that the rigid implementation of “Right care right person” did not provide sufficient scope for call handlers to escalate requests for senior professional judgment, including where other professionals expressed concern for life and limb and requested police attendance.
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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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient scope for call handlers to escalate RCRP calls for senior professional judgment
Wider context from the report “"Right care right person" (RCRP) is being implemented in a very rigid manner suggesting that call handlers may be using it as "tramlines not guidelines" .
I am concerned that it does not leave sufficient scope for call handlers to escalate calls for a senior member of staff to consider exercising professional judgment . In particular, where other professionals who are familiar with RCRP are nevertheless indicating a professional view that they need police attendance to secure entry and are expressing a concern for life and limb.
” 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 Conduct live and retrospective quality assurance of concern-for-safety incidents, provide feedback and arrange further development where required.
Verbatim wording from the response “Quality assurance is undertaken by the RCRP project and implementation team conducting live QA of incidents as they occur to ensure consistent application of RCRP in line with training. Direct feedback is given to FCC call handlers, and they can discuss decisions with the QA team as well as the FCC Supervisors. At the commencement of RCRP the FCC call handlers were all supported by RCRP subject matter experts (SME’s) and professionals from the mental health charity MIND who floor walked to assist call handlers become familiar with using the toolkits.” Source location Response from Cheshire Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train FCC staff, supervisors, managers and wider force personnel in RCRP law, procedures, toolkits, escalation and professional judgment.
Verbatim wording from the response “This is supported by a policy document that explains the legal and statutory obligations, as well as the context and considerations that underpin Right Care Right Person implementation in Cheshire. Every member of staff in the FCC received detailed training in the law, the process and the application of RCRP prior to implementation. This included all Force Incident Sergeants (“FIS”), Force Incident Managers (“FIM”), FCC Supervisors and the Senior leadership team. Wider engagement and training were rolled out within the force to all departments. The training and supporting documents have also been shared with partner agencies to assist their own training and approach to RCRP (RCRP Legal and Escalation slides attached as Appendix three).” Source location Response from Cheshire 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 supervisor and Force Incident Manager escalation process for disputed, uncertain or exceptional deployment decisions.
Verbatim wording from the response “3. Caller insists on deployment (after no deployment decision reached) and the matter thus requires escalation to a supervisor for review.” Source location Response from Cheshire 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 Employ trained RCRP floorwalkers and subject-matter support staff to assist call handlers during implementation and operational rollout.
Verbatim wording from the response “During go live and throughout 2024 RCRP floorwalkers were employed to support staff in making decisions and answering questions. This was via experienced staff who received additional training and were selected for their knowledge of law and procedure and their ability to consistently apply RCRP to reported incidents. This was complemented by the FCC Supervisors on duty, and the RCRP project team who worked alongside staff in FCC Calls room. The training is as follows:” Source location Response from Cheshire 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 RCRP toolkits, structured questions, training and escalation procedures provide consistent decision-making and adequate review where deployment decisions are disputed.
Verbatim wording from the response “Whilst the RCRP process involves individual decision making, the toolkits and procedures ensure consistency and sound decision making to avoid differing interpretations of policy. The policy reflects decisions being made based on the information provided rather than decisions made based on who is providing the information.” Source location Response from Cheshire Police
Open published response
14 Sep 2025 Charlotte Tetley · Prevention of Future Deaths report Cheshire
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Concerns raised 2 Failure to deploy police resources for high-risk missing persons unless they have expressed an intention to end life View source Unavailability of ambulance response for missing persons whose whereabouts are unknown View source
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. 7
Action
Establish supervisor and Force Incident Manager reviews, including override and partner-requested mutual-aid escalation routes for disputed or uncertain deployment decisions.
Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Deliver RCRP legal, procedural and toolkit training to FCC staff, supervisors, incident managers and wider force personnel.
Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Implement RCRP decision-support toolkits, standard questions, digital recording and escalation scripts for concern-for-safety calls.
Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Operate live quality assurance of concern-for-safety incidents, with feedback, supervisory learning and further development sessions where required.
Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Provide RCRP training materials and communications to partner agencies to support their education, awareness and use of the escalation process.
Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Deploy trained RCRP floorwalkers and subject-matter experts to support call handlers during implementation and operational use.
Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source
Action
Revise the Missing From Home policy to align with RCRP and require consideration of known location, reasonable enquiries and expressed concerns.
Stated completedThe respondent said that this action was complete when they made their response on 19 September 2025. View source See 4 more actions
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AI-generated summary
Charlotte Tetley · 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
Charlotte Tetley died on 24 September 2024 after deliberately sitting on railway tracks and being struck by a train. The report describes concerns about the police and ambulance response after she left hospital on 18 September 2024 despite reported suicidal feelings and professional concerns about her immediate safety. It also identifies concerns about the application of missing-person response policy when the person’s whereabouts are unknown.
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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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to deploy police resources for high-risk missing persons unless they have expressed an intention to end life
Wider context from the report “That despite Ms Tetley being found on train tracks on the 18 September 2024, and reporting to workers who found her that she felt suicidal, the police would respond when she absconded from the Accident and Emergency Department the same day. When the Clinical Lead of Psychiatry Liaison escalated the matter and expressed concern of an immediate risk for safety given her extensive medical history, and her lack of engagement in the department that day, she was informed that as Ms Tetley had not expressed an intention to end her life before leaving the department, it could not be known that it was her intention to end life. The police informed the Clinical Lead to contact the ambulance response vehicle. When she did this, they declined to respond as they were unaware of Ms Tetley’s whereabouts.
I am concerned that if a very narrow interpretation of policy is applied by the police when professionals report a concern for a high risk missing person in circumstances where they consider there to be an immediate risk to life , there will be a risk of future deaths occurring. If the policy is interpreted such that police resources will only be deployed if the missing person has expressed an intention to end life as they leave the hospital , there is a risk that future deaths will occur. It is unlikely that the ambulance response vehicle will be deployed if the whereabouts of the missing person is unknown, which will result in the missing person not being able to receive medical attention until their whereabouts are known. By the time that they are located, there is a risk that they will no longer be alive.
” 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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ambulance response for missing persons whose whereabouts are unknown
Wider context from the report “That despite Ms Tetley being found on train tracks on the 18 September 2024, and reporting to workers who found her that she felt suicidal, the police would respond when she absconded from the Accident and Emergency Department the same day. When the Clinical Lead of Psychiatry Liaison escalated the matter and expressed concern of an immediate risk for safety given her extensive medical history, and her lack of engagement in the department that day, she was informed that as Ms Tetley had not expressed an intention to end her life before leaving the department, it could not be known that it was her intention to end life. The police informed the Clinical Lead to contact the ambulance response vehicle. When she did this, they declined to respond as they were unaware of Ms Tetley’s whereabouts.
I am concerned that if a very narrow interpretation of policy is applied by the police when professionals report a concern for a high risk missing person in circumstances where they consider there to be an immediate risk to life, there will be a risk of future deaths occurring. If the policy is interpreted such that police resources will only be deployed if the missing person has expressed an intention to end life as they leave the hospital, there is a risk that future deaths will occur. It is unlikely that the ambulance response vehicle will be deployed if the whereabouts of the missing person is unknown, which will result in the missing person not being able to receive medical attention until their whereabouts are known. By the time that they are located, there is a risk that they will no longer be alive.
” 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 Establish supervisor and Force Incident Manager reviews, including override and partner-requested mutual-aid escalation routes for disputed or uncertain deployment decisions.
Verbatim wording from the response “3. Caller insists on deployment (after no deployment decision reached) and the matter thus requires escalation to a Supervisor for review.” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver RCRP legal, procedural and toolkit training to FCC staff, supervisors, incident managers and wider force personnel.
Verbatim wording from the response “This is supported by a policy document that explains the legal and statutory obligations, as well as the context and considerations that underpin Right Care Right Person implementation in Cheshire. Every member of staff in the FCC received detailed training in the law, the process and the application of RCRP prior to implementation. This included all Force Incident Sergeants (“FIS”), Force Incident Managers (“FIM”), FCC Supervisors and the Senior leadership team. Wider engagement and training was rolled out within the force to all departments. The training and supporting documents have also been shared with partner agencies to assist their own training and approach to RCRP (RCRP Legal and Escalation slides attached as Appendix Four).” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement RCRP decision-support toolkits, standard questions, digital recording and escalation scripts for concern-for-safety calls.
Verbatim wording from the response “• Phase 1 launched on 8th January 2024 and focussed on ‘Concern for Safety’. This introduced a toolkit regarding general concern for welfare calls that Cheshire Police receive from the public and partners.” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate live quality assurance of concern-for-safety incidents, with feedback, supervisory learning and further development sessions where required.
Verbatim wording from the response “Quality assurance is undertaken by the RCRP project and implementation team conducting live QA of incidents as they occur to ensure consistent application of RCRP in line with training. Direct feedback is given” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide RCRP training materials and communications to partner agencies to support their education, awareness and use of the escalation process.
Verbatim wording from the response “This is supported by a policy document that explains the legal and statutory obligations, as well as the context and considerations that underpin Right Care Right Person implementation in Cheshire. Every member of staff in the FCC received detailed training in the law, the process and the application of RCRP prior to implementation. This included all Force Incident Sergeants (“FIS”), Force Incident Managers (“FIM”), FCC Supervisors and the Senior leadership team. Wider engagement and training was rolled out within the force to all departments. The training and supporting documents have also been shared with partner agencies to assist their own training and approach to RCRP (RCRP Legal and Escalation slides attached as Appendix Four).” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy trained RCRP floorwalkers and subject-matter experts to support call handlers during implementation and operational use.
Verbatim wording from the response “During go live and throughout 2024 RCRP floorwalkers were employed to support staff in making decisions and answering questions. This was via experienced staff who received additional training and were selected for their knowledge of law and procedure and their ability to consistently apply RCRP to reported incidents. This was complemented by the FCC Supervisors on duty, and the RCRP project team who worked alongside staff in FCC Calls room. The training is as follows:” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Missing From Home policy to align with RCRP and require consideration of known location, reasonable enquiries and expressed concerns.
Verbatim wording from the response “Cheshire Police revised the Missing From Home (MFH) policy to ensure it was aligned with the introduction of Right Care Right Person. This sets three aspects for consideration if someone is missing. These three considerations were included in part of the training all FCC staff received prior to the introduction of RCRP. They are:-” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ambulance deployment policy is determined by North West Ambulance Service, and its application cannot be commented on by the police.
Verbatim wording from the response “There are established and published protocols by North West Ambulance Service (NWAS) regarding their deployment policy, which are designed to ensure the safe and effective use of emergency resources. These protocols are based on clinical prioritisation and operational feasibility. We are unable to comment on NWAS policy but are aware that ambulances are unlikely to be deployed where the whereabouts of the individual is unknown for obvious reasons.” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police deployment is not limited to cases involving an expressed intention to end life; deployment occurs where a real and immediate risk is identified.
Verbatim wording from the response “To reassure, it is not the case that police will only deploy if an expression to end life is made on leaving the hospital. In the case referred to, there was no such expression at all on the evidence available but in general terms, the assessment is detailed but there must be real and immediate risk to life or a serious risk of harm (ie present, continuing and happening now).” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation RCRP training, toolkits, procedures and escalation processes provide a sufficient framework for consistent risk assessment and police deployment decisions.
Verbatim wording from the response “Whilst the RCRP process involves individual decision making, the toolkits and procedures ensure consistency and sound decision making to avoid differing interpretations of policy.” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hospital procedures for patients leaving healthcare settings provide sufficient arrangements for making enquiries and resolving concerns before requesting police assistance.
Verbatim wording from the response “In this case, the RCRP policy was correctly applied and appropriate advice given. The hospital have clear processes and procedures in place when patients simply walk out of hospital. Having made further enquiries, the hospital called back to confirm the matter was resolved.” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hospitals should undertake reasonable enquiries and use their available avenues to establish a missing patient's whereabouts before requesting police assistance.
Verbatim wording from the response “In this case, there were enquiries the hospital could and should undertake. Indeed, the Royal College of Emergency Departments publication “The Patient who Absconds” (2020) process makes that clear. In the case of incidents of this type, we would reasonably expect that the professionals calling would have made suitable checks with relevant teams and gathered information before contacting police. They would also utilise appropriate avenues at their disposal.” Source location Response from Cheshire Constabulary
Open published response
Concerns raised 3 Delays in delivering required control-room training and actions View source Unclear control-room methodology for adding vehicles to the ANPR/Vehicle Finder System View source Failure to require and confirm officer acknowledgement and action on reports 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
Carl Anthony Butler and Sean Brett · 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 26 February 2022, Carl Anthony Butler drove the wrong way along the A55 while intoxicated and collided with Sean Brett’s vehicle, resulting in both men’s deaths. Concerns were raised about the handling and acknowledgement of reports by Cheshire Constabulary, processes for adding vehicles to the ANPR/Vehicle Finder System, and delays in providing relevant training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Delays in delivering required control-room training and actions
Wider context from the report “2. There was also confusion within the control room as to the methodology by which a vehicle could be added to an ANPR/Vehicle Finder System, and although an IOPC investigation was finalised in February 2023 which identified potential learning for the force in respect of ensuring control room staff understand the appropriate processes, evidence was heard at the inquest that a witness had not received this training until December 2024 due to a lack of time being made available to her to undertake the same . (Where learning identifies required training/actions, any delays in delivering this, can only serve to perpetuate the risks which such training/actions is aimed at mitigating .)
” 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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Unclear control-room methodology for adding vehicles to the ANPR/Vehicle Finder System
Wider context from the report “2. There was also confusion within the control room as to the methodology by which a vehicle could be added to an ANPR/Vehicle Finder System , and although an IOPC investigation was finalised in February 2023 which identified potential learning for the force in respect of ensuring control room staff understand the appropriate processes, evidence was heard at the inquest that a witness had not received this training until December 2024 due to a lack of time being made available to her to undertake the same. (Where learning identifies required training/actions, any delays in delivering this, can only serve to perpetuate the risks which such training/actions is aimed at mitigating.)
” 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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to require and confirm officer acknowledgement and action on reports
Wider context from the report “1. There was a confused picture of the management of the reports and information being handled by Cheshire Police insofar as a request for observations would be put out to officers by a communications operator, however there was no requirement for any officer to acknowledge that they had received such a request and therefore no means by which it could be confirmed that any actions were being undertaken as a result of the reports which had been received .
” 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 Issue new guidance requiring communications operators and operational officers to confirm patrol responses, record deployment details, escalate unavailable patrols, and end ‘nothing heard’ responses.
Verbatim wording from the response “Cheshire Constabulary has reviewed the way in which reports of dangerous driving / drivers are processed. As part of that change, all communications operators who work within the resource deployment centre (RDC) and all operational officers will receive new guidance as a direct result of the learning from investigation into the deaths of Mr Butler and Mr Brett on 26th February 2022:” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require communications operators to repeat refresher training through ongoing professional development.
Verbatim wording from the response “All communications operators who currently work within the resource deployment centre have attended a specific course which includes ANPR, Hotlist (Cleartone) and Vehicle Finder. There is also ongoing continued professional development plan in which all operators (including call taking function) will be required to repeat refresher training. Additional support will be provided by the ANPR coordinator.” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional support from the ANPR coordinator to communications operators.
Verbatim wording from the response “All communications operators who currently work within the resource deployment centre have attended a specific course which includes ANPR, Hotlist (Cleartone) and Vehicle Finder. There is also ongoing continued professional development plan in which all operators (including call taking function) will be required to repeat refresher training. Additional support will be provided by the ANPR coordinator.” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure all resource deployment centre communications operators complete training covering ANPR, Hotlist and Vehicle Finder processes.
Verbatim wording from the response “In court, communications operator Natalia Komorowska stated that she had not received her training until December 2024. Natalia has clarified that she was referring to refresher training and Constabulary training records show that she had received her initial training in March 2021, and she was confirmed as being a competent deployment operator in October 2021. In December 2024 Natalia received a refresher of the foundation and dispatcher NCALTS training.” Source location Response from Cheshire Constabulary
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The operator had received initial training in March 2021; the December 2024 training was refresher training, not initial training.
Verbatim wording from the response “In court, communications operator Natalia Komorowska stated that she had not received her training until December 2024. Natalia has clarified that she was referring to refresher training and Constabulary training records show that she had received her initial training in March 2021, and she was confirmed as being a competent deployment operator in October 2021. In December 2024 Natalia received a refresher of the foundation and dispatcher NCALTS training.” Source location Response from Cheshire Constabulary
Open published response
8 Dec 2023 Claire Nicole Briggs · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses View source Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service 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
Claire Nicole 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
Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.
” 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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses .
” 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 Sign and endorse the revised joint operating protocol.
Verbatim wording from the response “1. Cheshire Constabulary has been in liaison with NWAS and throughout the development of the JOP has been supportive and keen to move this forward.” Source location Response from Cheshire Constabulary
Open published response
6 Oct 2023 John George CONDRON · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of agreed timescales for informing suspects of police decisions to take no further action 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
John George CONDRON · 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
John George Condron was found dead at his home on 2 November 2017, suspended from loft roof beams by a rope ligature. He was under police investigation and had not been informed that no further action had been decided in relation to the most serious allegation, which the report states exacerbated the extreme anxiety and stress he was experiencing. The principal concern was the absence of an agreed timescale or protocol for informing suspects of such decisions, with concern that further self-inflicted deaths could occur as a result.
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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed timescales for informing suspects of police decisions to take no further action
Wider context from the report “(1) I received evidence confirming the absence of any agreed protocol relating to timescales for a suspect to be informed by the police of a decision to take no further action in respect of allegations made against them . At the conclusion of the Inquest, it was confirmed that this was the position both at the time of Mr Condron’s death in November 2017 and at the conclusion of the Inquest in September 2023.
(2) I received evidence that at a National Level, the Victim’s Code of Practice provides that a victim has a right to be informed of key decisions in an investigation within 5 working days, or within 1 working day if they are eligible for Enhanced Rights. This includes a decision by the police to take no further action in respect of the allegations they have made. There is no such code of practice in respect of informing suspects of the same .
(3) I have concerns that further self-inflicted deaths will occur in circumstances where a suspect is not informed, within a specified time period, of a decision to take no further action in respect of allegations made against them .
” 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 Update the Suspect Policy and Procedure to require suspects to be informed of no-further-action decisions within 48 hours and record notification on the OEL.
Verbatim wording from the response “The Constabulary has now reviewed the existing Suspect Policy and Procedure, that was originally introduced in August 2023 (in order to address the management of suspects in line with Force Crime Investigation Policy and Authorised Professional Practice), and the policy now specifies:” Source location Response from Cheshire Constabulary
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to condition firearms licensing delegation on adequate training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training .
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training .
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of a mandatory requirement for role-specific firearms licensing training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training . I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular .
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff ;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
12 Aug 2022 Brandon James Pryde and David Ernest Faulkner · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to verify transfer of Command and Control between police supervisors View source Failure of GMP Force Duty Supervisors to recognise their authority to perform Command and Control on the motorway network View source Failure of the Command and Control protocol to operate effectively throughout pursuits View source Failure to communicate clearly whether Command and Control has been taken View source See 1 more concern
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
Brandon James Pryde and David Ernest Faulkner · 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
Brandon Pryde and David Faulkner died at the scene after a stolen BMW, driven by Brandon Pryde, travelled against the flow of traffic on the M60 and collided with David Faulkner’s vehicle at high speed. Concerns arose that the protocol for transferring command and control of police pursuits between GMP and NWMPG did not operate in practice, resulting in no effective command and control during the pursuit.
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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to verify transfer of Command and Control between police supervisors
Wider context from the report “I received evidence in both inquests that there is a Protocol between GMP and NWMPG (which is based at the Cheshire Constabulary) dated June 2015 in accordance with the College of Police Authorised Professional Practice for Police Pursuits, for the Command and Control of pursuits. That Protocol is intended to provide a mechanism for Command and Control to be undertaken and transferred between GMP and NWMPG when pursuits move between the normal road network and the motorway network, so that Command and Control is maintained throughout. The Supervising Officer in the control room has the authority to direct that a pursuit be discontinued if they assess that it is right to do so, having regard to all of the circumstances which are known to them, which may include information not immediately available to the police officer(s) involved in the pursuit.
Although I found that the absence of any control-room Command and Control had not contributed to either death in this case, the following matters gave rise to concern, having regard to the inherent risk of pursuits, which are likely to move between ordinary road and motorway networks in the Greater Manchester area;
(1) The GMP Force Duty Supervisor assumed that the NWMPG Supervisor had taken Command and Control when they had not done so ;
(2) The NWMPG Supervisor did not communicate whether they had taken Command and Control clearly;
(3) The GMP Force Duty Supervisor did not consider that they had any authority to perform Command and Control of the pursuit once it had entered the motorway network; and
(4) The Protocol did not operate in practice so that there was no effective Command and Control at any point during the pursuit.
” 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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure of GMP Force Duty Supervisors to recognise their authority to perform Command and Control on the motorway network
Wider context from the report “I received evidence in both inquests that there is a Protocol between GMP and NWMPG (which is based at the Cheshire Constabulary) dated June 2015 in accordance with the College of Police Authorised Professional Practice for Police Pursuits, for the Command and Control of pursuits. That Protocol is intended to provide a mechanism for Command and Control to be undertaken and transferred between GMP and NWMPG when pursuits move between the normal road network and the motorway network, so that Command and Control is maintained throughout. The Supervising Officer in the control room has the authority to direct that a pursuit be discontinued if they assess that it is right to do so, having regard to all of the circumstances which are known to them, which may include information not immediately available to the police officer(s) involved in the pursuit.
Although I found that the absence of any control-room Command and Control had not contributed to either death in this case, the following matters gave rise to concern, having regard to the inherent risk of pursuits, which are likely to move between ordinary road and motorway networks in the Greater Manchester area;
(1) The GMP Force Duty Supervisor assumed that the NWMPG Supervisor had taken Command and Control when they had not done so;
(2) The NWMPG Supervisor did not communicate whether they had taken Command and Control clearly;
(3) The GMP Force Duty Supervisor did not consider that they had any authority to perform Command and Control of the pursuit once it had entered the motorway network ; and
(4) The Protocol did not operate in practice so that there was no effective Command and Control at any point during the pursuit.
” 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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure of the Command and Control protocol to operate effectively throughout pursuits
Wider context from the report “I received evidence in both inquests that there is a Protocol between GMP and NWMPG (which is based at the Cheshire Constabulary) dated June 2015 in accordance with the College of Police Authorised Professional Practice for Police Pursuits, for the Command and Control of pursuits. That Protocol is intended to provide a mechanism for Command and Control to be undertaken and transferred between GMP and NWMPG when pursuits move between the normal road network and the motorway network, so that Command and Control is maintained throughout. The Supervising Officer in the control room has the authority to direct that a pursuit be discontinued if they assess that it is right to do so, having regard to all of the circumstances which are known to them, which may include information not immediately available to the police officer(s) involved in the pursuit.
Although I found that the absence of any control-room Command and Control had not contributed to either death in this case, the following matters gave rise to concern, having regard to the inherent risk of pursuits, which are likely to move between ordinary road and motorway networks in the Greater Manchester area;
(1) The GMP Force Duty Supervisor assumed that the NWMPG Supervisor had taken Command and Control when they had not done so;
(2) The NWMPG Supervisor did not communicate whether they had taken Command and Control clearly;
(3) The GMP Force Duty Supervisor did not consider that they had any authority to perform Command and Control of the pursuit once it had entered the motorway network; and
(4) The Protocol did not operate in practice so that there was no effective Command and Control at any point during the pursuit .
” 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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate clearly whether Command and Control has been taken
Wider context from the report “I received evidence in both inquests that there is a Protocol between GMP and NWMPG (which is based at the Cheshire Constabulary) dated June 2015 in accordance with the College of Police Authorised Professional Practice for Police Pursuits, for the Command and Control of pursuits. That Protocol is intended to provide a mechanism for Command and Control to be undertaken and transferred between GMP and NWMPG when pursuits move between the normal road network and the motorway network, so that Command and Control is maintained throughout. The Supervising Officer in the control room has the authority to direct that a pursuit be discontinued if they assess that it is right to do so, having regard to all of the circumstances which are known to them, which may include information not immediately available to the police officer(s) involved in the pursuit.
Although I found that the absence of any control-room Command and Control had not contributed to either death in this case, the following matters gave rise to concern, having regard to the inherent risk of pursuits, which are likely to move between ordinary road and motorway networks in the Greater Manchester area;
(1) The GMP Force Duty Supervisor assumed that the NWMPG Supervisor had taken Command and Control when they had not done so;
(2) The NWMPG Supervisor did not communicate whether they had taken Command and Control clearly ;
(3) The GMP Force Duty Supervisor did not consider that they had any authority to perform Command and Control of the pursuit once it had entered the motorway network; and
(4) The Protocol did not operate in practice so that there was no effective Command and Control at any point during the pursuit.
” Open source report
14 Aug 2019 Gladys Esme FURNIVAL (known as Esme FURNIVAL) · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 2 Lack of provision to provide updates to other emergency services during significant ambulance delays View source Lack of provision to utilise other emergency services during significant ambulance delays 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
Gladys Esme FURNIVAL (known as Esme FURNIVAL) · 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
Esme Furnival had an unwitnessed fall at her sheltered accommodation on 8 July 2018 and was suspended by the waist cord of her dressing gown. Although emergency services were called, an ambulance arrived after a significant delay, and the report raised concern that other emergency services were not used to assist when there were no eyes on the ground.
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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of provision to provide updates to other emergency services during significant ambulance delays
Wider context from the report “When the ambulance service is faced with significant delays in circumstances where there are no eye’s on the ground, there was no provision to utilise the other emergency services to assist in its place or to provide an update to them .
” 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 Cheshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of provision to utilise other emergency services during significant ambulance delays
Wider context from the report “When the ambulance service is faced with significant delays in circumstances where there are no eye’s on the ground, there was no provision to utilise the other emergency services to assist in its place or to provide an update to them.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations