30 Mar 2026 Grant Nicholas LOWRY · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 8 Failure to communicate accurate heat-source information to the family View source Failure to accurately record search locations and outcomes View source Delays in requesting Polsa Mutual Aid View source Unavailability of a full set of operational PPE for night searches View source Lack of liaison between officers during searches View source Failure to heed identified heat-source details View source Delays in requesting specialist search resources View source Failure to maintain charged batteries for search equipment and work mobile phones View source See 5 more concerns
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
Grant Nicholas LOWRY · 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
Grant Nicholas LOWRY left home on 1 June 2022 after sending a text indicating suicidal intent and was found deceased in the early hours of 3 June 2022 following an uncoordinated search. Concerns included inaccurate and incomplete recording of search information, communication failures, delayed requests for additional search resources, and inadequate operational equipment for one officer. The inquest found that missed opportunities in mental health care and the search deficiencies contributed to the circumstances surrounding 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate accurate heat-source information to the family
Wider context from the report “There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include:
1. The location of the first NPAS heat source was not recorded accurately.
2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.
7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces.
8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit.
In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record search locations and outcomes
Wider context from the report “There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include:
1. The location of the first NPAS heat source was not recorded accurately.
2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around ████████ had been searched , which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.
7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces.
8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit.
In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Delays in requesting Polsa Mutual Aid
Wider context from the report “There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include:
1. The location of the first NPAS heat source was not recorded accurately.
2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.
7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces.
8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit.
In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a full set of operational PPE for night searches
Wider context from the report “There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include:
1. The location of the first NPAS heat source was not recorded accurately.
2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.
7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces.
8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit.
In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area . The batteries on his torch and work mobile phone were flat.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Lack of liaison between officers during searches
Wider context from the report “There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include:
1. The location of the first NPAS heat source was not recorded accurately.
2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.
7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces.
8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit.
In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Failure to heed identified heat-source details
Wider context from the report “There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include:
1. The location of the first NPAS heat source was not recorded accurately.
2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded , whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.
7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces.
8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit.
In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Delays in requesting specialist search resources
Wider context from the report “There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include:
1. The location of the first NPAS heat source was not recorded accurately.
2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.
7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces.
8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit.
In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain charged batteries for search equipment and work mobile phones
Wider context from the report “There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include:
1. The location of the first NPAS heat source was not recorded accurately.
2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area.
3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded.
4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search.
5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas.
6. The family were told that no heat sources had been identified by NPAS.
7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces.
8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit.
In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat.
” 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 Amend the Silver Commander rota to provide shift-based supervisory leadership during evening and heightened-demand periods for high-risk missing-person incidents.
Verbatim wording from the response “Additional supervision has also been increased with explicit scrutiny of high-risk missing persons investigations by senior officers (Silver Commanders):” Source location Response from Cleveland 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 Promote the PolSA role and provide search-resource awareness through PolSA training and Mountain Rescue input for Licensed Search Officers.
Verbatim wording from the response “Promotion of the PolSA role was undertaken in 2022 and 2023 to raise awareness among operational frontline Inspectors and Sergeants. PolSAs often provide advice remotely particularly in the early stages of an incident. Although specialist resources can be co-ordinated and scaled as an incident develops, the organisation is not always in a position, particularly during the earliest stages of a response, to immediately deploy fully constituted specialist teams or specialist capabilities.” Source location Response from Cleveland 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 one-to-one reflective learning on officers’ operational equipment responsibilities and escalation of equipment problems to supervisors.
Verbatim wording from the response “This will be referred to the force’s Dress and Equipment Group and the Heath & Safety Group to review the matter and learning from the inquest. Both the Dress and Equipment Group and the Health and Safety Group will review officer equipment requirements and personal protective equipment. Both Groups will consider whether the current provision and equipment requirements meet the requirements of conducting searches. In addition, direct one-to-one reflective learning will be included regarding individual officers’ responsibilities in respect of operational equipment and escalating issues with equipment to their supervisor.” Source location Response from Cleveland 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 Increase and redistribute minimum Licensed Search Officer staffing levels following review through the Specialist Capabilities Strategic Threat and Risk Assessment.
Verbatim wording from the response “Actions taken to address this concern is as follows:
The force has significantly improved the operating procedures and governance around its Specialist Capabilities areas, including police dogs, to ensure sufficient resilience is maintained. In addition, the geographical distribution of Licensed Search Officers (LSOs) has been reviewed as part of the Specialist Capabilities Strategic Threat and Risk Assessment (STRA). Consequently, minimum staffing levels will be increased and more evenly aligned across the force area.” Source location Response from Cleveland 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 officer equipment and personal protective equipment requirements for searches through the Dress and Equipment Group and Health and Safety Group.
Verbatim wording from the response “This will be referred to the force’s Dress and Equipment Group and the Heath & Safety Group to review the matter and learning from the inquest. Both the Dress and Equipment Group and the Health and Safety Group will review officer equipment requirements and personal protective equipment. Both Groups will consider whether the current provision and equipment requirements meet the requirements of conducting searches. In addition, direct one-to-one reflective learning will be included regarding individual officers’ responsibilities in respect of operational equipment and escalating issues with equipment to their supervisor.” Source location Response from Cleveland 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 Share search-related organisational learning and recording requirements with staff, the Search portfolio lead, and specialist training governance.
Verbatim wording from the response “Actions taken to address these concerns are as follows:
The feedback and organisational learning set out in the statement provided by Greater Manchester Police (GMP) has been shared with staff via the force’s Specialist Training Tactical Governance Group. This group is responsible for ensuring that specialist training is identified and delivered through the force’s mandatory or annual training schedule, and that appropriate training is delivered to support operational requirements. The learning from GMP’s feedback has also been provided to the force lead for the Search portfolio, and includes prioritisation of the requirement to record:” Source location Response from Cleveland 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 Immediate deployment of fully constituted specialist teams or capabilities cannot always be achieved during the earliest response stages.
Verbatim wording from the response “Promotion of the PolSA role was undertaken in 2022 and 2023 to raise awareness among operational frontline Inspectors and Sergeants. PolSAs often provide advice remotely particularly in the early stages of an incident. Although specialist resources can be co-ordinated and scaled as an incident develops, the organisation is not always in a position, particularly during the earliest stages of a response, to immediately deploy fully constituted specialist teams or specialist capabilities.” Source location Response from Cleveland 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.
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 Cleveland 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 Cleveland 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 Cleveland 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
14 Nov 2014 Kirk William Williams · Prevention of Future Deaths report Teesside
View report summary
Concerns raised 4 Lack of dialogue between police and local A&E departments about treatment misunderstandings View source Lack of memorandum of understanding or guideline for taking aggressive detainees to A&E departments View source Insufficient A&E consultant understanding of which detainees will be accepted for treatment View source Insufficient police understanding of A&E treatment for detainees View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kirk William Williams · 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
Kirk William Williams ingested several drugs and displayed highly agitated and aberrant behaviour before being restrained by police. Although one officer considered that he should be taken to hospital, he was taken to a police station and later suffered cardiac arrest and died in hospital. The concerns included differing understandings between police and A&E staff about treating aggressive detainees, and the absence of clear dialogue or guidance for managing such medical emergencies.
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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Lack of dialogue between police and local A&E departments about treatment misunderstandings
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Lack of memorandum of understanding or guideline for taking aggressive detainees to A&E departments
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient A&E consultant understanding of which detainees will be accepted for treatment
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient police understanding of A&E treatment for detainees
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the effectiveness of the guidance after six months.
Verbatim wording from the response “It is my intention to review the effectiveness of the guidance in six months’ time and to take any appropriate action where necessary, whether that is amendments to the guidance in conjunction with the two Trusts, or further training to ensure staff are aware of and are implementing the guidance.” Source location 2014-0499-Response-by-Cleveland-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 Cleveland Police guidance for managing aggressive detainees transferred to emergency or mental-health services, incorporating agreed police and NHS arrangements.
Verbatim wording from the response “At point 8 in your report you identified that there did not appear to be a Memorandum of Understanding or guidance to cover aggressive detainees in Custody being taken to A&E Departments.” Source location 2014-0499-Response-by-Cleveland-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 Brief custody staff, medical staff and frontline officers on the new detainee-transfer guidance.
Verbatim wording from the response “• All staff both NHS and Police to be informed of the guidelines agreed for future reference.” Source location 2014-0499-Response-by-Cleveland-Police
Open published response
22 Sep 2014 Jerome Antoine Marie GONNET · Prevention of Future Deaths report Teesside
View report summary
Concerns raised 3 Failure of temporary no-entry signs to remain noticeable at the slip road exit View source Continuing hazard of drivers entering the exit slip road View source Lack of advance road-sign information identifying the slip road as no entry 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
Jerome Antoine Marie GONNET · 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 2 May 2012, Jerome Antoine Marie GONNET was a passenger in a car involved in a head-on collision after a female driver travelled the wrong way along the A66 eastbound carriageway. Concerns included unclear advance signage for the no-entry slip road and temporary no-entry signs that could be knocked over and become unnoticeable; two further drivers reportedly later used the exit slip road in the same way.
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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Failure of temporary no-entry signs to remain noticeable at the slip road exit
Wider context from the report “(2) At present there are temporary large ‘no entry’ signs at the exit of the slip road junction which have, on occasions, been knocked over and subsequently rendered unnoticeable .
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Continuing hazard of drivers entering the exit slip road
Wider context from the report “(3) It has been brought to the Coroners attention that since Mr Gonnet’s passing a further two drivers have driven down the exit slip road , in the same manner as the female driver who caused Mr Gonnet’s passing.
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Lack of advance road-sign information identifying the slip road as no entry
Wider context from the report “(1) It is unclear in advance of approaching the junction that the slip road upon which the female drove is ‘no entry’ slip road. There is no information in this regard on the road signs surrounding the junction.
” Open source report
18 Nov 2013 STUART ARRON COLLINS · Prevention of Future Deaths report Teesside
View report summary
Concerns raised 5 Hand sanitiser gel stored within possible patient reach in A&E View source Failure to keep A&E nursing notes complete and up to date View source Failure to record nursing-observation frequency on the A&E whiteboard View source Uncertainty over assessment on arrival at A&E View source Failure to take hourly nursing observations in A&E View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
STUART ARRON COLLINS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stuart Arron Collins was taken to hospital while intoxicated and fully conscious, but was discharged several hours later with a reduced level of consciousness. After arriving at an address, he became unconscious and suffered cardiorespiratory arrest before being returned to hospital, where he died later that day. Concerns included uncertainty about his assessment on arrival, the absence of required hourly nursing observations, incomplete nursing records, and the possible accessibility of alcohol hand sanitiser gel.
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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Hand sanitiser gel stored within possible patient reach in A&E
Wider context from the report “5. Evidence was given that the hand sanitiser gel was collected from the A&E department. However further evidence was given that the collected hand gels (estimated at 20 in number) were placed on the nurses station very close to Mr Collins’s cubicle . There was contradictory evidence as to whether Mr Collins could have accessed the hand gel from the nurses station .
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Failure to keep A&E nursing notes complete and up to date
Wider context from the report “4. Evidence was given that the nursing notes in A&E were not fully completed and were not kept up to date . There was no apparent recording about Mr Collins’s epilepsy or the need for the hand sanitiser gel to be moved out of his reach .
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record nursing-observation frequency on the A&E whiteboard
Wider context from the report “3. Evidence was given that Mr Collins was added to the whiteboard in the A&E dept but that the information regarding the frequency of his nursing observations was not . It was stated that this led to no nursing observations being taken during his first time at A&E on 9.10.12
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Uncertainty over assessment on arrival at A&E
Wider context from the report “1. There appeared to be a degree of uncertainty as to whether Mr Collins was assessed upon his arrival at the A&E department at James Cook University Hospital ("the hospital")at approx. 00.45 or whether information previously obtained by paramedics was utilised in lieu of an assessment on arrival .
” 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 Cleveland Police; that does not assign responsibility.
PFD Monitor interpretation Failure to take hourly nursing observations in A&E
Wider context from the report “2. It was stated that Mr Collins should have had hourly nursing observations taken during his first admission to A&E on 9.10.12, ie between 00.45 and his discharge at 04.30, but none were taken .
” 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