6 Oct 2023 John George CONDRON · Prevention of Future Deaths report Cheshire
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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.
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
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.
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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 College of Policing; 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
3 Jul 2023 Andre Felipe Mendes Moura · Prevention of Future Deaths report Manchester South
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Concerns raised 7 Lack of formal training on suspected feigned unresponsiveness View source Failure to share AVPU findings with other officers View source Failure to recognise and perform the safety officer role during restraint incidents View source Failure to use objective AVPU checks for unresponsiveness View source Lack of formal measurement of ABD training knowledge View source Failure of ABD training to enable recognition in real-life settings View source Failure to require body worn video during prisoner escorts nationally View source See 4 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
Andre Felipe Mendes Moura · 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
Andre Moura died on 7 July 2018 after suffering cardiac arrest in a police vehicle while under arrest and being transported following a significant struggle. The report identified concerns about officers’ recognition and training in acute behavioural disturbance, use of objective responsiveness checks, the safety officer role, and the absence of body-worn camera recording during escort.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of formal training on suspected feigned unresponsiveness
Wider context from the report “4. Many of the officers who gave evidence indicated that they believed that Mr Moura was feigning his lack of responsiveness. This was despite the fact that there was very limited evidence of officers carrying out the recognised AVPU checks. Officers relied on their own perceptions rather than AVPU. An officer who did carry out AVPU did not clearly share his lack of responsiveness with other officers. The Inquest heard that there is no formal training on what officers should do if they believe a prisoner under arrest is feigning unresponsiveness . Clarification and enforcement of the need for objective use of AVPU may well prevent subjective assessments leading to erroneous and potentially fatal conclusions that a prisoner is feigning lack of responsiveness;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to share AVPU findings with other officers
Wider context from the report “4. Many of the officers who gave evidence indicated that they believed that Mr Moura was feigning his lack of responsiveness. This was despite the fact that there was very limited evidence of officers carrying out the recognised AVPU checks. Officers relied on their own perceptions rather than AVPU. An officer who did carry out AVPU did not clearly share his lack of responsiveness with other officers . The Inquest heard that there is no formal training on what officers should do if they believe a prisoner under arrest is feigning unresponsiveness. Clarification and enforcement of the need for objective use of AVPU may well prevent subjective assessments leading to erroneous and potentially fatal conclusions that a prisoner is feigning lack of responsiveness;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and perform the safety officer role during restraint incidents
Wider context from the report “3. The role for a safety officer which is part of the College of Policing training in a situation such as this was not recognised . The Inquest heard evidence from an expert witness that a safety officer plays a key role in an incident such as the one involving Mr Moura and ensures key information is not lost/shared. This lack of an officer at his head taking on such a role emphasised the fact that although officers had attended the PST training key points had not been retained. Greater emphasis on this role in training would be beneficial in reducing the risk to prisoners being restrained;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to use objective AVPU checks for unresponsiveness
Wider context from the report “4. Many of the officers who gave evidence indicated that they believed that Mr Moura was feigning his lack of responsiveness. This was despite the fact that there was very limited evidence of officers carrying out the recognised AVPU checks . Officers relied on their own perceptions rather than AVPU . An officer who did carry out AVPU did not clearly share his lack of responsiveness with other officers. The Inquest heard that there is no formal training on what officers should do if they believe a prisoner under arrest is feigning unresponsiveness. Clarification and enforcement of the need for objective use of AVPU may well prevent subjective assessments leading to erroneous and potentially fatal conclusions that a prisoner is feigning lack of responsiveness;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of formal measurement of ABD training knowledge
Wider context from the report “2. The Inquest heard that the ABD training did not have any formal way of measuring/testing knowledge but was reliant of the perception of the trainer . A more formalised approach may have increased the ability of officers to recognise ABD;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of ABD training to enable recognition in real-life settings
Wider context from the report “1. During the course of the Inquest, evidence was heard about the understanding and training in relation to Acute Behaviour Disturbance (ABD). All of the officers who had received their College of Policing Personal Safety Training had been trained on the ABD module within that package. However it was clear that the training package had not achieved the objective i.e. to recognise ABD in a real life setting . The Inquest heard that ABD is an umbrella term and not all of the symptoms need to be present for someone to be suffering from ABD. It was clear from the officers’ evidence that the videos played in the training particularly of extreme examples of ABD had led them to not consider or recognise ABD in this situation . The Inquest heard that it could be difficult to recognise ABD in a dynamic situation but the training was there to ensure officers considered it in situations where it was a possible explanation for behaviour seen by officers. An emphasis on the nuances and less on extreme examples may assist in improving the recognition of ABD;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to require body worn video during prisoner escorts nationally
Wider context from the report “5. The officers escorting Mr Moura to the police station did not have their body worn cameras on. Greater Manchester Police (GMP) at the time did not have a policy at that time requiring escorting officers to switch on their Body Worn Video (BWV) cameras. GMP do now require that BWV cameras are on. This is an important change but it was not clear if all forces have implemented such a change . Given that the evidence before the inquest made it clear that the change in practice by GMP was important in allowing clarity around how a prisoner is behaving whilst being escorted to custody it is important that its use at all times should be promoted nationally .
” 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 quality-assurance and licence-moderation visits to check forces’ compliance with the new national training standards.
Verbatim wording from the response “Assessment criteria for the new PPST includes a requirement that officers must be able to demonstrate to trainers the correct response to a person experiencing ABD. This includes the appropriate use of a Safety Officer. The requirement for the use of a Safety Officer is also a learning outcome for all multi-officer restraints within the PPST programme. From April 2024, the College of Policing will be conducting a quality assurance process and will undertake licence moderation visits to ensure that forces comply with the new national standards.” Source location Response from College of Policing
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the revised First Aid Learning Programme with a learning outcome requiring recognition of acute behavioural disturbance signs and symptoms.
Verbatim wording from the response “In 2020, the College of Policing commenced a national working group to update the First Aid Learning Programme (FALP). The review that took place considered recommendations made by Coroners and the IOPC, including the detail of learning outcomes on Acute Behavioural Disturbance and treatment of head injuries.” Source location Response from College of Policing
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 Use observed scenario assessments, knowledge checks and pass-or-fail decisions to test officers’ responses to acute behavioural disturbance.
Verbatim wording from the response “The new PPST is designed to be an interventionalist style of training delivery. The trainers observe the students managing the scenarios. The training is stopped at regular intervals when the trainers will test the knowledge of the students and get the students to explain the rationale for their decisions. PPST is a pass or fail course.” Source location Response from College of Policing
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 officers to demonstrate appropriate use of a Safety Officer during ABD responses and multi-officer restraints within PPST.
Verbatim wording from the response “Assessment criteria for the new PPST includes a requirement that officers must be able to demonstrate to trainers the correct response to a person experiencing ABD. This includes the appropriate use of a Safety Officer. The requirement for the use of a Safety Officer is also a learning outcome for all multi-officer restraints within the PPST programme. From April 2024, the College of Policing will be conducting a quality assurance process and will undertake licence moderation visits to ensure that forces comply with the new national standards.” Source location Response from College of Policing
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the revised acute behavioural disturbance training package.
Verbatim wording from the response “The new PPST training implementation went live in 2023 and forces are required to have implemented or be in the process of implementation by April 2024. The revised ABD training package will be published mid-September 2023.” Source location Response from College of Policing
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 scenario-based Public and Personal Safety Training covering ABD recognition, de-escalation, containment, medical emergencies and immediate medical assistance.
Verbatim wording from the response “The new Public and Personal Safety Training (PPST) for all police officers has recently been developed with the emphasis on de-escalation. It is a scenario-based method of delivering training and is focused on learning, decision making, understanding decisions and debriefing decisions. The updated training will include identification of the signs and symptoms of ABD and management of the incident with the focus now being on de-escalation and ‘contain rather than restrain’, where officers suspect a person to be experiencing ABD. There will also be an emphasis on treating ABD as a medical emergency and seeking immediate medical assistance.” Source location Response from College of Policing
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 ABD guidance is sufficient; officers should treat displayed symptoms consistently even when they suspect feigned unresponsiveness, so no approach change is supported.
Verbatim wording from the response “The College guidance does not support any change in approach where officers may believe that someone is feigning a lack of responsiveness. All ABD guidance is focused on how to treat the displayed symptoms and should be followed regardless of any suspicions that symptoms are feigned.” Source location Response from College of Policing
Open published response
19 Jun 2023 Nicholas LEGER · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to proactively seek information about the mental health of people being charged by PCR View source Lack of a formal mental health and suicide or self-harm risk assessment at PCR delivery 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
Nicholas LEGER · 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
Nicholas Leger took his own life sometime between 7:30pm and 10:30pm on 20 February 2023, after learning via his solicitor that he had been charged. He had previously attempted to take his own life and had disclosed concerns about his mental health, but there had been no formal police assessment of his mental health or risk of suicide or self-harm for more than three months. The report identified a risk that people charged by Postal Charge Requisition could take their own lives where there was no formal mechanism to assess their mental health and risk at the time of charge.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively seek information about the mental health of people being charged by PCR
Wider context from the report “• That whether an individual is, exceptionally, considered to be in a high-risk category (such as to cause a PCR to be delivered in person) is reliant on information about their mental health coming to the attention of the OIC . There is no formal requirement for the OIC proactively to seek this information.
• That there is no formal process for assessing an individual’s mental health and/or risk of suicide or self-harm at the time of delivery of a PCR.
It is important to note the following:
• At the point of charge, nothing has been proven against the individual concerned. They face an allegation, and are innocent if and until proven guilty to the criminal standard.
• Many people are RUI’d. As such, PCR is now routinely used to bring most criminal charges.
• Individuals who have been RUI’d can remain with this status for long periods of time (months or years) before a decision is made whether or not to charge them.
• Whilst there are formal procedures to assess an individual’s mental health and risk of self-harm or suicide when they attend a police station for interview, once they have left the police station there are no such formal procedures (as above), notwithstanding the potential for a substantial period to elapse between the time they last attended a police station and the time that they are charged.
• Being charged with any criminal offence, especially one which carries the potential for a custodial sentence, can, self-evidently, have a significant deleterious effect on an individual’s mental health.
It appears to me that, in the absence of a formal mechanism to assess, at the time of being charged, an individual’s mental health and risk of suicide or self-harm, there is an obvious risk of individuals in the future taking their own lives as a result of being charged by way of a PCR (potentially following a lengthy period of having been RUI’d and potentially months or years since there was last any consideration by the police of their mental health and risk of suicide or self-harm).
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal mental health and suicide or self-harm risk assessment at PCR delivery
Wider context from the report “• That whether an individual is, exceptionally, considered to be in a high-risk category (such as to cause a PCR to be delivered in person) is reliant on information about their mental health coming to the attention of the OIC. There is no formal requirement for the OIC proactively to seek this information.
• That there is no formal process for assessing an individual’s mental health and/or risk of suicide or self-harm at the time of delivery of a PCR.
It is important to note the following:
• At the point of charge, nothing has been proven against the individual concerned. They face an allegation, and are innocent if and until proven guilty to the criminal standard.
• Many people are RUI’d. As such, PCR is now routinely used to bring most criminal charges.
• Individuals who have been RUI’d can remain with this status for long periods of time (months or years) before a decision is made whether or not to charge them.
• Whilst there are formal procedures to assess an individual’s mental health and risk of self-harm or suicide when they attend a police station for interview, once they have left the police station there are no such formal procedures (as above) , notwithstanding the potential for a substantial period to elapse between the time they last attended a police station and the time that they are charged.
• Being charged with any criminal offence, especially one which carries the potential for a custodial sentence, can, self-evidently, have a significant deleterious effect on an individual’s mental health.
It appears to me that, in the absence of a formal mechanism to assess, at the time of being charged, an individual’s mental health and risk of suicide or self-harm , there is an obvious risk of individuals in the future taking their own lives as a result of being charged by way of a PCR (potentially following a lengthy period of having been RUI’d and potentially months or years since there was last any consideration by the police of their mental health and risk of suicide or self-harm).
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current pre-charge bail arrangements and guidance provide further opportunities to assess suicide risk, so additional assessment at postal charge requisition is not identified.
Verbatim wording from the response “Conclusion
It is unlikely that someone released on bail for sexual offences would now revert to RUI. This means that they would be recalled to custody for charge, where a pre-release risk assessment can be completed, for which there is full guidance. There is specific custody training aimed at reducing the risks of post detention suicides.” Source location Response from College of Policing
Open published response
8 Jun 2023 Ivan Rumenov Ignatov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Insufficient guidance for custody sergeants assessing detainee risk View source Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services View source Inaccessibility of post-release detainee information due to language or literacy barriers View source Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system View source Lack of guidance for releasing detainees without an address to reside at View source See 2 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
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for custody sergeants assessing detainee risk
Wider context from the report “ii. There is not sufficient guidance given to custody sergeants on a national basis of how to assess a person’s risk .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
Wider context from the report “iv. There is a lack of knowledge and/or understanding amongst emergency services and search and rescue services, especially around terminology, process and communication for them to be able to work together when an incident arises without confusion or misunderstanding arising . I would request that consideration is given to further national and local training or guidance across emergency and search and rescue services to ensure communication can be facilitated without delay, and ensure terms and processes are understood to avoid any doubt of what action is being taken when an incident is ongoing.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of post-release detainee information due to language or literacy barriers
Wider context from the report “v. Leaflets given to detainees when released from police custody are not always accessible due to language or literacy barriers and I would request that consideration is given nationally by NHS England and all Police Forces to ensure that any documentation detainees, especially any providing help and assistance, is accessible 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system
Wider context from the report “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for releasing detainees without an address to reside at
Wider context from the report “iii. There is no guidance, that I am aware of, which addresses what should be done by police forces, and particularly custody sergeants, when a person is to be released without an address to reside at and I would request consideration is given to such guidance being provided.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide national risk-assessment principles addressing professional judgement and uncertainty in custody risk assessment.
Verbatim wording from the response “There is very limited evidence on the effectiveness of risk assessment tools. These tools are designed to assist professional judgement. The College has produced risk assessment principles that give strong and consistent messages about assessing risk. The first of the ten principles makes clear that risk assessing is not a certain process and that assessors make decisions in situations of considerable uncertainty. Principle three makes clear that risk assessing is a matter of judgement and balance. Principle four states that harm can never be totally prevented. The ten risk principles, taken together, give comprehensive guidance on how to carry out risk assessment.” Source location Response from College of Policing
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a first-time-in-police-custody question to the APP risk-assessment checklist.
Verbatim wording from the response “1. No set Risk Assessment question re first time in custody on the Niche/RMS custody record application or in APP.” Source location Response from College of Policing
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 Maintain APP guidance on release of detainees without an address, including risk assessment, referrals and written self-referral information.
Verbatim wording from the response “other powers to detain (S34 Police and Criminal Evidence Act 1984). As set out below, in our experience, there would not have been sufficient grounds to detain Mr Ignatov for mental health assessment. This means that, regardless of his accommodation situation, he had to be released when the custody officer concluded that there were no grounds for continued detention.
There is content in Detention and Custody APP on action to take if a person does not have an address when being released from custody. It must be borne in mind that it is not unusual for detainees to be of no fixed address, and it is noted in the APP that detainees could be referred to social care, hostels/refuges etc. There are two issues to be considered.” Source location Response from College of Policing
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 Notify police forces when the amended risk-assessment checklist is issued.
Verbatim wording from the response “The checklist sets out the questions which custody officers must ask when assessing detainees. Once this amendment has been made the College will write to forces informing them of the change. We are aware that many force’s custody systems are embedded within a wider records management systems and may take some time to update their systems.” Source location Response from College of Policing
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 Detention and Custody APP guidance, including signposting and referrals before release, is considered sufficient for releasing people without a fixed address.
Verbatim wording from the response “other powers to detain (S34 Police and Criminal Evidence Act 1984). As set out below, in our experience, there would not have been sufficient grounds to detain Mr Ignatov for mental health assessment. This means that, regardless of his accommodation situation, he had to be released when the custody officer concluded that there were no grounds for continued detention.
There is content in Detention and Custody APP on action to take if a person does not have an address when being released from custody. It must be borne in mind that it is not unusual for detainees to be of no fixed address, and it is noted in the APP that detainees could be referred to social care, hostels/refuges etc. There are two issues to be considered.” Source location Response from College of Policing
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 professional-judgement arrangements are considered sufficient for assessing and managing custody risks; categorical high, medium and low grades are not needed.
Verbatim wording from the response “There is very limited evidence on the effectiveness of risk assessment tools. These tools are designed to assist professional judgement. The College has produced risk assessment principles that give strong and consistent messages about assessing risk. The first of the ten principles makes clear that risk assessing is not a certain process and that assessors make decisions in situations of considerable uncertainty. Principle three makes clear that risk assessing is a matter of judgement and balance. Principle four states that harm can never be totally prevented. The ten risk principles, taken together, give comprehensive guidance on how to carry out risk assessment.” Source location Response from College of Policing
Open published response
23 May 2023 Daniel LYLE · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2 Insufficient focus in police officer training on symptoms and presentation of mental health conditions View source Insufficient focus in police officer training on practical strategies for decision making in mental health situations 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
Daniel LYLE · 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
Daniel LYLE, who suffered from paranoid psychosis, experienced a psychotic episode on 20 March 2020 and climbed approximately 30 feet into a tree while displaying paranoid and delusional beliefs. He fell from the tree, sustained fatal head and chest injuries, and died despite resuscitation efforts. The principal concern was that police training was not sufficiently focused on understanding mental health symptoms and presentation, or on practical strategies to support decision-making during mental health crises.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient focus in police officer training on symptoms and presentation of mental health conditions
Wider context from the report “(1) Whilst recognising that police officers cannot be doctors or nurses nor should they be, it is a concern that training for officers whether initial or refresher is not sufficiently focused on:
(a) an understanding of the symptoms and presentation of mental health conditions ;
(b) possible practical strategies informed by mental health professionals and those suffering such conditions as will enable officers to optimise their decision making under the national decision making model.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient focus in police officer training on practical strategies for decision making in mental health situations
Wider context from the report “(1) Whilst recognising that police officers cannot be doctors or nurses nor should they be, it is a concern that training for officers whether initial or refresher is not sufficiently focused on:
(a) an understanding of the symptoms and presentation of mental health conditions;
(b) possible practical strategies informed by mental health professionals and those suffering such conditions as will enable officers to optimise their decision making under the national decision making model.
” Open source report
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Maxine Betty Davison and 4 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to College of Policing; 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 College of Policing; 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop national firearms licensing training materials and accompanying quality assurance processes.
Verbatim wording from the response “We will adapt national approaches to training used in other high-risk areas of policing, for example, armed policing. As part of this approach, national materials and accompanying quality assurance (QA) processes will be developed to ensure a consistent approach to training across forces in England and” Source location Response from College of Policing
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 Adapt national high-risk policing training approaches for firearms licensing.
Verbatim wording from the response “We will adapt national approaches to training used in other high-risk areas of policing, for example, armed policing. As part of this approach, national materials and accompanying quality assurance (QA) processes will be developed to ensure a consistent approach to training across forces in England and” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a national training course for staff involved in firearms licensing, including firearms enquiry officers and delegated decision-makers.
Verbatim wording from the response “The College is currently developing significantly revised and updated Authorised Professional Practice (APP) on firearms licensing. The APP – and other national products such as the Home Office’s Statutory Guidance – will underpin the development of a national training course for staff involved in firearms licensing. This will include Firearms Enquiry Officers (FEOs) and others who may have delegated authority to make decisions.” Source location Response from College of Policing
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 Review and update national learning outcomes for firearms licensing training.
Verbatim wording from the response “Wales. The material and QA will be based on national learning outcomes which are also currently being reviewed and updated.” Source location Response from College of Policing
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 State in Authorised Professional Practice that chief officers should delegate firearms licensing decisions only to trained decision-makers.
Verbatim wording from the response “Once the training course has been designed, we will state in the APP that chief officers should only delegate their firearms licensing decisions to people who have been trained to take those decisions.” Source location Response from College of Policing
Open published response
Concerns raised 2 Lack of formal guidance, training, and protocols for correlating COMPACT risk assessments with ACT stop priority instructions View source Mismatch between COMPACT risk assessments and ACT stop priority instructions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
HANNAH WARREN · 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
Hannah Warren was reported missing on 3 February 2016 after leaving London by car while expressing delusional thoughts, and her body was found in Port Talbot harbour the following morning. The inquest concluded that she died from drowning and a head injury. Concerns included shortcomings in the missing-person investigation, including delayed or insufficient use of the ANPR Bureau, communication failures, failure to contact family, and the use of a low-priority vehicle stop despite a medium risk assessment; the report also identified a lack of formal guidance, training, or protocols linking these systems.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of formal guidance, training, and protocols for correlating COMPACT risk assessments with ACT stop priority instructions
Wider context from the report “(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling;
(2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle.
(3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems ; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all.
(4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT.
(5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.
(6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Mismatch between COMPACT risk assessments and ACT stop priority instructions
Wider context from the report “(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling;
(2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle.
(3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all.
(4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT.
(5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.
(6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically.
” Open source report
×
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 Current ACT instructions require a STOP instruction for comparable missing-person cases and specify the action officers should take after an ANPR activation.
Verbatim wording from the response “If a medium or high ACT report is added, there must be one of three words to start the report indicating the activity that a force should undertake if there is a relevant ANPR activation. These words are – Stop, Monitor or Assess (as described in the above extract).” Source location Response from National Police Chiefs' Council and College of Policing
Open published response
15 Dec 2022 Neal Terence Saunders · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 8 Inconsistent terminology for the ABD umbrella term across services View source Lack of paramedic guidance on the danger of prolonged restraint View source Lack of guidance defining prolonged restraint View source Lack of checking of infrequently used guidance View source Incorrect training about ambulance response categorisation for ABD View source Failure of classroom-based ABD training to be retained and embedded View source Unclear applicability of restraint guidance to people under arrest View source Incorrect training about chemical sedation by first responding ambulance staff View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neal Terence Saunders · 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
Neal Terence Saunders was restrained by police for 58 minutes, including 14 minutes in a prone position, after police attended his address following an assault report and concerns about recent cocaine use and paranoid behaviour. He suffered a cardiac arrest while being transported to hospital and died there on 4 September 2020. Concerns included inadequate guidance and training about prolonged restraint, ambulance response expectations, prone transportation, and coordination and training between police and ambulance services.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Inconsistent terminology for the ABD umbrella term across services
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic guidance on the danger of prolonged restraint
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance defining prolonged restraint
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint , and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of checking of infrequently used guidance
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed . The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Incorrect training about ambulance response categorisation for ABD
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of classroom-based ABD training to be retained and embedded
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received . I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively .
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded ?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Unclear applicability of restraint guidance to people under arrest
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified ).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Incorrect training about chemical sedation by first responding ambulance staff
Wider context from the report “Brief summary of matters of concern
Police training
There was extensive BWV footage in this case, which both I and the jury were able to see multiple times. It appeared to me, and (presumably) to the jury, (given their conclusion), that the officers at the scene were trying to take Neal’s welfare into account. The real issue was around their training. Whilst there may not have been any realistic or practicable alternative to restraining Neal, at least initially, it was clear from the evidence that none of the officers recalled their training which had told them that “prolonged” restraint should be avoided.
The training gives no guidance as to what constitutes “prolonged” restraint, and this an issue which the jury highlighted. There are also a number of concerns regarding College of Policing training in this respect.
The key concerns around training can be summarised as follows:-
1. How long is “prolonged” restraint?
2. One of the witnesses questioned whether the guidelines applied at all if somebody is under arrest, particularly regarding “contain rather than restraint”. Given that these are police guidelines, it seems to me likely that they would apply, whether a person is arrested for public order offences or other matters (but that should be clarified).
3. The College of Policing slides regarding ABD state that a “Cat 1 call” should be made to the ambulance service. The slides go on to say that the ambulance service should respond to ABD as a “category 1” [response]. It is clear that categorisation would be a matter for the ambulance service rather than the police, and this training may result in inappropriate expectations on behalf of officers at scene, who are expecting an ambulance to arrive more quickly that it in fact does. This in turn could affect their decision making.
4. The guidelines also refer to providing “chemical sedation”. This appears to me to indicate an incorrect understanding of what is likely to be done medically by a first responding paramedic or emergency care assistant.
5. It was interesting to note that the parts of the training the officers did seem to remember were around when the training was provided in a very physical way (around positions for restraint etc.) and the final slide “ABD = A&B”. It appears that the more “classroom based” training is less well received. I understand that the College of Policing is changing its methods, and it may be that an educational consultant with policing background could assist with this in trying to achieve training which will stick with those being trained more effectively.
6. Is there a better way for the College of Policing to ensure that the training has worked and is embedded?
Training generally
I raise 2 points here:
1. Checking of guidance which is infrequently used
2. Joint training with ambulance services
Thames Valley Police and the College of Policing will be aware of my Regulation 28 report dated 9th July 2019, following the death of Leroy Medford in 2017.
I raised a number of concerns about police training, and received responses from Thames Valley Police and the College of Policing. These are publicly accessible documents on the Chief Coroner’s website.
I am concerned that the issues raised around training in that report have been insufficiently addressed. The only substantive change appears to relate to better remote access to guidance.
In both inquests, the guidance was in relation to a matter which is not commonly faced by police officers.
Whilst I consider ABD training could and should be improved, I accept that there has to be proportionality, given that officers will require training in a number of areas, some of which are far more frequently relevant than this.
In addition to achieving better training, I consider that Thames Valley Police (and police nationally), should consider a change of approach. I consider that police officers should be mandated to review guidance (whether APP guidance or otherwise) in any scenario that they have not (or not recently) dealt with. I fully appreciate that this will need to have a “where practicable” caveat, since that will not always be operationally possible. In this case, however, there was ample time for an officer to check. One of the officers is heard saying words to the effect of “there is nothing more we can do here”, whilst waiting for the ambulance to arrive.
I consider that Thames Valley Police (and police forces nationally) should consider not only requiring officers to do this wherever possible, but also for control to remind teams to do this or assist them with that. It would be best practice for this to be recorded on the log as having been completed. This could be achieved by a phone call to a senior officer, or by checking guidance directly.
It was suggested by the Medical Director of South Central Ambulance Service that police and ambulance services should work together in reviewing their policies and perhaps train together as well. This is something I would endorse completely.
Ambulance issues
One of the reasons that I consider that joint training would be more effective is that it would appear (based on the evidence I heard at least), that police are potentially given more training on ABD than paramedics. We heard, for instance, that police training includes reference to prolonged restraint being dangerous. The paramedic evidence we heard indicated that this was not known by them, and not referred to in JRCALC guidance.
I consider that the JRCALC guidelines should be reviewed to account for this, and potentially to recommend that paramedic staff be encouraged to ask how long somebody has been restrained for when they arrive, as this may affect their management.
There should also be care taken regarding terminology, to ensure that all services refer to this umbrella term using the same terminology.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarify in PPST content that the guidance applies to restraint in all circumstances, including arrest.
Verbatim wording from the response “2. The new PPST content will be clear that the guidance applies to those who are restrained in any circumstances, including people who are under arrest.” Source location Response from College of Policing
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 Discuss defining prolonged restraint and explore using clinical expertise to inform work with PPST leads.
Verbatim wording from the response “1. ‘Prolonged restraint’ is not currently defined. This issue has been tabled for discussion at the national Clinical Governance Panel and we will look at ways to use clinical expertise to inform work in conjunction with College PPST leads.” Source location Response from College of Policing
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 Remove references to chemical sedation from training.
Verbatim wording from the response “4. References to ‘chemical sedation’ will be removed from training.” Source location Response from College of Policing
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 Clarify in revised training and guidance that ambulance-service response is their responsibility and relevant information must be communicated for dispatch prioritisation.
Verbatim wording from the response “3. We will ensure that the revised training and guidance makes it clear that the response from the ambulance service is a matter for them, and the important point for policing is to ensure that relevant information is communicated so that ambulance dispatchers can make appropriate decisions on prioritisation.” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the mandatory PPST package, updated national curriculum and APP, with nationwide rollout and ongoing College quality assurance.
Verbatim wording from the response “The College is currently implementing a new mandatory training package for Public and Personal Safety Training (PPST) along with an updated national curriculum and Authorised Professional Practice (APP). The nationwide roll out of this programme will commence in April 2023 and all forces must achieve implementation by April 2024. This will result in police forces delivering PPST to a common national standard which will be subject to an ongoing quality assurance process by the College. The training is a two-day annual package which is delivered in person and is focused on supporting learners with information retention.” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ambulance service response decisions are its responsibility; policing’s role is to communicate relevant information for ambulance dispatch prioritisation.
Verbatim wording from the response “3. We will ensure that the revised training and guidance makes it clear that the response from the ambulance service is a matter for them, and the important point for policing is to ensure that relevant information is communicated so that ambulance dispatchers can make appropriate decisions on prioritisation.” Source location Response from College of Policing
Open published response
15 Sep 2022 Harper DENTON · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Lack of an offender register or equivalent protection for children from people convicted of cruelty against a child View source Failure to require Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children View source Failure to adopt MOSOVO guidance for managing sexual and violent offenders, particularly PDPs View source Lack of proactive police information sharing to protect children from people convicted of violence or cruelty against a child 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
Harper DENTON · 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
Harper DENTON, aged one month, was unlawfully killed by her father, who had previously been convicted of violent offences against a two-year-old child. The inquest found that failures by state agencies to manage the continuing risk he posed contributed to her death. Concerns included police information-sharing and risk-management practices, the absence of an offender register for people convicted of cruelty offences against children, and the non-mandatory nature of full safeguarding assessments by health visitors.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of an offender register or equivalent protection for children from people convicted of cruelty against a child
Wider context from the report “3. There is nothing today, such as form of Offender Register, to protect children from an individual who has already been convicted of a cruelty offence against a child and served their sentence.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to require Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children
Wider context from the report “4.The need for a Health Visitor to carry out a full safeguarding assessment of a father’s/co-parent's potential risks to a child is currently only ‘best practice’ and not mandatory .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to adopt MOSOVO guidance for managing sexual and violent offenders, particularly PDPs
Wider context from the report “1.The MPS does not appear to have adopted ACPO Guidance on Protecting the Public: Managing Sexual Offenders and Violent Offenders 2010 and subsequent APP College of Policing MOSOVO Guidance , particularly with respect to PDPs .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of proactive police information sharing to protect children from people convicted of violence or cruelty against a child
Wider context from the report “2. There appears to be a lacuna in pro-active information sharing practices by Police (similar to those found under Clare’s Law and Sarah’s Law) in order to protect children from those who may present a threat to them as a result of having previous convictions for violence/cruelty offences against a child - this concern is directed to the CEO College of Policing and the Chair of the NPCC.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Child Abuse APP within three months to clarify disclosure of relevant risk information to parents and carers of potentially endangered children.
Verbatim wording from the response “College APP on child abuse refers to the powers of police to share information, and this includes employers and regulatory bodies. In response to your report the College will, in the next three months, update APP to make clear that disclosure can also be made to parents and / or carers of children who may be at risk of harm from a particular person.” Source location Response from National Police Chiefs' Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop risk principles and vulnerability and risk guidelines for identifying, assessing and managing potentially dangerous persons and serial domestic-abuse perpetrators.
Verbatim wording from the response “In addition, the College has developed risk principles, vulnerability and risk guidelines and, principles for the management of potentially dangerous and serial perpetrators domestic abusers.” Source location Response from National Police Chiefs' Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing statutory and common-law disclosure mechanisms provide routes for proactive and reactive sharing of risk information to safeguard children.
Verbatim wording from the response “Response
Where policing becomes aware of a Potentially Dangerous Person, or any person who may pose a risk to a partner or their children, there is a well-developed legal framework to share information with a person considered to be at risk of harm, such as a new partner or the parent / carer of a vulnerable child.” Source location Response from National Police Chiefs' Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual chief constables retain operational independence and responsibility for implementing or departing from APP guidance.
Verbatim wording from the response “Chief Constable ████████ is the National Policing Lead for the Management of Sexual Offenders and Violent Offenders, she drives consistency of policing approaches by supporting forces to implement guidance and adopt new, promising practice. Additionally, the Vulnerability Knowledge and Practice Programme (VKPP) actively engages with forces to assist them to assess their own operating processes and offers coordinated peer support when forces ask for assistance. However, the Metropolitan Police Commissioner and individual Chief Constables have operational independence and so can deviate from APP if they choose.” Source location Response from National Police Chiefs' Council
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The 2010 ACPO guidance is superseded by current APP, which sets out up-to-date professional practice for potentially dangerous persons.
Verbatim wording from the response “1) The MPS does not appear to have adopted ACPO Guidance on Protecting the Public: Managing Sexual Offenders and Violent Offenders 2010 and subsequent APP College of Policing MOSOVO Guidance, particularly with respect to PDPs. Because this concern may be relevant to other police forces nationally, this concern is directed to the CEO College of Policing and the Chair of the NPCC as well as the Commissioner for the MPS.” Source location Response from National Police Chiefs' Council
Open published response
21 Jul 2022 Gaia Kima Pope-Sutherland · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 12 Failure of Mental Health teams to provide assessment information directly to GPs View source Lack of policy for handling sexual harassment or assault in DHUFT inpatient units View source Lack of police officer knowledge of life-threatening illnesses and their behavioural impact View source Failure to flag key information on DHUFT RiO records View source Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment View source Lack of DHUFT policy for contact with patients’ families View source Failure to create, complete and store Dorset Police records appropriately View source Delay in AMHP feedback of Mental Health Act assessment information to GPs View source Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies View source Lack of resourcing of epilepsy services View source Ambiguity and inconsistency in access to Community Mental Health care processes View source Lack of communication between neurology and psychiatric teams View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gaia Kima Pope-Sutherland · 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
Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health teams to provide assessment information directly to GPs
Wider context from the report “x. As per paragraph 1(xiii) above, when a Mental Health Act assessment is undertaken, there is a possibility that information may not be fed back to the GP in the best way or in a timely manner, if it is not fed back by those from the Mental Health team, and I therefore request that consideration is given to the DHUFT representatives forwarding information, directly to the GP, rather than through the discharging team at the acute hospital . This may include their RiO record notes, or their assessment notes.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for handling sexual harassment or assault in DHUFT inpatient units
Wider context from the report “vi. As per paragraph 1(ix) above, the occurrence of sexual harassment or assault whilst an inpatient at one of DHUFT’s inpatient units could have a detrimental effect on a person’s mental health which could have fatal consequences. I request that consideration is given to a policy being put into place to provide guidance to staff as to how to deal with this situation.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer knowledge of life-threatening illnesses and their behavioural impact
Wider context from the report “iii. As per paragraph 1(iv) above, there could be future deaths due to the lack of knowledge Police Officers in England and Wales have around life threatening illnesses , such as epilepsy and mental health illness, and I request that consideration is given by the College of Policing to providing national training to all staff across all police forces, on illnesses such as epilepsy and mental health illness, and the impact they have on individuals and their behaviour. I also request consideration to be given to these topics forming part of the syllabus for the College of Policing induction training for Police Officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to flag key information on DHUFT RiO records
Wider context from the report “viii. As per paragraph 1(xi) above, information could be lost on lengthy RiO records held by DHUFT if there is a significant number of records, and I therefore request that consideration is given to a guidance document dealing with how and what information should be flagged on RiO which could be provided to all staff at DHUFT. I would further request consideration is given to training staff how to record information, so it is flagged on the record.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of DHUFT policy for contact with patients’ families
Wider context from the report “vii. As per paragraph 1(x) above, there is no specific policy in place within DHUFT around how to engage with the family or dealing with the Think Family approach. A lack of contact with family members , who know the patient best, could lead to information gaps, which could lead to future deaths. I request that consideration is given to a policy being created around contact both to, and from, a patient’s family.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to create, complete and store Dorset Police records appropriately
Wider context from the report “v. As per paragraphs 1(vii-viii) above, there is currently a risk that Dorset Police records are not being created, completed or stored in an appropriate way . This could result in a lack of detail, or incorrect information being recorded and relied upon , which could lead to a future death. I therefore request that consideration is given to reviewing how all Dorset Police records are held, to ensure integrity of the information, and that consideration is given to providing a training session on record keeping for all Dorset Police staff, across all areas of the Force.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Delay in AMHP feedback of Mental Health Act assessment information to GPs
Wider context from the report “xi. As per paragraph 1(xiv) above, in respect of the feeding back of information to the GP by the AMHP which is detailed at paragraph 2.10 of Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours . Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideration too.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy , and for control room staff only, the call handling, grading and deployment policy .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of resourcing of epilepsy services
Wider context from the report “i. As per paragraphs 1(i-iii) above, there could be future deaths locally and across the country due to the lack of resourcing of epilepsy services . I request consideration is given to a review of the nursing resources in epilepsy care locally in Dorset Epilepsy Service, and generally nationally across England and Wales.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Ambiguity and inconsistency in access to Community Mental Health care processes
Wider context from the report “ix. As per paragraph 1(xii) above, I would request that consideration is given to providing training to all staff on the access to Community Mental Health services which could also cover the processes regarding discharge planning from the care of the mental health teams.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between neurology and psychiatric teams
Wider context from the report “ii. Further I am concerned that there could be future deaths as a result of the lack of communication between neurology and psychiatric teams and request that there is consideration as to how to ensure effective lines of communication between the 2 disciplines.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete consideration of higher-level medical-condition training and conclude that the current policing approach remains appropriate.
Verbatim wording from the response “We have recently considered this question in relation to other conditions, such as neuro diversity, and further concluded that seeking to give a higher level of expertise is unfortunately not practical. Policing deals with an almost limitless variety of incidents, some situations or medical issues may only being encountered by officers very rarely – their training would be almost irrelevant because of the time that had lapsed between the training and the time the knowledge was needed to deal with the incident.” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Comprehensive training on epilepsy and mental health conditions is considered impractical because medical conditions and missing-person circumstances are too complex and variable.
Verbatim wording from the response “Additionally, the College is committed to providing the highest standards of training for those working in policing however, that training also must be accessible and practicable. Medical conditions can be very complex, those conditions in themselves can be variable and they do not exist in isolation. Different conditions have differing levels of severity that interact with the myriad of circumstances in which people go missing. The quantity of variables is simply too great to reasonably and effectively train.” Source location Response from College of Policing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing first aid, vulnerability training and authorised professional practice are considered proportionate and appropriate for responding to medical risks.
Verbatim wording from the response “We recognise that policing must have some medical knowledge and this is provided through our first aid programme. This programme and medical knowledge makes explicit links to our vulnerability training. To ensure police responders are equipped to effectively respond to missing persons, our training focuses on managing the full spectrum of vulnerabilities through effective and proportionate risk management. In reality, this means that College standards require front line responders to ask good questions that enable an informed understanding of the range or risks affecting a missing person, on a case by case basis, to identify their severity and impact. Additionally, police responders should seek information from informed sources, such as family or doctor, to understand the impact and degree of any medical conditions potentially affecting a missing person.” Source location Response from College of Policing
Open published response
29 Jun 2022 Louise Theresa Bailey · Prevention of Future Deaths report South London
View report summary
Concerns raised 2 Failure to provide drivers with information about whether other units are closer for emergency-call risk assessment View source Lack of training on when officers should assign themselves over the radio 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
Louise Theresa Bailey · 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
Louise Theresa Bailey died after being struck by a police car responding to an incident while she was running across the road to catch a bus. The concern was that the police system and training did not ensure responding drivers had information about whether other units were closer, preventing them from completing a full risk assessment.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide drivers with information about whether other units are closer for emergency-call risk assessment
Wider context from the report “Chapter 13 of Roadcraft, the Police Driver’s Handbook, provides that before officers begin their response to an emergency call, they should go through a process of risk assessment. That includes consideration of whether other units are closer. However, in this case the driver and operator did not know the answer to that question. In part that was due to the fact that officers are encouraged to avoid assigning themselves over the radio during an ongoing incident to prevent clogging up of airwaves. However, I heard evidence that several units did in fact assign themselves over the radio, though not all with their location, and that no training is provided as to when to assign over the radio and when not to. Moreover, there is an emergency button which allows the originating officer to override other broadcasts if needed mitigating any risk of clogging up airwaves. My concern is that the current system and training does not facilitate drivers being provided with the information they need to answer the question “are other units closer?” which means they are unable to complete a full risk assessment .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of training on when officers should assign themselves over the radio
Wider context from the report “Chapter 13 of Roadcraft, the Police Driver’s Handbook, provides that before officers begin their response to an emergency call, they should go through a process of risk assessment. That includes consideration of whether other units are closer. However, in this case the driver and operator did not know the answer to that question. In part that was due to the fact that officers are encouraged to avoid assigning themselves over the radio during an ongoing incident to prevent clogging up of airwaves. However, I heard evidence that several units did in fact assign themselves over the radio, though not all with their location, and that no training is provided as to when to assign over the radio and when not to . Moreover, there is an emergency button which allows the originating officer to override other broadcasts if needed mitigating any risk of clogging up airwaves. My concern is that the current system and training does not facilitate drivers being provided with the information they need to answer the question “are other units closer?” which means they are unable to complete a full risk assessment.
” Open source report
21 Jan 2022 Anthony Walgate and 3 others · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Lack of clarity about specialist and forensic support available when BCU retains primacy View source Use of “unexplained” death categorisation distracting officers from treating sudden deaths as suspicious until investigation establishes otherwise View source Failure to carry out handwriting verification appropriately and sensitively View source Lack of ownership and responsibility among officers leading unexplained-death investigations View source Closure of CRIS investigations without completion review and critical assessment of non-suspicious classification View source Lack of identity verification for users engaging escorts through the Sleepyboy website View source Lack of clarity in the policy framework guiding primacy decisions View source Inaccessibility or poor understanding of the SCRG as a complex-investigation review resource View source Failure to record investigation lines, actions and outcomes View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony Walgate and 3 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
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor were four young men who were drugged with GHB and murdered. The report raises concerns about serious investigative failings, including how sudden deaths were categorised, the allocation and support of homicide investigations, leadership, recording and review of investigative actions, handwriting verification, death notifications and the response to coroners’ concerns. It also identifies concern that users of the Sleepyboy website could engage escorts without verifying their identities.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about specialist and forensic support available when BCU retains primacy
Wider context from the report “It remains a matter of concern that there is a lack of clarity surrounding the levels of support that can be expected from the specialist homicide investigators and crime scene managers or other forensic practitioners in the investigation of deaths where primacy remains with the BCU (MC2B).
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Use of “unexplained” death categorisation distracting officers from treating sudden deaths as suspicious until investigation establishes otherwise
Wider context from the report “It is a matter of concern that although the current MPS policy, the Death Investigation Policy, dated 24 May 2021, similarly stipulates that officers attending the scene of a sudden death should treat the scene and incident as suspicious until satisfied that it is not, the term “unexplained” as used in the current policy may once again distract officers from the correct and necessary approach , which is for the death to be treated as suspicious unless and until the police investigation has established that it is not (MC1).
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out handwriting verification appropriately and sensitively
Wider context from the report “Therefore, although it may only very rarely be the case that the verification of a person’s handwriting might have a critical impact on future deaths, it is a matter of concern to me that this task be carried out appropriately and sensitively to afford the police the best opportunity of any identification being accurate (MC5).
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of ownership and responsibility among officers leading unexplained-death investigations
Wider context from the report “It is a matter of concern that despite the regularly refreshed training that is now in place for detective sergeants and detective inspectors, and the additional leadership training in which the MPS has invested, a lack of ownership and responsibility for the investigations of unexplained deaths may persist in officers who are supposed to be leading investigations into unexplained deaths (MC3A).
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Closure of CRIS investigations without completion review and critical assessment of non-suspicious classification
Wider context from the report “A further, related, matter of concern is that the CRIS was closed by supervising officers without any review of whether the actions had been completed or any critical assessment at detective sergeant level or detective inspector level of whether the investigation had established that the death was non-suspicious (MC4B).
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of identity verification for users engaging escorts through the Sleepyboy website
Wider context from the report “It is a matter of concern that users of the Sleepyboy website can engage escorts without having to verify their identity (MC6).
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in the policy framework guiding primacy decisions
Wider context from the report “It is a matter of concern that the current policy framework guiding decisions on primacy still lacks clarity (MC2A).
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility or poor understanding of the SCRG as a complex-investigation review resource
Wider context from the report “It nevertheless remains a matter of concern that the SCRG, which DAC ████████ commended as an asset to assist in the process of review of complex investigations is not, in practice, accessible and/or properly understood as a resource (MC3B).
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to record investigation lines, actions and outcomes
Wider context from the report “It remains a matter of concern that whatever the system, CRIS or CONNECT, officers may not record lines of investigation, actions and outcomes (MC4A).
” 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 Investigative Supervisor/Manager Programme and APP for Investigation to specify appropriate sources and levels of specialist support.
Verbatim wording from the response “In their letter to Chief Constables, the NPCC national lead for homicide investigation will be requesting they undertake the appropriate action to ensure national guidance is shared and understood within their police force and to assure themselves that the policies followed in the force or collaborative arrangements, provide the appropriate clarity and specialist support for investigators.” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
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 national primacy guidance with forces and request review and assurance of their death-investigation allocation policies and procedures.
Verbatim wording from the response “Regardless of how such investigations are resourced and led, it is important that there are clear decision making criteria as to which investigation units take primacy for particular death investigations. The learning from the inquests is being used to update national policing guidance and will be shared with forces so that they can review, and where required, update their own force policies for death investigation.” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update Authorised Professional Practice to require consideration of how unexpected deaths are allocated and suitable force policies for allocation decisions.
Verbatim wording from the response “The NPCC national lead for homicide investigation will be writing to all Chief Constables, detailing this specific aspect of learning from the investigations into the murders committed by ████████. This will include a request for all Chief Constables to review their force policies and procedures and assure themselves that they have clear decision making processes, which are understood, when deciding which units should investigate different death investigations. This request will be supported by the College of Policing who will be” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a consistent England-and-Wales approach to recording homicide and death investigations, including reviewing Home Office Counting Rules.
Verbatim wording from the response “The NPCC are also working with the Home Office to develop a new consistent approach to recording homicide and death investigations across police forces in England and Wales, which is hoped will continue to build public confidence in police death investigations. This project includes a review of the current Home Office Counting Rules to identify any changes that may be required in how deaths are recorded by police. The above classifications for death investigations will be cross-referenced to any new definitions within the Home Office Counting Rules.” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
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 Finalise a four-category national classification system for death investigations.
Verbatim wording from the response “In close consultation with the Metropolitan Police Service, the NPCC and the College of Policing are in the process of finalising a new classification for death investigations (to be completed by Summer 2022). The revised classifications will be:” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
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 learning with Chief Constables and request action to ensure force arrangements clarify responsibilities for those leading death investigations.
Verbatim wording from the response “In their letter to Chief Constables, the NPCC national lead for homicide investigation will be requesting forces undertake the appropriate action to ensure that force or collaborative arrangements have the required policies and processes to assure themselves that those leading death investigations understand their responsibilities.” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
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 Review the Forensic Submissions Good Practice Guide with the police Forensic Capability Network.
Verbatim wording from the response “Awareness of handwriting comparison as a forensic discipline and access to expertise is managed through police forensic management and submission teams. Whilst not a frequently used forensic discipline, it is a widely recognised capability within the forensic community. Good practice awareness on forensic submissions, including handwriting comparison, is available through the ‘Forensic Submissions Good Practice Guide’ (published by the NPIA, now superseded by the College of Policing). This guidance was published in 2012 and a review has been initiated between the College of Policing and the police Forensic Capability Network.” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue raising awareness of review units and their capabilities through the national review-officer network and homicide investigation and review leads.
Verbatim wording from the response “The importance of raising the profile and awareness of review units and their capabilities will continue to be raised through the national network of review officers and by the NPCC lead for homicide investigation and reviews.” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
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 Remove and replace references to “unexplained deaths” in national policing curricula and publications.
Verbatim wording from the response “The College of Policing and NPCC have undertaken a joint review of the policing curriculum and national policing publications that inform death investigations for use of the term “unexplained deaths”. In some publications it was identified the term had been used interchangeably with the term “unexpected deaths”. References to “unexplained” in the policing curriculum, or publications, are in the process of being removed and replaced with the word ‘unexpected’. This work will be largely concluded by the end of March 2022. For clarity, references to “unexplained” were found in the following publications:” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
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 Review and update national guidance and publications following finalisation of the death-investigation classification system.
Verbatim wording from the response “Once the new guidance on the classification of death investigations (as set out in response to MC1) has been finalised, all relevant national guidance and publications will be updated. The College of Policing is also in the process of reviewing the “Investigative supervisor / manager programme” to ensure there is clear reference to unexpected deaths and decision making processes for the allocation of investigations. It is expected this review will conclude by April 2022.” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
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 Review the Investigative Supervisor/Manager Programme to clarify allocation decision-making for unexpected deaths.
Verbatim wording from the response “Once the new guidance on the classification of death investigations (as set out in response to MC1) has been finalised, all relevant national guidance and publications will be updated. The College of Policing is also in the process of reviewing the “Investigative supervisor / manager programme” to ensure there is clear reference to unexpected deaths and decision making processes for the allocation of investigations. It is expected this review will conclude by April 2022.” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
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 Review and amend the national curriculum, Investigative Supervisor/Manager Programme and APP to clarify responsibilities for leading death investigations.
Verbatim wording from the response “The College of Policing will be reviewing and making any required changes to the national curriculum, the “Investigative supervisor / manager programme” and APP, to ensure there is clear guidance on the responsibilities of those leading death investigations.” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing guidance and forensic standards are considered sufficient to govern sensitive, accurate handwriting analysis and evidence collection.
Verbatim wording from the response “The NPCC and College of Policing guidance and training states that investigative decisions should be recorded. This would include a line of enquiry to establish who has, or may have, written a note, letter or other document. How such enquiries are undertaken should be in accordance with the Senior Investigating Officer’s strategy.” Source location 2022-0017-Response-from-NPCC-and-College-of-Policing_Published-1
Open published response
17 Nov 2021 Trevor Alton SMITH · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of a clear process for cascading relevant MARAC information to involved officers View source Failure of officers to understand the need for rescue breaths during resuscitation View source Failure to allocate a single coordinator for CPR when sufficient personnel are available View source Lack of clear processes for accurately recording information at MARAC View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Trevor Alton SMITH · 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
Trevor Smith died after being shot by a member of a police armed response unit during an attempted arrest at his home. The principal concerns were that information about an alleged previous overdose was not recorded or cascaded to the firearms team, and that officers were confused about CPR rescue breaths and coordination during resuscitation.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear process for cascading relevant MARAC information to involved officers
Wider context from the report “1. MARAC Information: Before firearms officers deployed to Mr Smith’s address a MARAC (Multi Agency Risk Assessment Conference) meeting took place on 12/03/19 when agencies shared information about the alleged victim of domestic violence and the alleged suspect Mr Smith. The evidence at the inquest confirmed that it was likely that Birmingham and Solihull Mental Health NHS Foundation Trust shared information that Mr Smith had taken an overdose of medication in January 2019. This information was not minuted by WMP nor reported back to the Senior Investigating Officer or the firearms team. As a result, they were unaware of this information and Mr Smith was not declared EMD (emotionally and mentally distressed). The evidence at the inquest confirmed that actions would have been the same even had Mr Smith been declared EMD. It was clear during the evidence that there was no clear guidance/process for accurately recording information at MARAC by WMP and no clear process for ensuring relevant information is cascaded to officers involved in the case . Consideration should be given to updating existing processes and policies to ensure accurate and relevant information is cascaded from MARAC.
2. CPR coordinator. The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies and procedures and training to ensure one person is allocated to coordinate CPR if it is required.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of officers to understand the need for rescue breaths during resuscitation
Wider context from the report “1. MARAC Information: Before firearms officers deployed to Mr Smith’s address a MARAC (Multi Agency Risk Assessment Conference) meeting took place on 12/03/19 when agencies shared information about the alleged victim of domestic violence and the alleged suspect Mr Smith. The evidence at the inquest confirmed that it was likely that Birmingham and Solihull Mental Health NHS Foundation Trust shared information that Mr Smith had taken an overdose of medication in January 2019. This information was not minuted by WMP nor reported back to the Senior Investigating Officer or the firearms team. As a result, they were unaware of this information and Mr Smith was not declared EMD (emotionally and mentally distressed). The evidence at the inquest confirmed that actions would have been the same even had Mr Smith been declared EMD. It was clear during the evidence that there was no clear guidance/process for accurately recording information at MARAC by WMP and no clear process for ensuring relevant information is cascaded to officers involved in the case. Consideration should be given to updating existing processes and policies to ensure accurate and relevant information is cascaded from MARAC.
2. CPR coordinator. The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation . The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies and procedures and training to ensure one person is allocated to coordinate CPR if it is required.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate a single coordinator for CPR when sufficient personnel are available
Wider context from the report “1. MARAC Information: Before firearms officers deployed to Mr Smith’s address a MARAC (Multi Agency Risk Assessment Conference) meeting took place on 12/03/19 when agencies shared information about the alleged victim of domestic violence and the alleged suspect Mr Smith. The evidence at the inquest confirmed that it was likely that Birmingham and Solihull Mental Health NHS Foundation Trust shared information that Mr Smith had taken an overdose of medication in January 2019. This information was not minuted by WMP nor reported back to the Senior Investigating Officer or the firearms team. As a result, they were unaware of this information and Mr Smith was not declared EMD (emotionally and mentally distressed). The evidence at the inquest confirmed that actions would have been the same even had Mr Smith been declared EMD. It was clear during the evidence that there was no clear guidance/process for accurately recording information at MARAC by WMP and no clear process for ensuring relevant information is cascaded to officers involved in the case. Consideration should be given to updating existing processes and policies to ensure accurate and relevant information is cascaded from MARAC.
2. CPR coordinator. The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit . Consideration should be given to amending policies and procedures and training to ensure one person is allocated to coordinate CPR if it is required.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of clear processes for accurately recording information at MARAC
Wider context from the report “1. MARAC Information: Before firearms officers deployed to Mr Smith’s address a MARAC (Multi Agency Risk Assessment Conference) meeting took place on 12/03/19 when agencies shared information about the alleged victim of domestic violence and the alleged suspect Mr Smith. The evidence at the inquest confirmed that it was likely that Birmingham and Solihull Mental Health NHS Foundation Trust shared information that Mr Smith had taken an overdose of medication in January 2019. This information was not minuted by WMP nor reported back to the Senior Investigating Officer or the firearms team. As a result, they were unaware of this information and Mr Smith was not declared EMD (emotionally and mentally distressed). The evidence at the inquest confirmed that actions would have been the same even had Mr Smith been declared EMD. It was clear during the evidence that there was no clear guidance/process for accurately recording information at MARAC by WMP and no clear process for ensuring relevant information is cascaded to officers involved in the case. Consideration should be given to updating existing processes and policies to ensure accurate and relevant information is cascaded from MARAC.
2. CPR coordinator. The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies and procedures and training to ensure one person is allocated to coordinate CPR if it is required.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise establishing a first-aid or CPR coordinator as a substantive issue at the next NPCC First Aid Forum meeting.
Verbatim wording from the response “As a matter of course all coroner reports and inquests related to the provision of first aid by police officers is reviewed by the NPCC First Aid Forum as a standing agenda item. At the NPCC First Aid Forum meeting on the 9th December 2021 the chair raised the issue of establishing a ‘safety officer’ where, if possible, an officer at the scene might provide oversight for colleagues administering first aid. These discussions were not related to the inquest in question but in reflection of possible organisational learning from a similar role being considered for officer personal safety training, specifically when conducting restraint. There was broad support for the idea, and further discussions will take place at the next meeting on 25th March.” Source location 2021-0387-Response-from-College-of-Policing_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a national circular to chief officers raising the concerns and recommending that forces consider local MARAC information-recording and sharing practices.
Verbatim wording from the response “Police forces implement localised policies and practice in terms of the recording and dissemination of intelligence. The College Authorised Professional Practice for Armed Policing (APP-AP) Armed policing (college.police.uk) provides guidance to firearms commanders in respect of information and intelligence gathering, and the importance of considering the potential that the subject of an operation may be emotionally or mentally distressed. I consider the relevant APP-AP content to be appropriate. My Armed Policing Team has, however, agreed with the National Police Chiefs’ Council (NPCC) portfolio lead for armed policing (Chief Constable Simon Chesterman), to publish a national circular for dissemination to chief officers.” Source location 2021-0387-Response-from-College-of-Policing_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing APP-AP provides appropriate operational guidance for armed-policing medical assistance and does not require amendment.
Verbatim wording from the response “The APP-AP is regularly reviewed often in response to recommendation and investigation findings, and includes a requirement to prioritise medical assistance and some of the associated considerations for commanders. It was revised in May 2021, and the revised version contains additional guidance in respect of ensuring the prompt attendance of ambulance service staff in the event of police firearms discharge. This amendment was made in response to findings identified by the Independent Office for Police Conduct (IOPC) in their investigation into the fatal shooting of Mr Smith. I consider that the APP-AP already provides appropriate operational guidance. However I do feel that amendments to training could be considered.” Source location 2021-0387-Response-from-College-of-Policing_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A dedicated CPR coordinator cannot always be identified because armed officers may be deployed in small numbers with competing operational responsibilities.
Verbatim wording from the response “While the College sets the required learning standards to be achieved by armed officers, the training to support these outcomes is developed and delivered under local ‘clinical governance’ arrangements. This ensures the appropriate clinical expertise, and the currency and credibility of the first aid interventions that are included. The first aid training delivered to armed officers also has to be delivered within the context of armed operations to ensure its relevance to operational situations. Armed officers must receive first aid refresher training every year, during which they are assessed for their continued competence. The national training and policy do not currently include or mandate the appointment of a CPR or first aid coordinator.” Source location 2021-0387-Response-from-College-of-Policing_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation West Midlands Police and other forces are responsible for local policies and practices governing MARAC information recording and dissemination.
Verbatim wording from the response “The first concern raised in the report relates to the MARAC process undertaken by West Midlands police, and specifically that potentially significant information disclosed at a meeting to discuss Mr Smith was not effectively cascaded to the SIO or firearms team prior to the policing operation to arrest him. I understand that West Midlands police has provided a response to your concern.” Source location 2021-0387-Response-from-College-of-Policing_Published
Open published response
3 Nov 2021 Saskia Jones and 2 others · Prevention of Future Deaths report London City
View report summary
Concerns raised 24 Failure to inform MAPPA panels about regularity and form of overt offender-management contact View source Insufficient consideration of extremist offenders’ dishonest self-presentation View source Failure to share and consider counter-terrorism police intelligence in MAPPA management View source Failure to properly reason and record offender-manager licence-condition approvals View source Failure to provide MAPPA panels important prison-history information View source Failure to provide MAPPA panels direct input from the preparing forensic psychologist View source Failure to communicate between offender managers and event organisers before extremist offenders attend events View source Insufficient risk assessment and management for prison higher education programmes involving post-release offender contact View source Sudden disruption of DDP mentoring arrangements View source Sudden loss of supervised internet access for employment searches View source Failure to complete the full structured assessment before changing an OASys risk rating View source Failure to properly consider security-sensitive information in MAPPA decisions View source Lack of precautionary search capability for terrorist offenders on licence View source Failure to detect Class A drug use by terrorist offenders on licence View source Unavailability of offender risk-profile information to prison-based higher education providers View source Failure to ensure all MAPPA meeting attendees receive meeting minutes View source Failure to ensure direct forensic psychologist involvement in ERG 22+ assessment reports View source Failure to assess risks of continuing close contact between serious offenders and young students View source Excessive reliance on compliance in management of extremist offenders View source Failure to communicate high-risk event attendance to host venues View source Failure to directly address risks when approving licence-condition changes View source Lack of formal risk assessment for higher education events held outside university premises View source Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes View source Failure to record proper rationale for changes to OASys risk ratings View source See 21 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Saskia Jones and 2 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 29 November 2019, Usman Khan carried out a terrorist attack at Fishmongers’ Hall, fatally stabbing Saskia Jones and Jack Merritt before being fatally shot by firearms officers on London Bridge. The report raised concerns about risk assessment and communication for events involving high-risk offenders, and about the assessment, information-sharing, supervision and management of terrorist offenders released into the community.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to inform MAPPA panels about regularity and form of overt offender-management contact
Wider context from the report “The facts of this case give cause for concern that MAPPA panels responsible for managing terrorist offenders may be unaware of the regularity and form of contact with police officers responsible for overt offender management .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of extremist offenders’ dishonest self-presentation
Wider context from the report “The facts of this case give rise to concern that probation officers may give insufficient regard to instances of dishonesty in self-presentation by extremist offenders .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to share and consider counter-terrorism police intelligence in MAPPA management
Wider context from the report “This case gives cause for concern that counter-terrorism police may be in possession of intelligence or information which may be useful to the management of an offender by the MAPPA panel, but that such intelligence or information may not be brought to the knowledge of or taken into account by MAPPA agencies .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to properly reason and record offender-manager licence-condition approvals
Wider context from the report “This case gives rise to concern that offender managers may take significant decisions to give approvals under licence conditions without those decisions being properly reasoned and recorded .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MAPPA panels important prison-history information
Wider context from the report “The facts of this case give cause for concern that some members of MAPPA panels responsible for managing extremist offenders may not be aware of important information from the offender’s time in prison .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MAPPA panels direct input from the preparing forensic psychologist
Wider context from the report “It is a matter for concern that MAPPA panels managing even the most serious offenders may not have the benefit of hearing directly from a forensic psychologist who has prepared an ERG report shortly prior to the offender’s release .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate between offender managers and event organisers before extremist offenders attend events
Wider context from the report “This case gives rise to concern that an extremist offender may be permitted to attend an event or venue without there having been proper communication between the probation and police officers responsible for managing the offender and the event organisers and/or venue hosts .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient risk assessment and management for prison higher education programmes involving post-release offender contact
Wider context from the report “Consideration should be given to whether further measures of risk assessment and management can be introduced for any higher education programmes running in prisons which involve continued contact with offenders after their release into the community .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Sudden disruption of DDP mentoring arrangements
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Sudden loss of supervised internet access for employment searches
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the full structured assessment before changing an OASys risk rating
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to properly consider security-sensitive information in MAPPA decisions
Wider context from the report “The facts of this case give cause for concern that security sensitive information may not be properly taken into account in decision-making by MAPPA panels concerning the management of terrorist offenders.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of precautionary search capability for terrorist offenders on licence
Wider context from the report “The facts of this case gave cause for concern that those involved in managing terrorist offenders on licence may lack a valuable means of addressing risks they pose, namely an ability to carry out a search on a precautionary basis .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to detect Class A drug use by terrorist offenders on licence
Wider context from the report “The facts of this case give cause for concern that a terrorist offender on licence, who was subject both to strict licence conditions and to a priority investigation, could obtain and use Class A drugs without that being detected .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Unavailability of offender risk-profile information to prison-based higher education providers
Wider context from the report “It is a matter of concern that Learning Together could operate courses in prisons in the way it did without being given information about the risk profiles of offenders joining courses .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure all MAPPA meeting attendees receive meeting minutes
Wider context from the report “Based on the evidence in this case, there is cause for concern that effective procedures are not in place to ensure that all MAPPA meeting attendees receive meeting minutes .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure direct forensic psychologist involvement in ERG 22+ assessment reports
Wider context from the report “Notwithstanding the measures which the NPS has put in place since the attack, there remains cause for concern that ERG 22+ assessment reports may be prepared by a CTPO without the direct involvement of a forensic psychologist .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to assess risks of continuing close contact between serious offenders and young students
Wider context from the report “It is a matter of concern that focussed consideration was not given to the risks of serious offenders being placed in close and continuing contact with young students .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Excessive reliance on compliance in management of extremist offenders
Wider context from the report “Based on the facts of this case, there is cause for concern that probation officers may attach excessive weight in their management of extremist offenders to “compliance” (i.e. absence of evidence of breach of licence conditions and police behaviour).
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate high-risk event attendance to host venues
Wider context from the report “It is a matter of concern that a major event could be held by a University at a livery company hall in London without clear communication of the fact that it would be attended by serving and recently released serious offenders .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to directly address risks when approving licence-condition changes
Wider context from the report “This case gives cause for concern that an offender manager and/or MAPPA panel participants could approve a permission, variation or relaxation in relation to a licence condition without directly addressing the potential risks involved .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of formal risk assessment for higher education events held outside university premises
Wider context from the report “It is a matter of concern that there was no such risk assessment for Learning Together events as set out above.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes
Wider context from the report “The facts of this case give rise to concern that important decisions on approvals, variations and relaxations in relation to licence conditions may be taken without clearly reasoned discussion and decision-making in MAPPA panels .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to record proper rationale for changes to OASys risk ratings
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with partners and stakeholders to update offender-management guidance and products to reflect changes resulting from the report.
Verbatim wording from the response “The ‘offender management’ guidance and products have been developed over a number of years and we will continue to work with partners and stakeholders to ensure they are updated to” Source location 2021-0362-Response-from-College-of-Policing_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Other bodies are taking forward substantive work on the concerns, so further College guidance or training would risk duplicating their work.
Verbatim wording from the response “In developing our response, we are grateful to the other addressees (and national Counter Terrorism policing) who have shared their responses with us. We note from their responses that these addressees have taken forward, or plan to take forward, substantive work to address the seven MCs listed above.” Source location 2021-0362-Response-from-College-of-Policing_Published
Open published response
19 Oct 2021 Donna Constantine · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Unavailability of verbatim recording for calls received by officers View source Lack of a clear escalation policy for calls received by officers from members of the community View source Failure to monitor officers’ work mobile phones when they are off duty or on annual leave View source Lack of a clear policy for creating an audit trail of actions taken on received calls 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
Donna Constantine · 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
Donna Ann Constantine, a vulnerable adult known to multiple agencies, was found severely decomposed at her home on 21 September 2019 after neighbours raised concerns. The post-mortem examination could not establish a cause of death, and the inquest conclusion was open. Concerns included the use of unmonitored police work mobile phones for contact from vulnerable people, alongside the absence of clear escalation, audit-trail, and verbatim call-recording policies.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Unavailability of verbatim recording for calls received by officers
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately.
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear escalation policy for calls received by officers from members of the community
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately.
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor officers’ work mobile phones when they are off duty or on annual leave
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave . This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately .
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear policy for creating an audit trail of actions taken on received calls
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately.
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team.
” Open source report
×
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 National policing forces were not encouraged to provide officers’ mobile numbers as emergency or welfare-contact numbers.
Verbatim wording from the response “The notice sets out your principal concern which highlights a text message sent by a vulnerable person to a Police Officer’s mobile phone which was not being monitored and your concern that giving out officer’s phone numbers to victims was a national policing approach.” Source location Response from NPCC
Open published response
28 Sep 2021 Richard Boateng · Prevention of Future Deaths report South London
View report summary
Concerns raised 3 Lack of practical guidance for police conveyance of patients to hospital when ambulances are unavailable View source Lack of guidance for surgeries on managing non-clinical judgments about appointment urgency View source Failure to update and clarify ambulance-service guidance for crews and control staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Boateng · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Boateng became very unwell after contacting his GP surgery and was later found on a street bench. Police and ambulance services attended, but he died from Covid 19 shortly after arriving at hospital; concerns included the handling of urgent GP calls, communication between ambulance and police services, and practical guidance for police when ambulances were unavailable.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of practical guidance for police conveyance of patients to hospital when ambulances are unavailable
Wider context from the report “(3) College of Policing. Due to the Covid pandemic, no ambulances were available when police attended to Richard. The Metropolitan Police Service had a policy that permitted conveying patients to hospital in an emergency if no ambulances were available. However, the policy included no practical guidance as to how that could be achieved mitigating the risks . I heard that the Metropolitan Police Service is updating the guidance. However, I am concerned that other forces across the country may also lack such practical guidance , which is of particular concern due to ongoing pandemic and the demands that may continue of ambulance services.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for surgeries on managing non-clinical judgments about appointment urgency
Wider context from the report “(1) NHS England. A call to the GP surgery the day before Richard’s death was taken by a receptionist who arranged a routine appointment. She was not a clinician and only had on the job training. The surgery has since introduced a system called Klinik which is safer. It prompts questions and uses an algorithm to alert any urgent or emergency calls that are then flagged. All calls are also reviewed by clinicians. However, I am concerned that other surgeries may employ non-clinicians who may be required to make judgments as to the urgency of appointments , and there is no guidance available to surgeries as to how to mitigate the risks of this .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to update and clarify ambulance-service guidance for crews and control staff
Wider context from the report “(2) London Ambulance Service. The GP called LAS concerned about Richard’s welfare. LAS attended his home address. Richard was not there. The LAS paramedic advised his sister to call the police. The LAS quality manager accepted in evidence that it would have been better to have taken her number and to pass it on to the police to make contact. I was told that national guidance on this issue was published in the summer. To date, neither guidance to crews nor to control had been updated to make the LAS guidance clearer to those applying it .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use developed Authorised Professional Practice to guide officers’ dynamic risk assessments and decisions when transporting patients without an ambulance.
Verbatim wording from the response “That said, there will be instances when this may be necessary, and in those scenarios I would expect officers to conduct a dynamic risk assessment at the scene. The College has developed Authorised Professional Practice (APP) to aid decision making National Decision Model (college.police.uk); this practical guidance guides officers through a process of considering the information, assessing the risks, considering policy and available powers, identifying options and finally taking action. In the absence of an ambulance and taking account of the prevailing circumstances (in particular the risk to the patient), I consider that the APP already provides appropriate guidance.” Source location 2021-0335-Response-from-College-of-Policing_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate the issue to the NPCC First Aid Forum for consideration of practical advice that can be offered to forces.
Verbatim wording from the response “As a matter of course, all coroner reports and requests related to the provision of first aid by police officers are reviewed by the NPCC First Aid Forum as a standing agenda item. My staff have spoken with the forum chair and have agreed to escalate this issue to the Forum for consideration as to what practical advice can be offered to forces.” Source location 2021-0335-Response-from-College-of-Policing_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transportation of casualties to hospital falls outside the First Aid Learning Programme’s scope and first-aider responsibilities.
Verbatim wording from the response “The College licences the First Aid Learning Programme (FALP) used by Home Office Forces, including the Metropolitan Police Service. The programme is endorsed by the National Police Chiefs’ Council (NPCC) and the Health and Safety Executive (HSE). The College is responsible for ensuring appropriate quality assurance processes are in place to guide forces in the implementation of the HSE guidelines relating to the provision of first aid. However, transportation of casualties to hospital are not within the scope of the responsibility of a first aider (and therefore the FALP).” Source location 2021-0335-Response-from-College-of-Policing_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Authorised Professional Practice and dynamic risk assessment already provide appropriate guidance when officers transport casualties without an ambulance.
Verbatim wording from the response “That said, there will be instances when this may be necessary, and in those scenarios I would expect officers to conduct a dynamic risk assessment at the scene. The College has developed Authorised Professional Practice (APP) to aid decision making National Decision Model (college.police.uk); this practical guidance guides officers through a process of considering the information, assessing the risks, considering policy and available powers, identifying options and finally taking action. In the absence of an ambulance and taking account of the prevailing circumstances (in particular the risk to the patient), I consider that the APP already provides appropriate guidance.” Source location 2021-0335-Response-from-College-of-Policing_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The College does not issue specific transport guidance because police conveyance carries inherent risks, liabilities and risks of normalising the practice.
Verbatim wording from the response “The transportation of casualties in police vehicles carries inherent risks to the casualty, requiring skills and responsibilities significantly above those of a first aider, and significant liabilities to the officers themselves. For these reasons officers of police transporting casualties should be kept to the absolute minimum and there is concern that development of College issued guidance would not only ‘normalise’ such practices but add to an unrealistic expectation being placed on officers at the scene.” Source location 2021-0335-Response-from-College-of-Policing_Published
Open published response
23 Sep 2021 Hamish John Cameron HOWITT · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Absence of directives in police training material and national policy on referral of apparently intoxicated injured people View source Alcohol-appearing effects masking serious underlying medical conditions View source Insufficient police training to identify and refer apparently intoxicated people complaining of injury View source Failure to recommend hospital or ambulance assessment for apparently intoxicated people complaining of injury View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hamish John Cameron HOWITT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hamish John Cameron HOWITT, a 20-year-old university student, died unexpectedly overnight in Frome on 1 July 2016 after an evening involving alcohol, a traumatic brain injury and self-administered ketamine. The concerns were that police did not recommend hospital assessment after he reported being injured, and that police training and national policy should address the risk of serious underlying conditions being masked by apparent intoxication.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Absence of directives in police training material and national policy on referral of apparently intoxicated injured people
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to College of Policing; that does not assign responsibility.
PFD Monitor interpretation Alcohol-appearing effects masking serious underlying medical conditions
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient police training to identify and refer apparently intoxicated people complaining of injury
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to recommend hospital or ambulance assessment for apparently intoxicated people complaining of injury
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report
×
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 FALP learning outcomes with clinical leads and assess adding stronger coverage of alcohol, intentional overdoses, and head injuries to Module 2.
Verbatim wording from the response “As a matter of course, all coroner reports and requests related to the provision of first aid by police officers are reviewed by the NPCC First Aid Forum as a standing agenda item. The College is also working with clinical leads to review the high-level learning outcomes within the FALP with the aim of placing greater emphasis on the training elements that preserve life. The review is already considering addressing the issue of acute alcohol intoxication and intentional overdoses within Module 2. It is also considering extending the learning in relation to head injuries to Module 2. The matters of concern you raise with relation to the impact of alcohol and the assessment of head injuries will be raised formally at the next meeting (13th December) to assess whether it is feasible and practicable to address these concerns within the scope of the licence.” Source location 2021-0320-Joint-response-from-College-of-Policing-and-National-Police-Chiefs-Council_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The range of incidents makes it impracticable to train all officers for every medical emergency or specify a response for every context.
Verbatim wording from the response “Officers are called on to provide first aid in a wide range of incidents as part of their role. The range of incidents they attend mean it is not possible or viable for all officers to be trained for all types of medical emergencies, or for the FALP to explicitly outline the appropriate medical response in every context. That said, as detailed in this response, we acknowledge there is more that we can do to standardise our training and I trust that we have provided you with assurances that the matters of concern you have raised will be addressed.” Source location 2021-0320-Joint-response-from-College-of-Policing-and-National-Police-Chiefs-Council_Published
Open published response
26 Feb 2021 Mr Joseph Agnew · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness View source Failure to train officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable” View source Failure of post-incident performance review and organisational learning processes View source Failure to train officers on when to refer an intoxicated person for medical attention View source Lack of a safe referral facility for acutely intoxicated homeless people found on buses View source Failure to train officers to effectively monitor breathing and recognise dangerous breathing patterns View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Joseph Agnew · 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
Mr Joseph Agnew suffered an out-of-hospital cardiac arrest after being removed from a bus and left in a bus shelter, was later found unresponsive, and died five days after admission with a devastating brain injury. The report raised concerns about police training and assessment of intoxicated people with reduced responsiveness, including recognising snoring and monitoring breathing, post-incident learning, and the lack of a safe referral facility for acutely intoxicated homeless people found on buses.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness
Wider context from the report “2. For the attention of CoLP, MPS and College of Policing:
No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness , nor how to monitor breathing. My independent expert in A&E gave evidence that snoring indicates partial airway obstruction . He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention . The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing. He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to train officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable”
Wider context from the report “1. For the attention of CoLP and College of Policing:
CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable” . A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of post-incident performance review and organisational learning processes
Wider context from the report “3. For the attention of the MPS:
Two MPS officers who attended the scene gave evidence that they would do nothing different even in hindsight. No evidence was presented as to the post incident performance reviews and individual learning , and there is uncertainty about the adequacy of the corporate process of learning from incidents . There is a lack of assurance to the public that the risks related to the decisions of these officers or other incidents have been mitigated for the future .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to train officers on when to refer an intoxicated person for medical attention
Wider context from the report “1. For the attention of CoLP and College of Policing:
CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable”. A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a safe referral facility for acutely intoxicated homeless people found on buses
Wider context from the report “4. For the attention of the Mayor of London:
Evidence was heard that whilst the police can refer chronic rough sleepers to charities, there is no facility to which police can refer acutely intoxicated homeless people found on buses . It was reported that such facilities do exist elsewhere and that they create a place of safe refuge where monitoring can be effectively conducted. The potential of such a facility to save lives is drawn to the attention of the Mayor.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to train officers to effectively monitor breathing and recognise dangerous breathing patterns
Wider context from the report “2. For the attention of CoLP, MPS and College of Policing:
No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness, nor how to monitor breathing . My independent expert in A&E gave evidence that snoring indicates partial airway obstruction. He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention. The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing . He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and provide a vulnerability learning programme supporting consistent identification of hidden medical conditions and other risks requiring intervention.
Verbatim wording from the response “The PCDA places a high level of emphasis on the potential vulnerability of a person who, because of their situation or circumstances, is unable to take care or protect themself from harm or exploitation. This includes the importance of considering the possibility of hidden medical conditions or non-visible signs that may lead to a person being vulnerable. The College has developed a vulnerability learning programme which supports the PCDA programme and can also be used for officers who have not been trained through the PCDA to ensure consistency in learning.” Source location 2021-0055-Response-from-College-of-Policing-Redacted
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 Review FALP learning outcomes to incorporate concerns about assessing intoxicated people, referral for medical attention, and monitoring breathing and symptoms.
Verbatim wording from the response “In addition, a wider review of the high level learning outcomes for the FALP has already been initiated to ensure that they remain fit for purpose. We will ensure that your causes for concern will form part of this review. It is anticipated that this work will be completed towards the end of 2021 following the publication of updates expected from the UK Resuscitation Council this year.” Source location 2021-0055-Response-from-College-of-Policing-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Chief Officers may add medical training where local force risk assessments identify a critical need, under local clinical governance advice.
Verbatim wording from the response “It is recognised that some areas of policing, such as working in custody environments, firearms operations or public order teams, require additional skills and knowledge. The relevant staff have additional FALP training modules available to ensure they are prepared for situations they are likely to encounter in their specialist roles. Additionally, where local force risk assessments identify a critical need, Chief Officers are able to add additional medical training provisions under the advice of local clinical governance.” Source location 2021-0055-Response-from-College-of-Policing-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The programme cannot provide detailed training covering every medical emergency or policing context because officers attend a wide range of incidents.
Verbatim wording from the response “The FALP has five modules and the national recommendation is that police officers receive a minimum of Module 2 training (the equivalent to the qualification of a HSE Emergency First Aider). While Module 2 does not seek to provide detailed coverage of all specific medical conditions it does allow officers and staff to make an assessment of the casualty, including the known factors that may present a risk to their health.” Source location 2021-0055-Response-from-College-of-Policing-Redacted
Open published response
3 Mar 2020 Katrina Margaret Mary O’Hara · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Failure to provide replacement phones when victims’ phones are seized during an investigation View source Failure to recognise the perpetrator’s suicide risk as a significant domestic abuse risk factor for the victim View source Failure to ensure that non-emergency 999 calls from victims are taken or followed up without requiring the victim to call back View source Failure to ensure police officers are trained to use Niche for linking events and notifying investigation leads 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
Katrina Margaret Mary O’Hara · 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
Katrina Margaret Mary O’Hara was stabbed by her ex-partner outside her place of work on 7 January 2016 and was pronounced deceased at the scene. The report raises concerns about police handling of non-emergency domestic abuse calls, recognition of a perpetrator’s suicide risk, provision of replacement phones when victims’ phones are seized, and the use and training of the Niche police software system.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide replacement phones when victims’ phones are seized during an investigation
Wider context from the report “iii. It is not unusual that the mobile phones of victims are seized by police as part of investigation into domestic abuse related allegations. Until the death of Miss O’Hara, Dorset Police did not provide replacement phones, leaving victims potentially without a means to communicate with others, including in an emergency . As stated above, Dorset Police now have a store of mobile phones available to supply to victims where their phones have been seized as evidence. I am concerned that this may not be in place across the police forces of England and Wales and that victims in some areas are being left without the means of contacting others, including the emergency services, when their phones have been seized by police during an investigation .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the perpetrator’s suicide risk as a significant domestic abuse risk factor for the victim
Wider context from the report “ii. Dorset Police have changed their Domestic Abuse Investigation Policy and Procedure to include the suicide risk of the perpetrator of domestic abuse as a significant risk factor for the victim of domestic abuse . This is a recent change and reflects the growing understanding that the perpetrator who has “nothing left to lose” poses a significant risk to his or her victim. I am concerned that this change in policy in Dorset may not be reflected nationwide .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that non-emergency 999 calls from victims are taken or followed up without requiring the victim to call back
Wider context from the report “i. I am concerned that Police Forces across England and Wales may still be employing a policy similar to that previously employed by Dorset Police, with regard to non-emergency calls made to 999 . Dorset Police have recognised the courage it takes a victim of domestic violence to make a call to the police so have now ensured that, depending on the risk level and whether police attendance will be required, the call will either be taken by the 999 call handler, or, where it is deemed that no police attendance at any time is likely required, the caller will be called back at a later convenient time. It is no longer left to the victim to make a subsequent call to the police in relation to the same complaint. The concern is that if similar policies are not in place across the police forces in England and Wales, victims of offences, who may have had to take a huge risk to themselves or others to make the call to the police, are being asked to call back on a different number if their call is not categorised as an emergency .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police officers are trained to use Niche for linking events and notifying investigation leads
Wider context from the report “iv. “Niche” is a software program used by, I understand, 23 police forces across England and Wales. I do not know if more forces are due to adopt Niche in the future. I am concerned that appropriate training needs to be provided to police officers to ensure they have a good understanding of Niche and how to “link” events to an occurrence and to ensure that the appropriate individuals, for example the officer leading an investigation, are notified of any developments in a case .
” Open source report
Concerns raised 3 Insufficient independent data on the effects and lethality of Taser use View source Failure of police training to specify safe limits for the number and duration of Taser activations View source Lack of understanding of incremental risk from multiple Taser activations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marc Antony Cole · 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 23 May 2017, Marc Antony Cole ingested a substantial amount of cocaine, behaved in a paranoid and psychotic manner, self-harmed and was Tasered three times by police before suffering a cardiac arrest and dying in hospital. The report raised concerns about limited independent data on the lethality and incremental risks of multiple or sustained Taser activations, and whether police advice and training were therefore deficient or incomplete.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient independent data on the effects and lethality of Taser use
Wider context from the report “It was said by a number of witnesses that the Taser is not a device without risk but that there is limited data as to its effects upon individuals (both generally but more particularly in those classified as vulnerable).
In evidence it was clear that there is no understanding about the potential for incremental risk with multiple Taser activations and no training provided as to the maximum number of activations nor of their duration which is appropriate or safe.
The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’).
It was clear from the evidence of ████████ (an intensivist consultant) that a Taser does carry a risk – despite, he said, the claims of the manufacturers - but the extent of that risk is far from clear.
Two forensic pathologists gave evidence and confirmed their joint opinion that the Taser caused (together with other things) Mr Cole’s death in that it played a more than minimal, trivial or negligible part.
Although I found as a fact that the training given to the police officers was appropriate I did so ONLY upon the basis that it was given based upon the limited knowledge presently available.
I am concerned, based upon the evidence that was led before the jury, that there is insufficient independent data as to the lethality of Taser use and that, therefore the advice and training provided to police officers may be deficient or incomplete.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of police training to specify safe limits for the number and duration of Taser activations
Wider context from the report “It was said by a number of witnesses that the Taser is not a device without risk but that there is limited data as to its effects upon individuals (both generally but more particularly in those classified as vulnerable).
In evidence it was clear that there is no understanding about the potential for incremental risk with multiple Taser activations and no training provided as to the maximum number of activations nor of their duration which is appropriate or safe.
The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’).
It was clear from the evidence of ████████ (an intensivist consultant) that a Taser does carry a risk – despite, he said, the claims of the manufacturers - but the extent of that risk is far from clear.
Two forensic pathologists gave evidence and confirmed their joint opinion that the Taser caused (together with other things) Mr Cole’s death in that it played a more than minimal, trivial or negligible part.
Although I found as a fact that the training given to the police officers was appropriate I did so ONLY upon the basis that it was given based upon the limited knowledge presently available.
I am concerned, based upon the evidence that was led before the jury, that there is insufficient independent data as to the lethality of Taser use and that, therefore the advice and training provided to police officers may be deficient or incomplete.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of incremental risk from multiple Taser activations
Wider context from the report “It was said by a number of witnesses that the Taser is not a device without risk but that there is limited data as to its effects upon individuals (both generally but more particularly in those classified as vulnerable).
In evidence it was clear that there is no understanding about the potential for incremental risk with multiple Taser activations and no training provided as to the maximum number of activations nor of their duration which is appropriate or safe.
The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’).
It was clear from the evidence of ████████ (an intensivist consultant) that a Taser does carry a risk – despite, he said, the claims of the manufacturers - but the extent of that risk is far from clear.
Two forensic pathologists gave evidence and confirmed their joint opinion that the Taser caused (together with other things) Mr Cole’s death in that it played a more than minimal, trivial or negligible part.
Although I found as a fact that the training given to the police officers was appropriate I did so ONLY upon the basis that it was given based upon the limited knowledge presently available.
I am concerned, based upon the evidence that was led before the jury, that there is insufficient independent data as to the lethality of Taser use and that, therefore the advice and training provided to police officers may be deficient or incomplete.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide College guidance addressing risks from repeated and prolonged Taser discharges.
Verbatim wording from the response “College learning materials and guidance do address the risks associated with the number and duration of Taser activations. Section 3 and 4 below set out the relevant materials the College has provided to police forces. They are in line with the medical implications and advice provided by SACMILL.” Source location 2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Taser learning materials covering discharge duration, repeated activations, medical risks, vulnerable people and aftercare.
Verbatim wording from the response “Section 4. Learning materials” Source location 2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with SACMILL so Taser guidance and training reflect current independent scientific evidence.
Verbatim wording from the response “We would like to thank you for bringing the circumstances of Mr Cole’s death to our attention and we will ensure that our immediate and future work is informed by the events that culminated in Marc’s tragic death. We keep Taser training under regular review and we will carefully examine the findings of Mr Cole’s inquest to ensure learning continues to be reflected. The College will also continue to work with SACMILL to ensure that our guidance and training are always informed by the most up-to-date independent scientific evidence available to us.” Source location 2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
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 Keep Taser training under regular review.
Verbatim wording from the response “We would like to thank you for bringing the circumstances of Mr Cole’s death to our attention and we will ensure that our immediate and future work is informed by the events that culminated in Marc’s tragic death. We keep Taser training under regular review and we will carefully examine the findings of Mr Cole’s inquest to ensure learning continues to be reflected. The College will also continue to work with SACMILL to ensure that our guidance and training are always informed by the most up-to-date independent scientific evidence available to us.” Source location 2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation College training is not silent on the risks associated with multiple or prolonged Taser activations.
Verbatim wording from the response “2.1: No training provided as to the maximum number of activations nor of their duration which is appropriate or safe. The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’).” Source location 2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Home Office and SACMILL are better placed to comment on the evidence and whether further Taser research is required.
Verbatim wording from the response “In performing its role SACMILL has taken account of a body of evidence relating to the use of Taser. The College is not able to comment on the detail of the evidence that has been reviewed. The Home Office and SACMILL would be better placed to comment on the detail of the evidence and as to whether any further research is required.” Source location 2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing College guidance and learning materials address Taser activation risks and align with SACMILL medical advice.
Verbatim wording from the response “In summary, my detailed response explains that current College guidance and learning material address the risks associated with the number and duration of Taser activations. Our materials have been developed in close consultation with the independent body (SACMILL*) that advises the Home Office on the medical issues associated with conducted energy devices and are in line with their advice. The Home Office and SACMILL would be better placed to comment on the evidence base.” Source location 2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Definitive guidance on the number and duration of Taser discharges cannot be given because influencing factors are numerous and varied.
Verbatim wording from the response “The point should be made that it is not possible to give officers definitive guidance on the number and duration of discharges, as the factors that would influence this decision are many and varied. We take the position that every discharge must be lawful, necessary and proportionate to the threat posed and be informed by the risk factors identified, where possible. However, some risk factors may not be immediately apparent to the officer, meaning that it is not possible to account for them. We reiterate the SACMILL position that Taser activation should be minimised to reduce risk, however it is not possible to eliminate all risk.” Source location 2020-0087-Response-from-the-College-of-Policing-Redcated.pdf
Open published response
20 Jan 2020 Deborah Margaret LAMONT · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1 Lack of specific guidance on classification of hotel rooms under the s136(1A) exception View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Deborah Margaret LAMONT · 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
Deborah Margaret Lamont travelled to a hotel on 28 March 2019, where she suspended herself by a ligature and was found deceased by police officers shortly after 11pm. The principal concern was that police officers might incorrectly conclude that the power under section 136 of the Mental Health Act did not apply in a hotel room, potentially placing an individual at risk of 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance on classification of hotel rooms under the s136(1A) exception
Wider context from the report “Regard was had during the Inquest as to the Department of Health Guidance to the changes to the MHA 1983, published in October 2017. No specific guidance as to the classification of a hotel room for the purposes of whether that falls within the exception in s136 (1A) is provided.
Whilst it is accepted, both by myself, & in the Guidance, as above, that there will always be some degree of discretion for a police officer to exercise in relation to the interpretation of whether a person is living in a hotel room, the evidence here was that DL had booked into the room for one night & had no more than a bare licence to occupy it (which would contrast with, for example, an individual or family temporarily housed in a hotel room by a local authority, or a care home resident occupying indefinitely a room in a care home).
Hence, based upon the evidence I received, and my interpretation (in these particular circumstances) of whether a hotel room came within s136 (1A) MHA, I found it likely that ████████ did have the power to remove DL to a place of safety
My concern is that faced with a similar situation (albeit in circumstances were the officer did consider a person was suffering from mental disorder and requiring of immediate care, or control), an officer may reach the same conclusion as ████████ determine the power to remove did not exist, and this may lead to a risk of death to that individual.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Home Office to assess whether national guidance on section 136 and hotel rooms requires relevant changes.
Verbatim wording from the response “In summary, I share your view that s136 was an available option in this instance but there is no legal basis to mandate this. I am therefore going to be amending the College guidance in respect of the use of s136 powers and will ask that a summary of this issue is circulated to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. The College has already raised the issue with the Home Office and we will work together to assess the need for relevant changes to the current national guidance in relation to the use of s136 and hotel rooms. The College will keep forces appraised of developments.” Source location 2020-0008-Response-from-the-College-of-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend College guidance on using section 136 powers in hotel rooms.
Verbatim wording from the response “In summary, I share your view that s136 was an available option in this instance but there is no legal basis to mandate this. I am therefore going to be amending the College guidance in respect of the use of s136 powers and will ask that a summary of this issue is circulated to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. The College has already raised the issue with the Home Office and we will work together to assess the need for relevant changes to the current national guidance in relation to the use of s136 and hotel rooms. The College will keep forces appraised of developments.” Source location 2020-0008-Response-from-the-College-of-Police_Redacted
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 Circulate a summary of the hotel-room section 136 issue to police force mental health leads across England and Wales.
Verbatim wording from the response “In summary, I share your view that s136 was an available option in this instance but there is no legal basis to mandate this. I am therefore going to be amending the College guidance in respect of the use of s136 powers and will ask that a summary of this issue is circulated to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. The College has already raised the issue with the Home Office and we will work together to assess the need for relevant changes to the current national guidance in relation to the use of s136 and hotel rooms. The College will keep forces appraised of developments.” Source location 2020-0008-Response-from-the-College-of-Police_Redacted
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 Keep police forces informed of developments concerning section 136 use in hotel rooms.
Verbatim wording from the response “In summary, I share your view that s136 was an available option in this instance but there is no legal basis to mandate this. I am therefore going to be amending the College guidance in respect of the use of s136 powers and will ask that a summary of this issue is circulated to all police force mental health leads across England and Wales so that they can ensure that their officers consider the use of s136 in similar circumstances. The College has already raised the issue with the Home Office and we will work together to assess the need for relevant changes to the current national guidance in relation to the use of s136 and hotel rooms. The College will keep forces appraised of developments.” Source location 2020-0008-Response-from-the-College-of-Police_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use of section 136 in hotel rooms cannot be mandated because there is no legal basis; officers must assess each case individually.
Verbatim wording from the response “As this is a matter of law, the College has sought its own legal advice to assist in providing this response. The advice received agreed with your assessment that someone ‘living’ in a room implies that the person normally resides in that place and is not there temporarily. There are no definitions provided within the legislation and no stated cases that assist in providing clarification. Consequently, the use of s136 in these circumstances is a subjective one and requiring individual assessment and interpretation. In other words, the use of s136 in the case of Deborah Lamont could have been a consideration.” Source location 2020-0008-Response-from-the-College-of-Police_Redacted
Open published response
Concerns raised 1 Insufficient clarity of police guidance for missing-person risk-level decisions 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
Name not published · 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
The deceased was reported missing after telling his wife he was going to a supermarket, and was later found hanged in woodland on 30 April 2018. The report considered whether police should have raised the missing-person risk level from medium to high earlier. The concern was that clearer national guidance might support more consistent decision-making in complex cases.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient clarity of police guidance for missing-person risk-level decisions
Wider context from the report “The appropriateness of the police response to the report of ████████ as a missing person on 29 April was considered by the IOPC. In evidence at the inquest, I heard from their ████████ who concluded that there had been an opportunity to raise the risk to high at an earlier stage. He did note, however, that the matter had ostensibly been dealt with as a high-risk response for some time prior to its re-categorisation at that level. I was not able to conclude that the delay in raising the level of risk to high had been causative of the death as it was not known at what time ████████ had, in fact, hanged himself. It had to be noted that there was a period of approximately eight hours before he was first reported to police as a missing person.
It was accepted in evidence that the decision as to the appropriate level of risk was essentially a “judgement call” on the part of the individual officer . It was further accepted that there would be occasions when these judgements would be very finely balanced .
It was not felt that there had been any failure to follow practice or protocol at a local level. It was noted, however, that it would be sensible to share the salient facts with you in order that there could be a proper review of the guidance contained within the relevant College of Policing APP upon which the police officers relied. It was recognised that if the guidance could be clearer this may assist different officers from achieving a greater level of consistency in decision-making when faced with the same, complex set of facts.
” Open source report
19 Nov 2019 Katie Croft · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 15 Failure to share Child and Family Assessments in accordance with best practice View source Unclear dissemination of safeguarding investigation lessons beyond the local area View source Failure to establish available recordings and the scope of relevant social media evidence before case closure View source Lack of a formal school follow-up procedure after a Child and Family Assessment View source Lack of a mechanism for schools to receive relevant Child and Family Assessment information View source Failure to conduct a further face-to-face conversation with the child View source Lack of clear exam-board guidance for teachers to minimise risk to pupils when teaching sensitive material View source Failure to consider victimless prosecution before closing matters View source Failure to provide teachers with relevant information about a pupil's self-harm history and vulnerability View source Failure to fully hear the voice of the child throughout safeguarding investigations View source Failure to ensure case officers attend safeguarding strategy meetings View source Failure to complete Child and Family Assessments in accordance with best practice amid reliance on agency social workers View source Lack of officer capability in joint working with social services and applying the voice of the child View source Delays in seizing key digital evidence View source Failure to allocate appropriately experienced specialist officers to alleged sexual offences View source See 12 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
Katie Croft · 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
Katie Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to share Child and Family Assessments in accordance with best practice
Wider context from the report “2. The Local Authority at the time were using a substantial number of agency social workers. As a result the Child and Family Assessment was not completed in accordance with best practice and not shared in accordance with expectations around best practice . The Local Authority has since made significant progress in moving away from a reliance on agency staff to fill gaps in social work cover. The inquest was told that agency social workers are still used extensively in other Local Authorities creating a risk that a similar situation could arise;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Unclear dissemination of safeguarding investigation lessons beyond the local area
Wider context from the report “4. It was accepted by witnesses for both the Local Authority and GMP that the voice of the child was not fully heard throughout their investigations. They via the safeguarding board commissioned an independent report whose findings and recommendations have been fully adopted by the safeguarding board. It was unclear what if any steps would be taken to disseminate the lessons pan GM or nationally ;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to establish available recordings and the scope of relevant social media evidence before case closure
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages . No attempt was made to have a further face to face conversation with Katie;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal school follow-up procedure after a Child and Family Assessment
Wider context from the report “5. A further concern identified was that there was no mechanism for the school to be formally aware of information within the Child and Family Assessment. As a result there was no formal follow-up procedure set out in the best practice national guidance the school was working within . The inquest heard that Katie’s school recognising this gap has built on the working together guidance to develop guidance that ensures there is a proactive approach to engaging with a child and their family post the writing of a Child and Family Assessment;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for schools to receive relevant Child and Family Assessment information
Wider context from the report “5. A further concern identified was that there was no mechanism for the school to be formally aware of information within the Child and Family Assessment . As a result there was no formal follow-up procedure set out in the best practice national guidance the school was working within. The inquest heard that Katie’s school recognising this gap has built on the working together guidance to develop guidance that ensures there is a proactive approach to engaging with a child and their family post the writing of a Child and Family Assessment;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a further face-to-face conversation with the child
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie ;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of clear exam-board guidance for teachers to minimise risk to pupils when teaching sensitive material
Wider context from the report “6. On the day Katie committed suicide she had attended a GCSE English class. The exam board required poetry syllabus was being studied that day. The lesson included a poem where the contextualisation of it included the use of suicide. The teacher delivering the lesson had no way of understanding the history of self-harm of Katie and her particular vulnerability when delivering a set text in accordance with the exam board requirements. It was unclear what if any guidance is given by the exam board to assist teachers minimising risk to pupils in this scenario .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to consider victimless prosecution before closing matters
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution ; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to provide teachers with relevant information about a pupil's self-harm history and vulnerability
Wider context from the report “6. On the day Katie committed suicide she had attended a GCSE English class. The exam board required poetry syllabus was being studied that day. The lesson included a poem where the contextualisation of it included the use of suicide. The teacher delivering the lesson had no way of understanding the history of self-harm of Katie and her particular vulnerability when delivering a set text in accordance with the exam board requirements. It was unclear what if any guidance is given by the exam board to assist teachers minimising risk to pupils in this scenario.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to fully hear the voice of the child throughout safeguarding investigations
Wider context from the report “4. It was accepted by witnesses for both the Local Authority and GMP that the voice of the child was not fully heard throughout their investigations . They via the safeguarding board commissioned an independent report whose findings and recommendations have been fully adopted by the safeguarding board. It was unclear what if any steps would be taken to disseminate the lessons pan GM or nationally;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure case officers attend safeguarding strategy meetings
Wider context from the report “3. At the safeguarding strategy meeting an officer allocated to attend such meetings on behalf of GMP attended rather than an officer allocated to the case . As a result the quality of information sharing and understanding of the allegation was more limited . On the particular police division in question this practice has stopped. It was unclear how common the approach is on a wider basis;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Child and Family Assessments in accordance with best practice amid reliance on agency social workers
Wider context from the report “2. The Local Authority at the time were using a substantial number of agency social workers . As a result the Child and Family Assessment was not completed in accordance with best practice and not shared in accordance with expectations around best practice. The Local Authority has since made significant progress in moving away from a reliance on agency staff to fill gaps in social work cover. The inquest was told that agency social workers are still used extensively in other Local Authorities creating a risk that a similar situation could arise;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of officer capability in joint working with social services and applying the voice of the child
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case . At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Delays in seizing key digital evidence
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed . The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate appropriately experienced specialist officers to alleged sexual offences
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer . It was allocated to a probationary police constable with approximately 6 months experience . The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” Open source report
24 Oct 2019 Douglas Paul Oak · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 9 Lack of general awareness of Acute Behavioural Disturbance View source Insufficient frequency and variety of ABD training View source Unsuitability of existing ABD training package for control-room staff View source Failure of Emergency Services to use mutually understood control-room terminology View source Insufficient ABD training for Police and Ambulance Service front-line and control-room staff View source Confusion over Police procedures for requesting Ambulance support View source Absence of Clinical Governance Boards in Police Forces View source Lack of cross-working within the emergency services View source Absence of joint national guidance on Police and Ambulance Service management of ABD View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Douglas Paul Oak · 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 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency services.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of general awareness of Acute Behavioural Disturbance
Wider context from the report “i. There is a lack of awareness generally regarding ABD and I would request consideration is given to the inclusion of the signs, symptoms and management of ABD within the First Aid Manual so that all those trained in first aid are able to deal with a patient presenting with ABD.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient frequency and variety of ABD training
Wider context from the report “iv. I also have concerns in relation to the frequency of the delivery of the training referred to in (iii) and I therefore request consideration be given to that training being delivered regularly, at least on an annual basis and with a variety of training techniques, including simulation and role play scenarios.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of existing ABD training package for control-room staff
Wider context from the report “vii. In relation to the training package that has been provided by the College of Policing regarding ABD, although ████████ has recommended this could be rolled out to control room staff, the package is tailored for front-line staff . I would therefore request consideration is given to a specific training package on ABD being designed and rolled out to those working in the control room environment by the College of Policing together with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Services to use mutually understood control-room terminology
Wider context from the report “v. Given that the Police and Ambulance Services work very closely in treating and managing a patient with ABD, and other patients who present with life threatening conditions, it is important that they understand each other. It was clear from this Inquest that there is different terminology used by the different services, the meaning of which is not understood by the other Emergency Services . An example of this was the use of the phrase “on the hurry up”. Although the confusion regarding this terminology was not found to be causative or contributory to Doug’s death, it could be in respect of a future death. I therefore request that consideration is given to the joint national training packages for all Emergency Services, namely the Police Service, Ambulance Service and the Fire Service on the workings within each control room and around the language used in the control rooms.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Insufficient ABD training for Police and Ambulance Service front-line and control-room staff
Wider context from the report “iii. I believe it is likely there are persons working within Ambulance Service Trusts and Police Forces, whether it be on the front line or in the control room who are not aware of ABD and the serious risk to life it presents . I therefore request that consideration is given to ensuring all those working on the front line, or in control rooms in Ambulance Service Trusts and Police Forces in England and Wales are trained in ABD.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Confusion over Police procedures for requesting Ambulance support
Wider context from the report “ix. It was clear from the evidence that there appears to be confusion of when Dorset Police Officers should call 999 directly and when they should request assistance through the Police control room . I would request that there is consideration of the redrafting of the current “Police Requesting Ambulance Support” policy within Dorset Police and specifically when Police Officers should dial 999. In addition, I would request consideration of training be provided by Dorset Police to all Police Officers regarding the use of dialling 999 when contacting other Emergency Services. In doing this I would ask that consideration is given to liaising with the other local emergency services regarding their expectations, especially SWAST.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Absence of Clinical Governance Boards in Police Forces
Wider context from the report “viii. Evidence was given that Dorset Police have established a Clinical Governance Board which helps to create an awareness of, and improvement in, medical care provided by those working in the Police Service. This is not something adopted by all Police Forces in England and Wales and I therefore request that consideration is given to setting up a Clinical Governance Board in every Police Force in England and Wales.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-working within the emergency services
Wider context from the report “vi. Extending this point further, evidence was given that there would be benefit in cross working within the emergency services , so for example an Ambulance Clinician working within the Police control room to provide advice. I would therefore request that consideration is given on a national level to cross working within the emergency services.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Absence of joint national guidance on Police and Ambulance Service management of ABD
Wider context from the report “ii. There is no joint national guidance on the management of ABD by those who work for the Police and Ambulance Services, both on the front-line and in the control rooms. They are the people most likely to encounter those suffering with ABD and in most cases work together in the management of these patients. Accordingly, I request consideration is given to providing joint national guidance on the management of ABD patients by the Police and Ambulance Services to include:
• the provision of chemical sedation in pre-hospital care
• the training of all paramedics in administering chemical sedation
• the categorisation of Emergency Service calls relating to ABD
• the transfer of an ABD patient to hospital
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Medical and Police Advisory Committee with regional medical representation and local emergency-service liaison.
Verbatim wording from the response “The NPCC recognises the importance of Clinical Governance and multiagency working in developing safe working systems. The NPCC together with the College will be developing a Medical and Police Advisory Committee (MAPAC) with medical representation from each of the 9 police regions. These doctors will come from Emergency Medicine where the bulk of medical/police interactions take place. The MAPAC will form local liaisons with hospital and individual police forces and local ambulance trusts.” Source location 2019-0352-Response-by-College-of-Policing
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 Maintain and update the clinically informed ABD presentation covering recognition, management, emergency response and transfer options.
Verbatim wording from the response “The College and NPCC have developed a PowerPoint presentation on ABD which describes the behavioural and physical signs of ABD and makes very clear the need for rapid clinical assessment/intervention. The ABD PowerPoint was developed with the benefit of clinical input and was last updated in July 2019.” Source location 2019-0352-Response-by-College-of-Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local clinical-governance structures through joint College and NPCC work with police forces.
Verbatim wording from the response “The need for forces to establish local clinical governance is already a condition of the use of the College of Policing’s licence for the FALP. Additionally, the NPCC, through the National Clinical Governance Group, has issued guidance reiterating this requirement and articulating the specific requirements of good clinical governance. Joint work through the College of Policing and the NPCC First Aid Forum has already commenced to ensure that forces have developed suitable clinical governance structures.” Source location 2019-0352-Response-by-College-of-Policing
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 Circulate the ABD presentation to force contact-management leads with advice on briefing control-room staff.
Verbatim wording from the response “the meantime the College will ask the NPCC national lead for Contact Management, ACC ████████ (Police Service of Northern Ireland) to circulate the ABD PowerPoint presentation to force leads, with advice on how this could be delivered locally to brief staff working in control rooms.” Source location 2019-0352-Response-by-College-of-Policing
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 Refresh the National Contact Management Learning Programme to include recognition of ABD as a medical emergency for call handlers and dispatchers.
Verbatim wording from the response “The College is in the process of refreshing the National Contact Management Learning Programme (NCMLP). This is a detailed set of learning standards that forces use to develop their local training for all contact management staff including those taking calls from the public and tasking and informing resources who respond. In this refresh we will include the importance of call handlers and dispatchers understanding the medical emergency that is ABD. This will complement the ABD presentation referred to below.” Source location 2019-0352-Response-by-College-of-Policing
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 the ABD presentation with NHS trusts and ambulance partners for appropriate use and adaptation.
Verbatim wording from the response “The ABD PowerPoint has already been shared with NHS Trusts and Ambulance partners. The PowerPoint is aimed at frontline police officers and the College and NPCC have made it clear that ambulance partners are at liberty to utilise and amend the PowerPoint, as appropriate, to meet the needs of their staff.” Source location 2019-0352-Response-by-College-of-Policing
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 Pilot conflict-management and de-escalation training using role play, presentations and didactic learning.
Verbatim wording from the response “The College has produced Conflict Management Guidelines which contain information to assist in the development of de-escalation training and skills for front line staff. The College and NPCC will shortly be piloting conflict management/de-escalation training as part of its work to develop the national PST curriculum. The approach involves the use of role play as well as presentations and didactic learning. The College Guidelines recommend that role plays include resolution through de-escalation and of the medical impacts of any physical intervention used by learners.” Source location 2019-0352-Response-by-College-of-Policing
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 Issue guidance and reminders to force first-aid and governance leads on clinical-governance requirements.
Verbatim wording from the response “The need for forces to establish local clinical governance is already a condition of the use of the College of Policing’s licence for the FALP. Additionally, the NPCC, through the National Clinical Governance Group, has issued guidance reiterating this requirement and articulating the specific requirements of good clinical governance. Joint work through the College of Policing and the NPCC First Aid Forum has already commenced to ensure that forces have developed suitable clinical governance structures.” Source location 2019-0352-Response-by-College-of-Policing
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 Add ABD recognition and management to Module 2 of the First Aid Learning Programme for frontline refresher training.
Verbatim wording from the response “The College First Aid Learning Programme (FALP) already includes a learning outcome for recognising Acute Behavioural Disorder (ABD) as part of Module 3 (relating to first aid in a custody setting). In light of the above cause for concern the College will work with police stakeholders through the NPCC First Aid Forum and the national clinical governance panel to reflect this learning outcome in Module 2, the refresher training module for front line staff. This will ensure that this training is given to all front line officers. This amendment will be made as part of the wider scheduled review of the FALP following the release of updated guidance by the UK Resuscitation Council in 2020.” Source location 2019-0352-Response-by-College-of-Policing
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 the ABD presentation with the Tripartite Committee for consideration in the First Aid Manual.
Verbatim wording from the response “Recognising that concern about awareness of ABD extends beyond the police and ambulance services the College and NPCC will share the PowerPoint presentation on ABD with the Tripartite Committee who publish the First Aid Manual. The College and NPCC hope that this collaboration will increase knowledge of ABD amongst the first aid societies (St John Ambulance, The British Red Cross and St Andrews First Aid) and ultimately the public.” Source location 2019-0352-Response-by-College-of-Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue national work with emergency-service partners to improve consistency in ABD recognition and prioritisation.
Verbatim wording from the response “The College and the NPCC will continue to work at a national level to secure greater consistency in the recognition and prioritisation of ABD. It is also our position that forces should discuss communication issues with their local emergency service providers.” Source location 2019-0352-Response-by-College-of-Policing
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 Module 4 of the National Personal Safety Manual and implement an agreed interim ABD information update.
Verbatim wording from the response “Officers undergo personal safety training (PST) every year with the content varying in line with national priorities and local need. The PST is informed by the content of the National Personal Safety Manual (NPSM) which is developed jointly by the College and NPCC and published to policing by the College. ABD training also sits within NPSM contained in Module 4: Medical Implications. This part of the Manual is currently undergoing a full review by Dr Meng Aw-Yong. This is in response to a number of changes that have been included over the past 12 months due to PFD notices. An interim update to the information has been agreed with Dr Meng and will be instigated in the near future. Each change to Module 4 is communicated to forces so that they and their PST trainers are aware.” Source location 2019-0352-Response-by-College-of-Policing
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standardised ABD presentation and training template for police and ambulance control-room staff.
Verbatim wording from the response “The NPCC is working with ████████ and Subject Matter Experts in police and ambulance (SECAMBE and LAS) Control Rooms to produce a PowerPoint on ABD specifically for police and ambulance control room staff. This PowerPoint will form the basis of a template for both police force or ambulance trusts to train their staff with the aim of teaching recognition of ABD and the risk to life, thereby standardising the language and response to ABD (point 2.v). For the first time this PowerPoint is also endorsed by the Independent Ambulance Association and Heath Practice Associates (Council) increasing the reach of the material. We will also share this with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.” Source location 2019-0352-Response-by-College-of-Policing
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 Share the control-room ABD presentation with ambulance service leadership bodies.
Verbatim wording from the response “The NPCC is working with ████████ and Subject Matter Experts in police and ambulance (SECAMBE and LAS) Control Rooms to produce a PowerPoint on ABD specifically for police and ambulance control room staff. This PowerPoint will form the basis of a template for both police force or ambulance trusts to train their staff with the aim of teaching recognition of ABD and the risk to life, thereby standardising the language and response to ABD (point 2.v). For the first time this PowerPoint is also endorsed by the Independent Ambulance Association and Heath Practice Associates (Council) increasing the reach of the material. We will also share this with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.” Source location 2019-0352-Response-by-College-of-Policing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There are seldom misunderstandings about response urgency because call handlers seek details and ambulance triage is based on clinical presentation.
Verbatim wording from the response “We accept that clarity in language is important when communicating across emergency services. Contact Management officers and staff are trained to enquire and probe for additional details when receiving calls and our experience leads us to believe that there are seldom misunderstandings in relation to the importance of response required. It is however recognised that the ambulance service triage each call based on the description of the medical presentation of the patient not on the type of illness being stated.” Source location 2019-0352-Response-by-College-of-Policing
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 Forces should address communication issues, including local ambulance-service arrangements, with their local emergency-service providers.
Verbatim wording from the response “The College and the NPCC will continue to work at a national level to secure greater consistency in the recognition and prioritisation of ABD. It is also our position that forces should discuss communication issues with their local emergency service providers.” Source location 2019-0352-Response-by-College-of-Policing
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 Chemical sedation and emergency-call categorisation are clinical matters for ambulance services, to which police officers defer.
Verbatim wording from the response “The other matters within this area for concern (chemical sedation and categorisation of calls) are clinical matters in which police officers would not be directly involved other than to ensure that the ambulance service has access to the information that it needs. Police officers would defer to ambulance colleagues in these matters.” Source location 2019-0352-Response-by-College-of-Policing
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 Local clinical governance is already required through the first-aid programme licence and supported by national guidance and existing work.
Verbatim wording from the response “The need for forces to establish local clinical governance is already a condition of the use of the College of Policing’s licence for the FALP. Additionally, the NPCC, through the National Clinical Governance Group, has issued guidance reiterating this requirement and articulating the specific requirements of good clinical governance. Joint work through the College of Policing and the NPCC First Aid Forum has already commenced to ensure that forces have developed suitable clinical governance structures.” Source location 2019-0352-Response-by-College-of-Policing
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandating ABD training more frequently than the existing cycle is considered disproportionate given staffing levels and the relative infrequency of suspected cases.
Verbatim wording from the response “Through first aid and PST officers will receive training focusing on ABD at least every three years and probably more frequently in practice. The first aid and PST training represent a minimum requirement, balanced against the other significant training police officers require for their role. It would not be” Source location 2019-0352-Response-by-College-of-Policing
Open published response
15 Aug 2019 Dane Lee Pearson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to assess known vulnerability when issuing CAWNs View source Failure to clarify available steps when serving CAWNs View source Failure to notify people under investigation of decisions View source Lack of documentation explaining the rationale for CAWN issuance View source Failure to update OPUS with vulnerability markers View source Issuing CAWNs on limited evidence regarding identification View source Delays in issuing CAWNs and failure to follow issuance timelines View source See 4 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
Dane Lee Pearson · 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
Dane Lee Pearson, who had a history of mental health problems and amphetamine use, was found suspended from a ligature at his home on 13 December 2017. The investigation concluded that the death was suicide, with the medical cause recorded as hanging. Concerns included failures in the issuing and documentation of a Child Abduction Warning Notice, failure to assess or account for his vulnerability, inadequate recording of vulnerability markers, and failure to communicate that criminal proceedings had been discontinued.
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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to assess known vulnerability when issuing CAWNs
Wider context from the report “2. In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account . A risk assessment had not been carried out . In this case, officers attended at his home address and served the CAWN on him .He refused to sign it on the basis; he had no knowledge of it or the circumstances behind it. It was left with him with no clarification about what if any steps he could take in relation to it. The inquest heard evidence that he was deeply worried about it and the impact of it on his life.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify available steps when serving CAWNs
Wider context from the report “2. In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account. A risk assessment had not been carried out. In this case, officers attended at his home address and served the CAWN on him .He refused to sign it on the basis; he had no knowledge of it or the circumstances behind it. It was left with him with no clarification about what if any steps he could take in relation to it . The inquest heard evidence that he was deeply worried about it and the impact of it on his life.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to notify people under investigation of decisions
Wider context from the report “4. The inquest was told that he was placed under investigation for a suspected attempt burglary and possession of an offensive weapon. A decision was taken by the OIC and his sergeant that it should be NFAD. The decision was not communicated to Mr Pearson . The officer had not followed the process for notification of decisions to those under investigation . As a result, at the time of his death he believed he may be charged with a criminal offence.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation explaining the rationale for CAWN issuance
Wider context from the report “1. In this case, the CAWN had been issued on limited evidence particularly regarding identification. In addition, it had been issued many months after the allegation and after the authorisation. The inquest was told that the process had not been followed relating to timelines. There was no documentation in existence explaining the rationale for the issuing of the CAWN .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Failure to update OPUS with vulnerability markers
Wider context from the report “3. The inquest heard that OPUS the Police system did not appear to have been correctly updated with markers to flag his vulnerability .
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Issuing CAWNs on limited evidence regarding identification
Wider context from the report “1. In this case, the CAWN had been issued on limited evidence particularly regarding identification . In addition, it had been issued many months after the allegation and after the authorisation. The inquest was told that the process had not been followed relating to timelines. There was no documentation in existence explaining the rationale for the issuing of the CAWN.
” 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 College of Policing; that does not assign responsibility.
PFD Monitor interpretation Delays in issuing CAWNs and failure to follow issuance timelines
Wider context from the report “1. In this case, the CAWN had been issued on limited evidence particularly regarding identification. In addition, it had been issued many months after the allegation and after the authorisation . The inquest was told that the process had not been followed relating to timelines . There was no documentation in existence explaining the rationale for the issuing of the CAWN.
” 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