Crown Prosecution Service

Central government · Non-ministerial department

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First report 28 Jul 2014•Latest report 10 Apr 2026

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 4
Published responses: 25%
Concerns addressed: 0
Stated actions: 2

Concerns and recipient responses

Statements from Crown Prosecution Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

10 Apr2026
Surrey
Concerns raised1
1. Failure to review the CPS minimum weekly figure for reasonable living expenses
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Garry MILLS · 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

Garry MILLS, aged 46, died on 6 September 2021 after experiencing considerable anxiety and stress while subject to a financial restraint order limiting his and his family’s weekly living expenses to £250. The inquest concluded that he took his own life while suffering from the effects of stress and anxiety. The principal concern was that the £250 weekly figure had not been reviewed since 2009 despite increases in living costs, with the report stating that this significantly affected the mental health and wellbeing of people subject to restraint orders and their dependants.

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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to review the CPS minimum weekly figure for reasonable living expenses
Wider context from the report
“The sum of £250.00 per week has not been varied since 2009, despite considerable upward movement in the cost of living during the ensuing 17 years. Evidence heard at the Inquest was that no review of this figure has occurred since 2009. In Mr. MILLS’ case, he and his five dependants (his wife and four children) were to meet their reasonable living expenses from £250.00 per week, in part supplemented by Universal Credit payments. I am concerned that the figure used by the CPS to set the minimum per week figure for reasonable living expenses (£250.00) and which is initially imposed in ex parte proceedings has not been reviewed since 2009. The almost universal use of this figure, unadjusted for inflation or broader cost of living increases, on the subject of the Restraint Order and their dependants, significantly impacts on their mental health and wellbeing which gives rise to a risk of death. ”
Open source report
18 Nov2020
Manchester South
Concerns raised22
1. Limited police recognition and use of Claire's Law in domestic abuse cases
2. Unqualified staff making key MARAT decisions
3. Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators
1. Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators
2. Poor information sharing and joint risk recognition across statutory agencies
3. Limited police training and capability to identify coercive and controlling behaviour
4. Insufficient health visitor capacity for safeguarding and interagency work
5. Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible
6. Reduced specialist support and oversight for low and medium risk domestic abuse cases
7. Failure to share complete relevant information between police and CPS
8. Failure of CPS decision makers to follow guidance and document prosecution assessments
9. Limited health visitor understanding of coercive and controlling behaviour
10. Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs
11. Failure to share perpetrator risk information with alleged victims
12. Failure to place domestic abuse suspects on protective bail conditions during further investigation
13. Failure to provide safe opportunities for domestic abuse disclosure
14. Failure to pursue further enquiries supporting victimless domestic abuse prosecutions
15. Failure to routinely document police and CPS case discussions
16. Failure to use the MARAC framework when appropriate
17. Limited police training in domestic abuse risk evaluation and scoring
18. Insufficient resourcing of the MARAT frontline service
19. Failure to conduct required health visiting conversations face to face
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Alfie Gildea · 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

Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Limited police recognition and use of Claire's Law in domestic abuse cases
Wider context from the report
“7. Recognition of when and how Claire's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Unqualified staff making key MARAT decisions
Wider context from the report
“15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators
Wider context from the report
“2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different. It was unclear why that was the case. However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators
Wider context from the report
“4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Poor information sharing and joint risk recognition across statutory agencies
Wider context from the report
“12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Limited police training and capability to identify coercive and controlling behaviour
Wider context from the report
“5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour. Understanding of how coercive and controlling behaviour in a relationship could be identified was limited. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Insufficient health visitor capacity for safeguarding and interagency work
Wider context from the report
“14. The inquest was told that Health Visitor numbers were reducing due to national funding arrangements. As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible
Wider context from the report
“3. It is unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMPs systems. Officers giving evidence did not understand how such information could be accessed or 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Reduced specialist support and oversight for low and medium risk domestic abuse cases
Wider context from the report
“9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to share complete relevant information between police and CPS
Wider context from the report
“10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of CPS decision makers to follow guidance and document prosecution assessments
Wider context from the report
“10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Limited health visitor understanding of coercive and controlling behaviour
Wider context from the report
“13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs
Wider context from the report
“11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed. There was no evidence of a clear and effective system of notification on the Trafford Division of GMP. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to share perpetrator risk information with alleged victims
Wider context from the report
“13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to place domestic abuse suspects on protective bail conditions during further investigation
Wider context from the report
“1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required. Instead they were placed under 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide safe opportunities for domestic abuse disclosure
Wider context from the report
“13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to pursue further enquiries supporting victimless domestic abuse prosecutions
Wider context from the report
“8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to routinely document police and CPS case discussions
Wider context from the report
“10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to use the MARAC framework when appropriate
Wider context from the report
“12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Limited police training in domestic abuse risk evaluation and scoring
Wider context from the report
“6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Insufficient resourcing of the MARAT frontline service
Wider context from the report
“15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct required health visiting conversations face to face
Wider context from the report
“13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure. ”
Open source report
16 Apr2015
Manchester South
Concerns raised28
1. Failure of the youth diversion project to provide diversion before criminal justice processing
2. Failure to record and explain incomplete medical assessments
3. Failure to return completed Appropriate Adult forms to Social Services
1. Interagency confusion about safeguarding roles and access to information
2. Failure to initiate youth offending and mental health monitoring after case transfer
3. Failure to pass complete incident information to attending officers
4. Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
5. Insufficient availability of accommodation for children under 17
6. Insufficient recording of safeguarding information by Appropriate Adults
7. Failure of youth offending teams to transfer and oversee cases after relocation
8. Failure to assess police information when selecting an Appropriate Adult
9. Lack of legally required accommodation for 17-year-olds refused bail
10. Failure to make safeguarding referrals from custody medical information
11. Failure to record safeguarding intelligence on nominal profiles
12. Failure to conduct police database checks on standard-risk DASH referrals
13. Failure to route domestic violence cases involving 17-year-old children to child protection review
14. Lack of shared understanding between police and MEDACS about requested medical assessments
15. Lack of interagency understanding for sharing safeguarding information between police and CPS
16. Failure to provide Appropriate Adults with relevant custody risk information
17. Failure to provide differentiated mental health assessments for children in custody
18. Failure to document information provided to MEDACS before medical assessments
19. Failure to check and update Prisoner Escort Records before release
20. Custody handovers dependent on officers’ and staff’s unpaid free time
21. Lack of consistent child safeguarding coverage across Manchester local authorities
22. Lack of clear officer guidance for raising safeguarding concerns
23. Unclear referral routes for non-criminal safeguarding concerns
24. Lack of a process for recording safeguarding concerns
25. Lack of a non-criminal safeguarding policy
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Kesia Lena Mary Leatherbarrow · 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

Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of the youth diversion project to provide diversion before criminal justice processing
Wider context from the report
“The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway. There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to record and explain incomplete medical assessments
Wider context from the report
“It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to return completed Appropriate Adult forms to Social Services
Wider context from the report
“Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any cases. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Interagency confusion about safeguarding roles and access to information
Wider context from the report
“Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles, what they are able and not able to do and also where to access important and effective information. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to initiate youth offending and mental health monitoring after case transfer
Wider context from the report
“This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside. The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to pass complete incident information to attending officers
Wider context from the report
“The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife. The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
Wider context from the report
“This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Insufficient availability of accommodation for children under 17
Wider context from the report
“The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available. Attempts are being made to address this issue but at present the figure remains approximately 20% and the Inquest heard evidence that this was, “not good enough”. Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities. The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe to do so. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Insufficient recording of safeguarding information by Appropriate Adults
Wider context from the report
“The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure of youth offending teams to transfer and oversee cases after relocation
Wider context from the report
“There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess police information when selecting an Appropriate Adult
Wider context from the report
“It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of legally required accommodation for 17-year-olds refused bail
Wider context from the report
“There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to make safeguarding referrals from custody medical information
Wider context from the report
“Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to record safeguarding intelligence on nominal profiles
Wider context from the report
“No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers. It is a core function of the police to submit such intelligence. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct police database checks on standard-risk DASH referrals
Wider context from the report
“when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out. The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report
“For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of shared understanding between police and MEDACS about requested medical assessments
Wider context from the report
“It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of interagency understanding for sharing safeguarding information between police and CPS
Wider context from the report
“There was a lack of understanding between GMP and the CPS as to how such important information should be shared between 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide Appropriate Adults with relevant custody risk information
Wider context from the report
“She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS, nor that she had threatened to jump off a bridge on her 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide differentiated mental health assessments for children in custody
Wider context from the report
“The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to document information provided to MEDACS before medical assessments
Wider context from the report
“there was no clarity as to whether this included previous risk assessments, whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the information. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to check and update Prisoner Escort Records before release
Wider context from the report
“The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Custody handovers dependent on officers’ and staff’s unpaid free time
Wider context from the report
“The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of consistent child safeguarding coverage across Manchester local authorities
Wider context from the report
“This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear officer guidance for raising safeguarding concerns
Wider context from the report
“Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Unclear referral routes for non-criminal safeguarding concerns
Wider context from the report
“Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of a process for recording safeguarding concerns
Wider context from the report
“Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be 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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of a non-criminal safeguarding policy
Wider context from the report
“Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded. ”
Open source report
28 Jul2014
Surrey
Concerns raised3
1. Lack of clear and unequivocal advice to vulnerable witnesses about obtaining psychiatric counselling related to forthcoming criminal evidence
2. Failure to provide complainants with full and timely explanations of trial judge directions on indictment counts after no-case-to-answer submissions
3. Failure to secure medication prescribed to one family member from access by another family member with a history of overdoses
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Frances Claire ANDRADE · 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

Frances Claire Andrade died after taking an overdose of fluoxetine and insulin, following a period involving repeated overdoses and increasing distress around criminal proceedings. The report raised concerns about advice and support for vulnerable witnesses, explanations of trial directions, and securing medication prescribed to another family member after repeated overdoses.

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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear and unequivocal advice to vulnerable witnesses about obtaining psychiatric counselling related to forthcoming criminal evidence
Wider context from the report
“1. Consideration should be given to instituting measures that will ensure that clear and unequivocal advice is given to a vulnerable witness in relation to the obtaining of psychiatric counselling in relation to issues arising from evidence which they will be giving in forthcoming criminal proceedings. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide complainants with full and timely explanations of trial judge directions on indictment counts after no-case-to-answer submissions
Wider context from the report
“2. Consideration should be given to instituting measures that will ensure that complainants in criminal trials are given a full and timely explanation as to the directions given by a trial judge in relation to counts on an indictment following the receipt of submissions of there being no case to answer in respect of those counts. ”
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 Crown Prosecution Service; that does not assign responsibility.
PFD Monitor interpretation
Failure to secure medication prescribed to one family member from access by another family member with a history of overdoses
Wider context from the report
“3. Where there is a history of overdoses being taken by family member A using medication that is prescribed to family member B, consideration should be given to what steps could reasonably be taken to secure that medication with a view to restricting access to it by family member A. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Failure to review the CPS minimum weekly figure for reasonable living expenses

Concerns raised22

Limited police recognition and use of Claire's Law in domestic abuse cases

Unqualified staff making key MARAT decisions

Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators

Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators

Poor information sharing and joint risk recognition across statutory agencies

Limited police training and capability to identify coercive and controlling behaviour

Insufficient health visitor capacity for safeguarding and interagency work

Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible

Reduced specialist support and oversight for low and medium risk domestic abuse cases

Failure to share complete relevant information between police and CPS

Failure of CPS decision makers to follow guidance and document prosecution assessments

Limited health visitor understanding of coercive and controlling behaviour

Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs

Failure to share perpetrator risk information with alleged victims

Failure to place domestic abuse suspects on protective bail conditions during further investigation

Failure to provide safe opportunities for domestic abuse disclosure

Failure to pursue further enquiries supporting victimless domestic abuse prosecutions

Failure to routinely document police and CPS case discussions

Failure to use the MARAC framework when appropriate

Limited police training in domestic abuse risk evaluation and scoring

Insufficient resourcing of the MARAT frontline service

Failure to conduct required health visiting conversations face to face

Concerns raised28

Failure of the youth diversion project to provide diversion before criminal justice processing

Failure to record and explain incomplete medical assessments

Failure to return completed Appropriate Adult forms to Social Services

Interagency confusion about safeguarding roles and access to information

Failure to initiate youth offending and mental health monitoring after case transfer

Failure to pass complete incident information to attending officers

Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs

Insufficient availability of accommodation for children under 17

Insufficient recording of safeguarding information by Appropriate Adults

Failure of youth offending teams to transfer and oversee cases after relocation

Failure to assess police information when selecting an Appropriate Adult

Lack of legally required accommodation for 17-year-olds refused bail

Failure to make safeguarding referrals from custody medical information

Failure to record safeguarding intelligence on nominal profiles

Failure to conduct police database checks on standard-risk DASH referrals

Failure to route domestic violence cases involving 17-year-old children to child protection review

Lack of shared understanding between police and MEDACS about requested medical assessments

Lack of interagency understanding for sharing safeguarding information between police and CPS

Failure to provide Appropriate Adults with relevant custody risk information

Failure to provide differentiated mental health assessments for children in custody

Failure to document information provided to MEDACS before medical assessments

Failure to check and update Prisoner Escort Records before release

Custody handovers dependent on officers’ and staff’s unpaid free time

Lack of consistent child safeguarding coverage across Manchester local authorities

Lack of clear officer guidance for raising safeguarding concerns

Unclear referral routes for non-criminal safeguarding concerns

Lack of a process for recording safeguarding concerns

Lack of a non-criminal safeguarding policy