Recipient

Cumbria Constabulary

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First report 4 Jun 2015•Latest report 8 Dec 2023

Recipient record

Reports, concerns and published responses

Policing · Police force. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
3

Naming this recipient

Published responses
33%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
3

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

33%published responses found
3stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Manchester South

    AI-generated summary

    Claire Nicole Briggs · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses

    Wider context from the report

    “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022. Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved. Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service

    Wider context from the report

    “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022. Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved. Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses. ”
    Open source report

    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 officers with clinical support through the “treat and hear” facility for direct updates from NWAS.

    Verbatim wording from the response

    “We also have clinical support within Cumbria through our “treat and hear” facility which allows officers on the front line to provide updates direct to a member of NWAS.”

    Source location

    Response from Cumbria Constabulary
    Page 1 · response
    Published 12 December 2023

    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

    Operate under a Joint Operating Procedure defining agency responsibilities, information sharing and incident escalation.

    Verbatim wording from the response

    “We have been working under this Joint Operating Procedure (JOP) since the 12th October 2023. The JOP outlines the roles and responsibilities of each agency, how we share information and how to escalate any incidents through the command structure.”

    Source location

    Response from Cumbria Constabulary
    Page 1 · response
    Published 12 December 2023

    Open published response

  2. Plymouth, Torbay and South Devon

    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 Cumbria Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to condition firearms licensing delegation on adequate training

    Wider context from the report

    “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards. I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training. Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years. I am therefore reporting the matters above to: The NPCC lead for firearms licencing and all other Chief Constables in England and Wales So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff. I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance. The College of Policing (CoP) So that the College of Policing is made aware of my concern that (1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists. (2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular. The Home Secretary and The Minister of State for Crime, Policing and Fire So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996: (i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff; (ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training. I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of a mandatory requirement for role-specific firearms licensing training

    Wider context from the report

    “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards. I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training. Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years. I am therefore reporting the matters above to: The NPCC lead for firearms licencing and all other Chief Constables in England and Wales So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff. I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance. The College of Policing (CoP) So that the College of Policing is made aware of my concern that (1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists. (2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular. The Home Secretary and The Minister of State for Crime, Policing and Fire So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996: (i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff; (ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training. I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cumbria Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of nationally accredited training for firearms licensing staff

    Wider context from the report

    “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards. I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training. Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years. I am therefore reporting the matters above to: The NPCC lead for firearms licencing and all other Chief Constables in England and Wales So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff. I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance. The College of Policing (CoP) So that the College of Policing is made aware of my concern that (1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists. (2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular. The Home Secretary and The Minister of State for Crime, Policing and Fire So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996: (i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff; (ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training. I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths. ”
    Open source report

  3. Cumbria

    AI-generated summary

    Alice Anne McMeekin · 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

    Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

    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 Cumbria Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain and verify critical information about reported threats

    Wider context from the report

    “1.The Police The evidence revealed that on the 6th June 2013 the perpetrator made remarks to a member of the public to the effect that he “would not kill his mother”. This information was passed to the Officers who attended the area. Some 2 hours later the same officers attended a call about a man behaving strangely and covered in blood. An ambulance was called. The officers had not spoken to the original caller, who subsequently gave evidence that the remarks were that the perpetrator said he “would kill his mother”. “Common sense” told the officers that the person was one and the same and they did a welfare check on his mother. At no stage did they question the perpetrator about his originally reported remarks. Also, citing confidentiality they did not pass those remarks onto the Ambulance Team. This meant that when later seen by psychiatric nurse the latter was in ignorance of this significant statement. It is possible that had the nurse been aware this may have altered the outcome of the perpetrator’s initial assessment and how he was dealt with. ”
    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 Cumbria Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Discharge without timely and adequate follow-up care for a person remaining at risk

    Wider context from the report

    “2.The Partnership Trust The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6th June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that day. 3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder. He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence. The evidence at inquest shows that this was a very disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care, which could, as a consequence have made a difference. It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder. ”
    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 Cumbria Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate significant risk information to ambulance and psychiatric staff

    Wider context from the report

    “1.The Police The evidence revealed that on the 6th June 2013 the perpetrator made remarks to a member of the public to the effect that he “would not kill his mother”. This information was passed to the Officers who attended the area. Some 2 hours later the same officers attended a call about a man behaving strangely and covered in blood. An ambulance was called. The officers had not spoken to the original caller, who subsequently gave evidence that the remarks were that the perpetrator said he “would kill his mother”. “Common sense” told the officers that the person was one and the same and they did a welfare check on his mother. At no stage did they question the perpetrator about his originally reported remarks. Also, citing confidentiality they did not pass those remarks onto the Ambulance Team. This meant that when later seen by psychiatric nurse the latter was in ignorance of this significant statement. It is possible that had the nurse been aware this may have altered the outcome of the perpetrator’s initial assessment and how he was dealt with. ”
    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 Cumbria Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of psychiatric assessments to recognise mental disorder and suicide risk

    Wider context from the report

    “2.The Partnership Trust The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6th June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that day. 3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder. He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence. The evidence at inquest shows that this was a very disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care, which could, as a consequence have made a difference. It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

33%
33%All other recipients 58%
0%100%

How actions were described at the time

This respondent
100%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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