23 Apr 2025 Christopher Brazil · Prevention of Future Deaths report Ceredigion
View report summary
Concerns raised 7 Lack of dosage guidance View source Unregulated and unlawful online sale of prescription-only medicines and controlled drugs View source Inadequate age and identity verification for access to restricted medicines and drugs View source Exposure of vulnerable and susceptible people to counterfeit or unsafe medications View source Rapid delivery by unlawful online pharmaceutical providers View source Lack of safeguards against incorrect self-diagnosis or consumer misuse View source Insufficient or absent verification of patient medical history before medication sales 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
Christopher Brazil · 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
Christopher Brazil had physical pain, sciatica and poor mental health, and sourced additional medicines and drugs from unlawful online providers. He died in August 2022 after unintentionally overdosing on benzodiazepines. The concerns included the accessibility and legitimacy of unregulated websites, unsafe or counterfeit medicines, inadequate checks of medical history, dosage guidance, safeguards, age and identity verification, and rapid delivery.
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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Lack of dosage guidance
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Unregulated and unlawful online sale of prescription-only medicines and controlled drugs
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs , which look legitimate and are found easily from simple online searches ; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Inadequate age and identity verification for access to restricted medicines and drugs
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Exposure of vulnerable and susceptible people to counterfeit or unsafe medications
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Rapid delivery by unlawful online pharmaceutical providers
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources .
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Lack of safeguards against incorrect self-diagnosis or consumer misuse
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Insufficient or absent verification of patient medical history before medication sales
Wider context from the report “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6)
(2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications
(3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs
(4) There is a lack of guidance regarding dosage
(5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers
(6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs
(7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources.
” Open source report
13 Oct 2022 Molly Rose Russell · Prevention of Future Deaths report North London
View report summary
Concerns raised 7 Lack of separation between adult and child platform areas View source Use of algorithms to provide content together with adverts View source Lack of parental, guardian or carer access to material viewed by a child View source Lack of age verification at online platform sign-up View source Lack of parental, guardian or carer control over material viewed by a child View source Failure to control online content so that it is age specific View source Failure to separately link a child's account to a parent, guardian or carer's account for monitoring 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
Molly Rose Russell · 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
Molly Rose Russell, aged 14, was found having hanged herself on 21 November 2017. The report describes her depression and exposure to online content involving self-harm, suicide and other negative material, which was likely to have negatively affected her mental health and contributed to her death. Principal concerns included the lack of age verification, separation between adult and child users, age-specific content controls, algorithmic content provision and parental access or monitoring.
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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Lack of separation between adult and child platform areas
Wider context from the report “1. There was no separation between adult and child parts of the platforms or separate platforms for children and 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Use of algorithms to provide content together with adverts
Wider context from the report “4. That algorithms were used to provide content together with adverts .
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Lack of parental, guardian or carer access to material viewed by a child
Wider context from the report “5. That the parent, guardian or carer did not have access , to the material being viewed or any control over that material.
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Lack of age verification at online platform sign-up
Wider context from the report “2. There was no age verification when signing up to the on-line platform .
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Lack of parental, guardian or carer control over material viewed by a child
Wider context from the report “5. That the parent, guardian or carer did not have access, to the material being viewed or any control over that material .
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Failure to control online content so that it is age specific
Wider context from the report “3. That the content was not controlled so as to be age specific .
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Failure to separately link a child's account to a parent, guardian or carer's account for monitoring
Wider context from the report “6. That the child's account was not capable of being separately linked to the parent, guardian or carer's account for monitoring .
” Open source report
18 Mar 2022 Emiliano Raul Sala · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Risk of future deaths from illegal flights View source Failure of relevant organisations to communicate illegal-flight risks to their members View source Insufficient CAA powers for investigating and enforcing aviation regulation breaches View source Lack of effective public guidance about illegal flights and their risks 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
Emiliano Raul Sala · 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
Emiliano Raul Sala was a passenger on a flight from Nantes to Cardiff on 21 January 2019 when the aircraft crashed into the sea. He died from fatal head and trunk injuries; the flight was an unauthorised commercial operation. The report raised concerns about illegal flights, their safety risks, and limitations on the Civil Aviation Authority’s investigative and enforcement powers.
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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Risk of future deaths from illegal flights
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights , and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Failure of relevant organisations to communicate illegal-flight risks to their members
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members , and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Insufficient CAA powers for investigating and enforcing aviation regulation breaches
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations . I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role .
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public, especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them. I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Lack of effective public guidance about illegal flights and their risks
Wider context from the report “2. I have concerns with regard to the following:
i. There could be future deaths as a result of these illegal flights, and I request that the Secretary of State for Transport conducts a review of the powers available to the CAA in investigating breaches of aviation regulations. I request that the Secretary of State for Transport consider meeting with the CAA to establish what powers they would find of assistance in their investigative and enforcement role.
ii. I further request that a review is undertaken by the Secretary of State for Digital, Culture, Media and Sport of the guidance given to the general public , especially all those involved in the sporting and music worlds, about the illegality of these flights and the risks associated with them . I would again request that consideration be given to meeting with the CAA who can properly advise on the risks associated with these flights, especially of future deaths that can occur and what support may assist them in deterring people from using these flights.
iii. I would request that all the organisations identified at numbers 3-20 in the list at the beginning of this report, consider cascading to all their members, and anyone else they consider will benefit from the information, the illegality of these flights and the risks associated with them, especially of a future death, in order to discourage the use of these flights. I would again request that consideration be given to liaising with the CAA who can properly advise on the risks and what support would be of benefit to reduce the use of these flights and prevent future deaths.
” 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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Department for Digital, Culture, Media & Sport (2017 to 2023); 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 Department for Digital, Culture, Media & Sport (2017 to 2023); 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 Department for Digital, Culture, Media & Sport (2017 to 2023); 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 Department for Digital, Culture, Media & Sport (2017 to 2023); 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 Department for Digital, Culture, Media & Sport (2017 to 2023); 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 Department for Digital, Culture, Media & Sport (2017 to 2023); 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 Department for Digital, Culture, Media & Sport (2017 to 2023); 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 Department for Digital, Culture, Media & Sport (2017 to 2023); 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 Department for Digital, Culture, Media & Sport (2017 to 2023); 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
10 Mar 2021 Edward Lewis BILBEY · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 6 Failure to maintain current Welfare Officer registration records View source Failure to ensure that Level 2 coach registrations accurately reflect coaching activity View source Lack of systems to monitor and enforce compliance with child protection and safeguarding requirements View source Failure to display current Welfare Officer contact details prominently at clubs View source Lack of adequate and enforceable child protection and safeguarding measures View source Lack of a policy or procedure for checking and enforcing compliance with safeguarding and child protection procedures View source See 3 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
Edward Lewis BILBEY · 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
Edward Lewis Bilbey died at Kings Mill Hospital on 24 March 2017 after collapsing in a boxing ring following intensive training. The inquest found that his death resulted from an undiagnosed heart condition combined with metabolic disturbance associated with intense physical training and rapid weight loss by dehydration. The report raised concerns that Boxing England lacked systems to monitor and enforce child protection and safeguarding compliance, and that this issue might be more widespread among national sporting bodies.
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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Failure to maintain current Welfare Officer registration records
Wider context from the report “At Mr Bilbey’s club the registered Welfare Officer had left the club three years prior to Mr Bilbey’s death . However, his name was at the time registered on ‘The Vault’ held and maintained by England Boxing . From the evidence heard at inquest there no thing to demonstrate that the name of the Welfare officer and his contact details were displayed prominent in the club. In fact those details were not displayed at all. There was a registered level 2 couch registered on ‘The Vault’. However, in evidence the witness stated under oath that he did not undertake any training or coaching activities at the club.
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that Level 2 coach registrations accurately reflect coaching activity
Wider context from the report “At Mr Bilbey’s club the registered Welfare Officer had left the club three years prior to Mr Bilbey’s death. However, his name was at the time registered on ‘The Vault’ held and maintained by England Boxing. From the evidence heard at inquest there no thing to demonstrate that the name of the Welfare officer and his contact details were displayed prominent in the club. In fact those details were not displayed at all. There was a registered level 2 couch registered on ‘The Vault’. However, in evidence the witness stated under oath that he did not undertake any training or coaching activities at the club .
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Lack of systems to monitor and enforce compliance with child protection and safeguarding requirements
Wider context from the report “Boxing England, A National Governing Body did not have in place any systems to monitor and enforce compliance with Child Protection and Safeguarding issues . Given the media coverage of issues with Child Protection and Safeguarding with British Gymnastics and British Athletics I am concerned that this is endemic amongst Sporting National Bodies .
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Failure to display current Welfare Officer contact details prominently at clubs
Wider context from the report “At Mr Bilbey’s club the registered Welfare Officer had left the club three years prior to Mr Bilbey’s death. However, his name was at the time registered on ‘The Vault’ held and maintained by England Boxing. From the evidence heard at inquest there no thing to demonstrate that the name of the Welfare officer and his contact details were displayed prominent in the club . In fact those details were not displayed at all . There was a registered level 2 couch registered on ‘The Vault’. However, in evidence the witness stated under oath that he did not undertake any training or coaching activities at the club.
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Lack of adequate and enforceable child protection and safeguarding measures
Wider context from the report “1. England Boxing did not have in place adequate and enforceable child protection and safeguarding measures .
2. England Boxing did not have in place any policy or procedure for checking and enforcing compliance with its safeguarding or child protection procedures.
” 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Lack of a policy or procedure for checking and enforcing compliance with safeguarding and child protection procedures
Wider context from the report “1. England Boxing did not have in place adequate and enforceable child protection and safeguarding measures.
2. England Boxing did not have in place any policy or procedure for checking and enforcing compliance with its safeguarding or child protection procedures .
” Open source report
Concerns raised 2 Availability of online forum advice on misleading mental health professionals to avoid mental health detention View source Availability of online forum advice on methods of taking one's life 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
Callie Lewis · 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
Callie Lewis had chronic suicidal ideation and was actively planning to end her life, later dying by carbon monoxide poisoning after travelling to a remote location. The inquest concluded that her death was suicide by carbon monoxide poisoning contributed to by neglect. A substantive concern was that an online pro-suicide forum provided advice on methods of suicide and on misleading mental health professionals, frustrating assessment and enabling her to take her life.
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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Availability of online forum advice on misleading mental health professionals to avoid mental health detention
Wider context from the report “(1) Callie was using an online suicide forum, ████████ (the forum now appears under the internet address ████████.Through the forum she was able to engage in discussions with other pro-suicide members and obtain advice how to mislead mental health professionals to avoid being sectioned under the Mental Health Act and also how to perfect the methods of taking her life that she had been considering. She was enabled by the advice provided through the forum to frustrate a mental health assessment and thereafter take her 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 Department for Digital, Culture, Media & Sport (2017 to 2023); that does not assign responsibility.
PFD Monitor interpretation Availability of online forum advice on methods of taking one's life
Wider context from the report “(1) Callie was using an online suicide forum, ████████ (the forum now appears under the internet address ████████.Through the forum she was able to engage in discussions with other pro-suicide members and obtain advice how to mislead mental health professionals to avoid being sectioned under the Mental Health Act and also how to perfect the methods of taking her life that she had been considering. She was enabled by the advice provided through the forum to frustrate a mental health assessment and thereafter take her life
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations