25 Oct 2024 Chad George ALLFORD · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 3 Lack of police officer awareness of the risks and safety principles of manually removing drugs from a person's mouth View source Failure to communicate the life-threatening risks of retaining concealed drugs in the mouth View source Lack of standard guidance or training for police officers responding to concealment of drugs in the mouth View source
Responses linked to these concerns
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AI-generated summary
Chad George ALLFORD · 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
Chad George Allford died at King's Mill Hospital on 27 October 2021 after placing cocaine in his mouth during a police operation to arrest him for a drug offence. The inquest evidence raised concerns that officers had not received training on this situation, did not warn him of the risks to his life, and were unaware of risks associated with placing their hands in his mouth, including choking.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer awareness of the risks and safety principles of manually removing drugs from a person's mouth
Wider context from the report “The evidence in this inquest focused, in part, on police officers’ response to concealment of drugs in the mouth. The officers were part of a team, acting on intelligence, to make a drug offence arrest. None of the officers concerned had received prior training in this regard. They employed various methods to try and control Mr Allford and although each instructed Mr Allford to spit the drugs out, none of them warned him of the risks to his life of not doing so. It was not clear that officers understood the importance of communicating the dangers.
Attempts were made by officers to open his mouth and sweep the drugs out of the mouth with their hands. A number of officers gave evidence that they were not aware of some of the risks inherent in placing their hands in someone’s mouth, including the risk of packages entering the airway and therefore choking , and they were not aware of the relevant passages in the NPCC Personal Safety Manual or importantly, the principles relating to this contained within. This was not only the position in 2021 but remained the position at the time of the inquest.
I am concerned that there is no standard provision for guidance or training for police officers in units tasked to make arrests for drug offences, to equip them to make informed decisions when faced with this situation. In the Personal Safety Manual ( Module 12 pg 42), it is described as a 'common tactic used by some subjects during arrest to conceal controlled drugs in their mouths'.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the life-threatening risks of retaining concealed drugs in the mouth
Wider context from the report “The evidence in this inquest focused, in part, on police officers’ response to concealment of drugs in the mouth. The officers were part of a team, acting on intelligence, to make a drug offence arrest. None of the officers concerned had received prior training in this regard. They employed various methods to try and control Mr Allford and although each instructed Mr Allford to spit the drugs out, none of them warned him of the risks to his life of not doing so . It was not clear that officers understood the importance of communicating the dangers.
Attempts were made by officers to open his mouth and sweep the drugs out of the mouth with their hands. A number of officers gave evidence that they were not aware of some of the risks inherent in placing their hands in someone’s mouth, including the risk of packages entering the airway and therefore choking, and they were not aware of the relevant passages in the NPCC Personal Safety Manual or importantly, the principles relating to this contained within. This was not only the position in 2021 but remained the position at the time of the inquest.
I am concerned that there is no standard provision for guidance or training for police officers in units tasked to make arrests for drug offences, to equip them to make informed decisions when faced with this situation. In the Personal Safety Manual ( Module 12 pg 42), it is described as a 'common tactic used by some subjects during arrest to conceal controlled drugs in their mouths'.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of standard guidance or training for police officers responding to concealment of drugs in the mouth
Wider context from the report “The evidence in this inquest focused, in part, on police officers’ response to concealment of drugs in the mouth. The officers were part of a team, acting on intelligence, to make a drug offence arrest. None of the officers concerned had received prior training in this regard. They employed various methods to try and control Mr Allford and although each instructed Mr Allford to spit the drugs out, none of them warned him of the risks to his life of not doing so. It was not clear that officers understood the importance of communicating the dangers.
Attempts were made by officers to open his mouth and sweep the drugs out of the mouth with their hands. A number of officers gave evidence that they were not aware of some of the risks inherent in placing their hands in someone’s mouth, including the risk of packages entering the airway and therefore choking, and they were not aware of the relevant passages in the NPCC Personal Safety Manual or importantly, the principles relating to this contained within. This was not only the position in 2021 but remained the position at the time of the inquest.
I am concerned that there is no standard provision for guidance or training for police officers in units tasked to make arrests for drug offences, to equip them to make informed decisions when faced with this situation. In the Personal Safety Manual ( Module 12 pg 42), it is described as a 'common tactic used by some subjects during arrest to conceal controlled drugs in their mouths'.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandate delivery of at least one mouth-concealment scenario during initial and refresher safety training.
Verbatim wording from the response “2. It has been mandated that during both initial and refresher safety training, at least one scenario covering the concealment of an item in the mouth must be delivered.” Source location Response from Derbyshire Constabulary
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design and implement a lesson plan covering concealment of items in a subject’s mouth for Derbyshire Constabulary training.
Verbatim wording from the response “1. A lesson plan has been designed and implemented to cover the necessary points pertaining to concealment of an item in a subject’s mouth for training within Derbyshire Constabulary.” Source location Response from Derbyshire Constabulary
Open published response
16 Feb 2024 Sobia Tabasim Khan · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 12 Uncontrolled overseas travel by recently discharged s.41 restricted patients View source Absence of police power to arrest people posing a significant risk of death or serious injury View source Failure to provide clinicians with full risk-assessment reports for discharge decisions View source Inadequate and misleading risk and progress reports for restricted-patient discharge View source Failure to refer high-risk restricted-patient discharge decisions for Mental Health Tribunal scrutiny View source Inadequate recording of risk meetings, decisions and actions View source Over-reliance on self-reporting by a manipulative patient about relationships and risk View source Failure to recall s.41 patients solely posing a significant public risk without mental-health decline View source Lack of available forensic supervision pathways for s.41 restricted patients View source Inadequate clinical record-keeping of material risk information View source Failure to investigate culturally relevant family and community information View source Failure to complete and consider a pre-discharge family assessment View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sobia Tabasim Khan · 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
Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Uncontrolled overseas travel by recently discharged s.41 restricted patients
Wider context from the report “e. Travel overseas for s.41 restricted patients. ████████ was permitted to travel to and from Pakistan freely and to return seemingly as and when he saw fit. Whilst he was outside the jurisdiction there was no way of checking on him, including in terms of his mental health, but also his risk . There were concerns, for example, that he may have been arranging a forced marriage for his niece. He could have entered into a relationship, for all the authorities knew. It also allowed him an opportunity to push and test the boundaries. He was permitted to travel out of the jurisdiction as he pleased, sometimes returning late, sometimes early. By contrast, had he been on licence after serving a custodial sentence, he would in all probability have been prevented from travelling outside the jurisdiction, at least in the early stages. Whilst I acknowledged that there are qualitative differences between a prison sentence and a hospital order, it remains legitimate if not necessary to ensure that those who have recently discharged from a s.41 order are carefully monitored, in the jurisdiction , at least for the first 12 months. This is beneficial not only in terms of monitoring mental health, but also risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of police power to arrest people posing a significant risk of death or serious injury
Wider context from the report “c. Police power to arrest where there is a reason to believe a person is at risk of death/serious injury. Whilst I was critical of the failure of the police to take measures that were reasonably available to them to investigate the intelligence that had been received that ████████ was in a relationship, the one power that was not available to them was to arrest him . This leaves a significant gap in the powers that are available to the police to protect individuals who are at risk of death/serious injury . Although I cannot say whether the threshold would have been met in Sobhia’s case, such a power could in future cases ensure that it is understood that where an individual poses a significant risk of causing serious harm in relationships, and there is evidence that he is concealing a relationship, he can be arrested.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clinicians with full risk-assessment reports for discharge decisions
Wider context from the report “f. Clinicians should be provided with full reports when considering discharge. This was a particular concern in relation to the fact that those recommending discharge were not provided with the full Spousal Assault Risk Assessment, but only a summary . Given ████████ risk profile, and the catastrophic consequences that were liable to result from him being pre-emptively discharged, and that discharge was being recommended without recourse to the Tribunal, it was essential that the s.117 meeting was informed by detailed reports which, had they been properly considered, would have indicated a need for circumspection.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Inadequate and misleading risk and progress reports for restricted-patient discharge
Wider context from the report “a. Scrutiny of s.41 MHA 1983 cases by the Mental Health Tribunal. In this case ████████ was discharged by the Ministry of Justice (MoJ) following the receipt of reports from Cygnet Hospital which were inadequate and misrepresented the progress he had made and the risk that he posed . Nonetheless there were indicators which should have led the MoJ to question whether this case should have been referred to a Mental Health Tribunal, such as ████████ minimising his culpability for his previous offending. The offences against his former wife were of the utmost gravity, particularly in the context of his behaviour during the marriage that she later disclosed. This indicated a risk of such a level as to make it not only desirable but essential that discharge was not contemplated until there had been close and careful scrutiny by those with expertise in forensic risk assessment. The MoJ Guidance on restricted patients says that “the vast majority” of discharge decisions are made by the Tribunal. In a patient with ████████ risk profile it is difficult to envisage circumstances whereby that should have been displaced.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to refer high-risk restricted-patient discharge decisions for Mental Health Tribunal scrutiny
Wider context from the report “a. Scrutiny of s.41 MHA 1983 cases by the Mental Health Tribunal. In this case ████████ was discharged by the Ministry of Justice (MoJ) following the receipt of reports from Cygnet Hospital which were inadequate and misrepresented the progress he had made and the risk that he posed. Nonetheless there were indicators which should have led the MoJ to question whether this case should have been referred to a Mental Health Tribunal , such as ████████ minimising his culpability for his previous offending. The offences against his former wife were of the utmost gravity, particularly in the context of his behaviour during the marriage that she later disclosed. This indicated a risk of such a level as to make it not only desirable but essential that discharge was not contemplated until there had been close and careful scrutiny by those with expertise in forensic risk assessment . The MoJ Guidance on restricted patients says that “the vast majority” of discharge decisions are made by the Tribunal. In a patient with ████████ risk profile it is difficult to envisage circumstances whereby that should have been displaced.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of risk meetings, decisions and actions
Wider context from the report “h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken . In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that ████████ was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all . There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on self-reporting by a manipulative patient about relationships and risk
Wider context from the report “g. Over-reliance on self-reporting. This was a theme that ran throughout the inquest and the various agencies involved. This was a case that required a forensic approach throughout, both in hospital and in the community. It was recognised that ████████ was narcissistic and manipulative but he was nonetheless relied upon to provide updates as to his mental health, his travel plans and the reasons for them, and – critically - whether or not he was in a relationship . ████████ risk arose primarily in the context of relationships and he was not somebody that could be relied upon to disclose them. On the contrary, he had shown himself willing and adept at concealing them . This underlined why his self-reporting could not be relied upon and this something that should have featured in his management throughout, and flagged at the point of discharge.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to recall s.41 patients solely posing a significant public risk without mental-health decline
Wider context from the report “d. Ministry of Justice power to recall where a patient poses a significant risk to the public. The MoJ will not generally recall dangerous individuals unless there is a decline in their mental health presentation notwithstanding the fact that s.41 MHA 1983, to which ████████ was subject, is designed to protect the public from serious harm. Whilst there is the possibility of the judge imposing a hybrid order, and that was not considered appropriate in this case, it did not mean that ████████ risk only existed in the context of a decline in his mental health . If an individual subject to a s.41 restriction order poses a significant risk to the public he can be protected if he can be recalled to hospital where further assessment can be undertaken.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of available forensic supervision pathways for s.41 restricted patients
Wider context from the report “b. Ensuring that s.41 restricted patients are supervised under a forensic pathway. In this case no such pathway even existed in the locality . This meant that Mustafa’s supervision was inadequate having regard to the risk that he posed . Such orders are imposed to protect the public from the risk of serious harm. Even where it has been adjudged that any previous offending would not have happened but for a mental disorder, there is still the need for a forensic approach. The risk component must not be overlooked as it was here. Forensic pathways must be available across the country .
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical record-keeping of material risk information
Wider context from the report “h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not . The paucity of records and the poverty of their quality meant that ████████ was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate culturally relevant family and community information
Wider context from the report “i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues . Although it was intended that a family tree would be completed, and this should have been done pre-discharge, ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and consider a pre-discharge family assessment
Wider context from the report “i. Familiarisation of professionals with cultural issues. In this case there appears to have been a reluctance to make enquiries with the Mosque and the Islamic Meat Centre, and to be aware of how the family dynamics are impacted by cultural issues. Although it was intended that a family tree would be completed, and this should have been done pre-discharge , ████████ was able to some extent to throw a curtain around his family and thereby promote those working with him from understanding the lengths they were prepared to go to protect him. It was noted that him becoming the Head of the family after his father’s death was significant, but the wider consequences were not properly considered .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refer the absence of a specific arrest power for national consideration by the MOSOVO policing lead.
Verbatim wording from the response “There is no specific order or power of arrest where there is reason to believe that a person is at risk of death/serious injury, and this is something that requires national consideration. A letter explaining the circumstances of this case and the context concerning this recommendation has been sent to Assistant Chief Constable ████████, national policing lead for the Management of Sexual Offenders and Violent Offenders (MOSOVO), for his consideration.” Source location Response from Derbyshire Constabulary
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional training to officers and staff on self-reporting and disguised compliance, with MOSOVO personnel completing the national course.
Verbatim wording from the response “Since the recommendations from the DHR were received, the force has made several changes with both training and compliance. We have invested in additional training to upskill our officers and staff and equip them with the skills and knowledge to enable them to effectively manage self-reporting and disguised compliance. All officers and staff working in the Management of Sexual and Violent Offenders (MOSOVO) team have completed the College of Policing MOSOVO training course.” Source location Response from Derbyshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review ARMS recording processes, adapt Standard Operating Procedures, and rectify incorrectly recorded assessments.
Verbatim wording from the response “Following feedback from His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS), we have recently reviewed how we comply with the national ViSOR operating standards in recording Active Risk Management System (ARMS) assessments. We have reviewed our processes in response and adapted our Standard Operating Procedures to ensure that we are compliant and have rectified those that had been incorrectly recorded. The minutes of all Multi-Agency Public Protection Arrangements (MAPPA) meetings are recorded and are subject to scrutiny during the learning reviews conducted by the MAPPA partnership every six months. Additionally, we work with other forces in the region to peer review and scrutinise each other’s minutes from MAPPA meetings.” Source location Response from Derbyshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit a Digital Media Investigator to strengthen MOSOVO compliance monitoring through digital-device checks during unannounced visits.
Verbatim wording from the response “The Offender Managers generally conduct unannounced home visits to perpetrators, double-crewed, as this is recognised best practice to minimise the risk of disguised compliance. We can report that our compliance rates in the last six months are 86% for unannounced visits and 84% for double-crewed attendance. On the occasions of non-compliance, a supervisor will ratify the decision with supporting rationale. In May 2023, we recruited a Digital Media Investigator (DMI) into the MOSOVO team to further strengthen our capability to manage and monitor compliance. The DMI accompanies the Offender Manager on unannounced home visits to proactively conduct checks of digital devices, such as laptops, mobile phones and tablets, to ensure compliance with any conditions of a licence or other order.” Source location Response from Derbyshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver vulnerability training to frontline officers and staff covering controlling and coercive behaviour and disguised compliance.
Verbatim wording from the response “At the end of 2023, several officers and staff members were trained to deliver the College of Policing MOSOVO training course so that new people joining the team could be trained in-house and equipped with the skills and knowledge from the outset. Continuing Professional Development (CPD) events are held throughout the year in order to refresh the skills of our officers and staff so that they can share best practice. On a wider level, Vulnerability training was delivered to all frontline officers and staff during 2023 and 2024 and this has included the topics of controlling and coercive behaviour and disguised compliance.” Source location Response from Derbyshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scrutinise MAPPA meeting minutes through partnership learning reviews and regional peer review.
Verbatim wording from the response “Following feedback from His Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS), we have recently reviewed how we comply with the national ViSOR operating standards in recording Active Risk Management System (ARMS) assessments. We have reviewed our processes in response and adapted our Standard Operating Procedures to ensure that we are compliant and have rectified those that had been incorrectly recorded. The minutes of all Multi-Agency Public Protection Arrangements (MAPPA) meetings are recorded and are subject to scrutiny during the learning reviews conducted by the MAPPA partnership every six months. Additionally, we work with other forces in the region to peer review and scrutinise each other’s minutes from MAPPA meetings.” Source location Response from Derbyshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce the importance of record keeping through senior-management messaging and force-wide communications.
Verbatim wording from the response “Improving investigations is a key strategic priority and we have a comprehensive programme of activity to raise standards and improve record keeping, led by our Head of Crime, Detective Chief Superintendent ████████. The importance of record keeping has been reiterated as part of key messaging to frontline officers, staff, and supervisors through their senior management teams and force wide communications.” Source location Response from Derbyshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce dedicated operational teams to proactively manage perpetrators posing the greatest risk of harm.
Verbatim wording from the response “However, the force does have powers where there are risks to a known victim, and we have made significant progress in how we protect vulnerable people from harm by strengthening the protection that we can offer. Civil orders such as Domestic Violence Protection Orders (DVPO) and Stalking Protection Orders (SPO) have powers of arrest attached to them so that a perpetrator can be arrested if the conditions are breached. The introduction of dedicated” Source location Response from Derbyshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise Neighbourhood Profiles to capture cultural information, community groups, establishments, and significant community figures.
Verbatim wording from the response “We have recently revised our Neighbourhood Profiles so that Safer Neighbourhood Teams can capture vital cultural information to enable them to understand the needs of the community and improve their engagement. The profiles outline the demographics of the area and identify key community groups and religious establishments, as well as identifying significant persons within them such as religious leaders, Councillors, headteachers and community workers.” Source location Response from Derbyshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a strategic programme to raise investigation standards and improve record keeping.
Verbatim wording from the response “Improving investigations is a key strategic priority and we have a comprehensive programme of activity to raise standards and improve record keeping, led by our Head of Crime, Detective Chief Superintendent ████████. The importance of record keeping has been reiterated as part of key messaging to frontline officers, staff, and supervisors through their senior management teams and force wide communications.” Source location Response from Derbyshire Constabulary
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Creating a specific arrest power requires national consideration; the matter has been referred to the national MOSOVO policing lead.
Verbatim wording from the response “There is no specific order or power of arrest where there is reason to believe that a person is at risk of death/serious injury, and this is something that requires national consideration. A letter explaining the circumstances of this case and the context concerning this recommendation has been sent to Assistant Chief Constable ████████, national policing lead for the Management of Sexual Offenders and Violent Offenders (MOSOVO), for his consideration.” Source location Response from Derbyshire Constabulary
Open published response
27 Nov 2023 Gracie Elizabeth Spinks · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 6 Failure to maintain contemporaneous and sufficiently detailed investigation records View source Failure to deal effectively with reports of potential dangerous weapons found in the community View source Lack of consistent availability of stalking advocates for victims across the UK View source Failure to complete and regularly reassess comprehensive investigation risk assessments View source Failure to investigate stalking complaints fully and in line with available guidance View source Failure to individually record all stalking offence locations View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 19
Action
Maintain a Domestic Abuse Review Team for secondary risk assessments of domestic abuse, stalking and harassment cases.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2023. View source
Action
Replace the command and control system with capability to tag multiple locations and improve automated intelligence for risk assessment.
Stated plannedThe respondent said that this action was planned when they made their response on 1 December 2023. View source
Action
Operate Quality Assurance Thematic Testing to audit investigations, provide feedback and signpost relevant guidance and policy.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2023. View source
Action
Undertake an independent peer review of stalking policies, procedures and training materials with the National Police Chiefs’ Council lead.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023. View source
Action
Refresh stalking training content to cover risk indicators, reasonable enquiries, pattern analysis, ongoing risk assessment and record keeping.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2023. View source
Action
Update student-officer training products to incorporate current stalking guidance and learning from the report.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2023. View source
Action
Train the dedicated risk-assessment team on psychological harm and behavioural patterns, with further SafeLives input and an independent audit.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023. View source
Action
Conduct a further thematic audit of stalking investigations and review its findings through the strategic Performance Assurance Board.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023. View source
Action
Introduce Niche functionality enabling multiple stalking offence locations to be linked and communicate the change to force staff.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2023. View source
Action
Integrate non-domestic stalking risk assessment into the DASH public protection notice and require completion before closing incidents, with supervisory oversight.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2023. View source
Action
Review stalking resources and issue messages raising staff awareness of their availability for investigations.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2023. View source
Action
Deliver revised mandatory stalking training to frontline officers and staff, monitor attendance, evaluate it and include it in continuing professional development.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023. View source
Action
Publish a stalking policy and supporting standard operating procedure with investigation checklists and expectations for pattern analysis and reasonable enquiries.
Stated plannedThe respondent said that this action was planned when they made their response on 1 December 2023. View source
Action
Deliver investigative-mindset workshops and embed robust record-keeping requirements in the improvement strategy, with governance and QATT monitoring.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023. View source
Action
Create and operate a stalking coordinator role for secondary assessment of non-domestic stalking risk.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2023. View source
Action
Reinforce contemporaneous note taking and record keeping through senior messaging and refreshed training materials.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2023. View source
Action
Conduct stalking-focused crime audits and scrutinise performance outcomes through force performance meetings.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023. View source
Action
Refresh the Thrive policy to require documented ongoing reassessment of risk during investigations.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023. View source
Action
Introduce a specific policy for responding to found weapons and audit and monitor investigations until working practices meet the required standard.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023. View source See 16 more actions
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AI-generated summary
Gracie Elizabeth Spinks · 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
Gracie Elizabeth Spinks was unlawfully killed by a former work colleague on 18 June 2021, dying from a stab wound to the neck. The report describes serious police failings in investigating her stalking complaint and in dealing with a rucksack containing weapons, and raises concerns about stalking investigations, risk assessments, record keeping, dangerous items found in the community, and the availability of independent stalking advocates.
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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporaneous and sufficiently detailed investigation records
Wider context from the report “4. Contemporaneous note taking/record keeping – during the inquest I heard that police officers failed to make any contemporaneous notes of important steps in the police investigation including, for example, conversations with an informant/member of the public, words of advice given to a suspect, a telephone call to a potential witness and also an internal police discussion between a police constable and police sergeant discussing the closure of an investigation. The written crime reports reviewed during the inquest also lacked sufficient detail around these important conversations/investigative steps – in other words, the crime reports did not compensate for the lack of contemporaneous notes.
I am concerned that a lack of contemporaneous notes/insufficient detail within a crime report may impact on the ability to make properly informed risk assessments which rely on the existence of a good written record of important conversations/steps taken during an investigation. This may become an issue where, for example, an investigation is re-allocated to another police officer who has had no prior involvement in the investigation such that the newly allocated police officer will be reliant upon the quality of the original police officer’s records/notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to deal effectively with reports of potential dangerous weapons found in the community
Wider context from the report “5. Potential weapons/dangerous items found in the community – during the inquest I heard that police officers attended to a report of a rucksack containing weapons found by a member of the public in May 2021. Despite the rucksack containing weapons, it was treated by the attending police officers as if it were an item of found property . Derbyshire Constabulary accepted that there were serious failings in how the officers dealt with this incident. During the inquest, I heard that there has been another recent incident around 11 August 2023 in which a child found a knife concealed in bushes in a local park. The knife was concealed in a sock and the child’s parent was concerned that the knife had been concealed so that it could be used at a later date. Despite the obvious potential danger, the police call handler advised the member of the public to ‘destroy’ the knife and advised that police would not be attending . Whilst I recognise that further steps have been taken very recently in response to this latest incident, I am concerned that there appears to be an ongoing issue within Derbyshire Constabulary around the ability of some police officers/staff to deal effectively with reports of potential dangerous weapons found in the community .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent availability of stalking advocates for victims across the UK
Wider context from the report “6. Independent Stalking Advocates – during the inquest I heard evidence about the benefits that stalking advocates can provide to those who are victims of stalking. Whilst I was reassured to hear that Derbyshire would have benefits from stalking advocates, I heard evidence that many other areas around the UK do not have stalking advocates . This essentially creates a postcode lottery for victims who report stalking to the police . I am concerned about the lack of consistency and availability of stalking advocates to victims of stalking across the UK .
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and regularly reassess comprehensive investigation risk assessments
Wider context from the report “2. Risk assessments – during the inquest I saw a number of good quality risk assessments completed by police call handlers/officers who were involved in the very early stages of Gracie’s stalking complaint in February 2021 and also the rucksack incident in May 2021. However, it became apparent during the inquest that the police officers who were subsequently allocated to deal with the stalking complaint and the rucksack incident failed to record any form of risk assessment or fully assess the potential risks . As was recognised by the Detective Chief Superintendent who gave evidence for the Constabulary at the inquest, the crime report for the stalking investigation in February 2021 lacked any sort of risk assessment or even a recognition of potential risks . I heard evidence from the police officers involved in the stalking investigation and the rucksack incident and I am concerned that there may be an ongoing lack of understanding about the importance of completing comprehensive risk assessments which include the initial identification of risk and also, importantly, a regular re-assessment of risk as the investigation progresses . I consider that further steps should be considered in order to improve understanding and appreciation of the importance of completing comprehensive risk assessments.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate stalking complaints fully and in line with available guidance
Wider context from the report “1. Stalking – during the inquest I heard evidence from the police officers who were involved in investigating Gracie’s stalking complaint in February 2021. Derbyshire Constabulary accepted that there were serious failings in how Gracie’s complaint was investigated by these officers . I do recognise that Derbyshire Constabulary has taken some steps following Gracie’s death to improve knowledge around stalking. However, as the Detective Chief Superintendent who gave evidence for the Constabulary accepted, more needs to be done to improve knowledge and understanding around how officers should investigate complaints of stalking . Consideration may be given to:
• Reviewing the current force guidance/training on stalking and considering whether further guidance/training is required in light of the issues identified during the inquest (including consideration of whether there ought to be a force policy on stalking);
• Re-enforcing understanding of the existing training/guidance on stalking including consideration of further training sessions/briefings to emphasise the key issues around investigating complaints of stalking, particularly in relation to the need to investigate the stalking complaint fully in order to identify potential patterns in the suspect’s alleged behaviour ;
• Ensuring officers are aware of the available resources on stalking and, crucially, the importance of actually consulting the available resources on stalking when police officers are investigating stalking cases to ensure that investigations are conducted in line with expected standards.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to individually record all stalking offence locations
Wider context from the report “3. Independent Office for Police Conduct (“IOPC”) – the IOPC carried out an investigation into the conduct of the five officers involved in the stalking investigation and the rucksack incident. The IOPC made a number of recommendations to Derbyshire Constabulary which included:
‘2. To consider how stalking offence locations are recorded on Niche. There does not appear to be any guidance to suggest that all of the locations of the stalking offending are tagged to the incident individually . In this instance it may not have made any difference as the officers who received the bag did not do a search of police systems for the area. However, in future that may well be done, and it could make the difference between linking risk and suspects.’
I heard evidence about this issue from the Detective Chief Superintendent on behalf of the Constabulary and I am concerned that more needs to be done to engage with this specific recommendation from the IOPC. The inquest heard that specific geographical locations can be particularly important in stalking investigations (i.e the horse field in Gracie’s case). As such, it seems to me that the IOPC recommendation is an important one which could assist in future cases with linking suspects and particular locations relevant to the stalking investigation.
” 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 Maintain a Domestic Abuse Review Team for secondary risk assessments of domestic abuse, stalking and harassment cases.
Verbatim wording from the response “Since 2021, the force has introduced a Domestic Abuse Review Team (DART) to undertake secondary risk assessments of all domestic abuse, stalking and harassment (DASH) risk assessments. Similarly, in 2022, we created a new role, a stalking coordinator, to undertake secondary risk assessments of non-domestic related stalking. The purpose of these functions is to undertake an objective assessment of the risk, considering the cumulative risk from previous incidents or reports.” Source location Response from Derbyshire Constabulary
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 Replace the command and control system with capability to tag multiple locations and improve automated intelligence for risk assessment.
Verbatim wording from the response “In addition, the force’s command and control system, which records calls for service, dispatches officers and records attendance, is due to be replaced in July 2025. The new system will provide new capability across our telephony and command and control functions, including the ability to tag multiple locations. Its automated intelligence functions have improved capability, providing a greater amount of information to inform risk assessments, identifying more effectively repeat callers and locations without the need to search multiple systems. In the meantime, intelligence officers support call handlers, through assessing information linked to wider locations, as part of an incident’s initial intelligence assessment.” Source location Response from Derbyshire Constabulary
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 Quality Assurance Thematic Testing to audit investigations, provide feedback and signpost relevant guidance and policy.
Verbatim wording from the response “In March 2023, we developed a quality assurance framework in respect of investigations, known as Quality Assurance Thematic Testing (QATT). Through this framework, investigations are quality assured by officers of inspecting ranks across the organisation, focusing on the quality of investigation plans, victim care, suspect management, and effective supervision.” Source location Response from Derbyshire Constabulary
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 Undertake an independent peer review of stalking policies, procedures and training materials with the National Police Chiefs’ Council lead.
Verbatim wording from the response “We are collaborating with the National Police Chiefs’ Council’s stalking and harassment lead Deputy Chief Constable ████████, to undertake an independent peer review of the force’s policies, procedures, and training material.” Source location Response from Derbyshire Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh stalking training content to cover risk indicators, reasonable enquiries, pattern analysis, ongoing risk assessment and record keeping.
Verbatim wording from the response “As a force, we are committed to improving our staff’s understanding and identification of stalking and vulnerability. Since the inquest, we have reviewed and refreshed the content of our training on stalking as part of the force’s vulnerability programme. This emphasises to our officers and staff the risk indicators of stalking behaviour and the importance of pursuing all reasonable lines of enquiry. A focus is also placed on the importance of broadening intelligence parameters to include multiple locations to assess cumulative risk, and that officers should undertake ongoing risk assessments throughout the course of an investigation and keep accurate records.” Source location Response from Derbyshire Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update student-officer training products to incorporate current stalking guidance and learning from the report.
Verbatim wording from the response “During January 2024, we have also updated the force’s training products which are delivered to student officers, to ensure their inputs are current and take cognisance of the learning points highlighted within your report.” Source location Response from Derbyshire Constabulary
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 Train the dedicated risk-assessment team on psychological harm and behavioural patterns, with further SafeLives input and an independent audit.
Verbatim wording from the response “During the force’s 2023 PEEL Inspection, by HMICFRS, the quality and consistency of such assessments was inspected, and some areas for improvement were found. As a result, the force has immediately responded and throughout December 2023 we further trained our dedicated DART team to ensure a greater focus is placed on psychological harm and patterns of behaviour. We are currently working with Safe Lives, a nationally recognised charity within this field, who will offer further inputs in February 2024 along with an independent audit of risk assessments the following month, to independently evaluate the changes that have been made.” Source location Response from Derbyshire Constabulary
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 Conduct a further thematic audit of stalking investigations and review its findings through the strategic Performance Assurance Board.
Verbatim wording from the response “The force is evaluating the impact of the work being undertaken and the changes to policy with a further thematic audit throughout January 2024, to assess performance in this area, which shall be reviewed at the force’s strategic Performance Assurance Board, chaired by the Deputy Chief Constable.” Source location Response from Derbyshire Constabulary
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 Introduce Niche functionality enabling multiple stalking offence locations to be linked and communicate the change to force staff.
Verbatim wording from the response “In 2016, Derbyshire Constabulary adopted Niche as its Crime Management System. It is used across the force for investigation and case management, safeguarding referrals, intelligence submissions, property management and custody management. To ensure we can identify patterns and trends, the system relies on data being flagged or linked. Prior to December 2023 the force had been unable to link multiple locations to a crime report, due to a lack of functionality. However, following the recommendation made by the IOPC the force has worked with Niche and other police forces to introduce this functionality, which is now available following a system upgrade. These changes took effect in November 2023 and notification of this has been communicated to the force via the Chief’s Orders, a circular, on 11th December 2023 and reiterated in January 2024, on the force intranet.” Source location Response from Derbyshire Constabulary
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 Integrate non-domestic stalking risk assessment into the DASH public protection notice and require completion before closing incidents, with supervisory oversight.
Verbatim wording from the response “Further changes were implemented in December 2023 to improve the consistency and timeliness of submitting risk assessments for stalking cases. The previous form 90 risk assessment, which was used in non-domestic abuse stalking investigations, was a stand-alone form, separate to other force risk assessments. This has now been integrated into the DASH risk assessment form, known as a DASH public protection notice (PPN), meaning there is now one process for assessing both domestic and non-domestic stalking. The Control Room policy is now to no longer close incidents until such risk assessments have been completed and endorsed on the log. This is overseen by supervision from line managers.” Source location Response from Derbyshire Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review stalking resources and issue messages raising staff awareness of their availability for investigations.
Verbatim wording from the response “A full review of the force’s available resources on stalking was undertaken in December 2023, updating key points on multiple locations being assessed to identify potential patterns in a suspect’s behaviour. More specific messages have been issued to officers and staff, raising awareness of the availability of these resources to aid and inform investigations.” Source location Response from Derbyshire Constabulary
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 Deliver revised mandatory stalking training to frontline officers and staff, monitor attendance, evaluate it and include it in continuing professional development.
Verbatim wording from the response “The force is delivering the revised mandatory stalking training to all frontline police officers and staff. This commenced on 11th January 2024 and is expected to be completed by April 2024. The force will monitor attendance, undertake an evaluation of the training, and ensure it forms part of continued professional development (CPD) for officers and staff in the future.” Source location Response from Derbyshire Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a stalking policy and supporting standard operating procedure with investigation checklists and expectations for pattern analysis and reasonable enquiries.
Verbatim wording from the response “To formalise the existing guidance on stalking, Derbyshire Constabulary is due to publish a new stalking policy in February 2024. The policy has been reviewed, amended and sent out for consultation with key stakeholders across Contact Management, Divisional and Crime functions across the force. We have drawn upon and used best practice from other forces to formulate the policy. The policy specifically sets out the expectations required in response to stalking, supported by a standard operating procedure that provides clarity on the working practices and processes to be followed. This will include a specific checklist for officers to consider as part of the investigation strategy, including wider pattern analysis, multiple offence locations and the importance of adopting an ‘investigative mindset’ when pursuing all reasonable lines of enquiry.” Source location Response from Derbyshire Constabulary
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 Deliver investigative-mindset workshops and embed robust record-keeping requirements in the improvement strategy, with governance and QATT monitoring.
Verbatim wording from the response “Building upon this, as mentioned above, the force’s Improving Investigations strategy has been reviewed and refocused for 2024, in which building an ‘investigative mindset’ is a key priority. A series of workshops are underway throughout January and February 2024, with senior leaders as well as frontline officers and staff, to understand the capabilities required and opportunities to improve the desired behaviour.” Source location Response from Derbyshire Constabulary
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 Create and operate a stalking coordinator role for secondary assessment of non-domestic stalking risk.
Verbatim wording from the response “Since 2021, the force has introduced a Domestic Abuse Review Team (DART) to undertake secondary risk assessments of all domestic abuse, stalking and harassment (DASH) risk assessments. Similarly, in 2022, we created a new role, a stalking coordinator, to undertake secondary risk assessments of non-domestic related stalking. The purpose of these functions is to undertake an objective assessment of the risk, considering the cumulative risk from previous incidents or reports.” Source location Response from Derbyshire Constabulary
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 Reinforce contemporaneous note taking and record keeping through senior messaging and refreshed training materials.
Verbatim wording from the response “Since the inquest, the importance of contemporaneous note taking and record keeping has formed part of key messaging, through senior management teams, to frontline staff and supervisors. This area of learning has also been incorporated into the training material that has been refreshed. Officers have access to mobile devices upon which contemporaneous notes can be made.” Source location Response from Derbyshire Constabulary
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 Conduct stalking-focused crime audits and scrutinise performance outcomes through force performance meetings.
Verbatim wording from the response “QATT performance outcomes are monitored through force performance meetings, providing scrutiny and oversight at a senior level. During January 2024, all crime audits will relate to stalking investigations, providing a deeper assessment of the quality of investigations and the impact of the ongoing training being provided.” Source location Response from Derbyshire Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh the Thrive policy to require documented ongoing reassessment of risk during investigations.
Verbatim wording from the response “A thematic review of stalking investigations between June 2023 and November 2023 has been undertaken. Unfortunately, this demonstrated a continuing need for improvement, and the revised training material, together with effective supervision and oversight is reinforcing this. The Thrive policy is being refreshed in January 2024 to include a greater focus on the ongoing need for ‘re-Thrive’ assessments during an investigation, and the expectation for this to be fully documented on the crime report.” Source location Response from Derbyshire Constabulary
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 Introduce a specific policy for responding to found weapons and audit and monitor investigations until working practices meet the required standard.
Verbatim wording from the response “In 2021, the force issued guidance for responding to reports of found property. In October 2023, the force reviewed its policies in respect of property, realigning the earlier guidance through introducing a specific policy relating to found weapons. An audit of found property incidents between October 2023 and December 2023 has been undertaken. There is still more improvement needed to ensure revision of risk at all appropriate stages and divisional senior management teams are reinforcing expectations regarding the standards of investigations required in such cases, in accordance with the policy. The ongoing audit and performance monitoring shall remain in place until working practices are to the required standard. The Deputy Chief Constable will monitor these.” Source location Response from Derbyshire Constabulary
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 Derbyshire 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 Derbyshire 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 Derbyshire 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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train all Firearms Enquiry Officers through external training and local continuous professional development.
Verbatim wording from the response “All Firearms Enquiry Officers have attended the training course provided by South Yorkshire Police, enhanced further by local internal continuous professional development sessions. The force is also in the process of developing a digital learning package to raise awareness of firearms licensing amongst frontline officers. Members of the Firearms Licensing management team will shortly be attending a two-day event at the College of Policing to debrief the findings of the inquest and identify any learning for inclusion in our local delivery plan.” Source location Response from Derbyshire Police
Open published response
6 Oct 2014 Kai Lambe · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 3 Failure to dispatch Derbyshire officers immediately in urgent situations occurring on or close to the Staffordshire-Derbyshire border View source Extreme risk associated with travelling along the weir and descending the salmon chute View source Insufficient warning signage at the weir and salmon chute View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Kai Lambe · 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
Kai Lambe, aged 9, drowned in the River Dove after going down a salmon chute and sinking under the water. The report raises concern about a five-minute delay between Derbyshire receiving the emergency call and Staffordshire’s log commencing, and whether control room operators should dispatch officers immediately in urgent incidents on or near the county border.
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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to dispatch Derbyshire officers immediately in urgent situations occurring on or close to the Staffordshire-Derbyshire border
Wider context from the report “At the inquest I heard helpful evidence from Inspector ████████ from your force. The incident which led to death took place in the River Dove which borders Staffordshire and Derbyshire. Because of local masts the initial 999 call went to Derbyshire. Derbyshire determined that the incident was in Staffordshire (emulating from the Staffordshire side of the River) and transferred the emergency call to Staffordshire. Staffordshire Officers then responded. Inspector Abbot indicated that this was in accordance with protocol although protocol does not necessarily have to be followed. There was a difference of 5 minutes between the time that the call was received by Derbyshire and the Staffordshire log commencing. In a case of a drowning child, 5 minutes can be very significant. I wonder if there is a training need for control room operators in Derbyshire to be aware to dispatch immediately Derbyshire Officers in urgent situations occurring on or close to the border between the 2 counties.
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Extreme risk associated with travelling along the weir and descending the salmon chute
Wider context from the report “At the inquest I was told that children have played at this location for many years. Is does however appear that travelling along the weir and going down the salmon chute is extremely risky . I believe that you have some responsibility for the site and that there is one small warning sign. Although you may already be aware of the circumstances of this tragic death and are taking action I write to you know to ask you to consider if safety measures including signage at the scene should be improved. If you feel that this is not your responsibility could you please let me know who is responsible for the location?
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient warning signage at the weir and salmon chute
Wider context from the report “At the inquest I was told that children have played at this location for many years. Is does however appear that travelling along the weir and going down the salmon chute is extremely risky. I believe that you have some responsibility for the site and that there is one small warning sign . Although you may already be aware of the circumstances of this tragic death and are taking action I write to you know to ask you to consider if safety measures including signage at the scene should be improved . If you feel that this is not your responsibility could you please let me know who is responsible for the location?
” Open source report
3 Sep 2014 Ryan Reece Bramwell and 2 others · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of awareness among police officers of statutory powers to close hazardous roads View source Unsafe fitting of tyres with greater tread depth to the front View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Ryan Reece Bramwell and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert John Graham died after his car was struck by an out-of-control Mercedes on the A619 on 13 November 2009. The following day, Ryan Reece Bramwell and Richard Alan Barker were among the occupants of a Ford Escort that aquaplaned while overtaking, collided with an ambulance and entered an embankment. The concerns identified were the placement of tyres with greater tread depth on the front rather than the rear, and limited awareness among Derbyshire police officers of powers to close hazardous roads.
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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among police officers of statutory powers to close hazardous roads
Wider context from the report “(B) During the course of the taking of evidence it became apparent that not all officers within the police service in Derbyshire are aware of their statutory rights to require a road to be closed and to remain closed for up to 7 days for reasons of safety . Indeed, the Traffic Sergeant giving evidence appeared unaware of this power . Had he been aware of this he might have used that power to keep the road closed until it was deemed no longer hazardous. It would seem sensible that all officers, but especially those specifically directed towards road-policing, should be made aware of this power. (FOR THE CHIEF CONSTABLE)
” 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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Unsafe fitting of tyres with greater tread depth to the front
Wider context from the report “(A) Both the Mercedes vehicle involved in the first collision and the Ford Escort involved in the second collision had tyres which met the requirements for the minimum amount of tread depth, but there were tyres had considerably less tread depth than those on the front. Evidence was given by the expert vehicle examiners and police accident investigators, that this arrangement with the ‘better’ tyres to the front, is undesirable and did contribute to the effects of aquaplaning and loss of control in each case . It occurred to me that at the very least strong advice by tyre fitters should be given to any driver seeking to have the better tyres placed on the front, and preferably it should be made a legal requirement. (FOR THE SECRETARY OF STATE)
” Open source report
1 Nov 2013 Rachael Claire Slack and 2 others · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Failure to exchange relevant information between Police and Mental Health Services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Rachael Claire Slack and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 2 June 2010, Andrew David Cairns entered Rachael Claire Slack’s home, stabbed their son Auden George Slack and Rachael Slack to death, and then stabbed himself to death. The principal concerns were failures in information-sharing between Police and Mental Health Services, and failures to communicate the assessed risk and safety measures to Rachael regarding the threat posed by Andrew.
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 Derbyshire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to exchange relevant information between Police and Mental Health Services
Wider context from the report “1. At the time of arrest of Mr Cairns, the Police were aware of his assessment under Section 136 of the Mental Health Act the previous day. The Custody Nurse had contacted the Crisis Team to obtain information regarding the 136 assessment which was duly given by the Mental Health Team. However, there was no reciprocal exchange of information and the Mental Health Team were not informed that Mr Cairns had been arrested with regards to Threats to Kill his partner.
2. At the conclusion of the Inquest and after all the evidence was heard, it came to light that there was in existence a policy for mutual sharing of information between the Police and Mental Health Services if each respective organisation requested information from the other.
3. This document was not disclosed prior to the Inquest or during the Inquest itself and it would have been critical to ask witnesses from the Police and Mental Health Services about their knowledge of this document.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations