30 Mar 2026 Oliver John Roberts · Prevention of Future Deaths report Dorset
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Concerns raised 2 Lack of practical guidance on making communications data applications View source Lack of practical guidance on authorising communications data applications 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
Oliver John Roberts · 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
Oliver John Roberts was found suspended by a ligature in a wooded area on 28 January 2024, after being reported missing and after communications data had been requested by police. The principal concern was a lack of practical national guidance for police officers on when and how to make communications data requests, including urgent Grade 2 applications; in this case, the Grade 2 request was submitted almost 24 hours after he was reported missing.
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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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Lack of practical guidance on making communications data applications
Wider context from the report “(1) There is a lack of guidance to assist Police Officers in the practical application of their powers to obtain communications data, whether that be under a Grade 1, 2 or 3 application.
(2) Communications data can be obtained by Police forces in England and Wales pursuant to the Investigatory Powers Act 2016 (the Act). In November 2018 the Home Office issued the Communication Data Codes of Practice (the Codes of Practice) which is a document that extends to 144 pages and relates to the exercise of functions conferred by virtue of Parts 3 & 4 of the Act.
(3) Requests are submitted by police representatives to their Communication Data Investigation Teams to access data, and this will be done in different ways depending on the grading of the request.
(4) Grade 1 requests are made when there is an immediate risk to life. Grade 2 requests are made when there is an exceptionally urgent requirement for the prevention or detection of serious crime; a credible and immediate threat to national security; or a serious concern for the welfare of a vulnerable person where urgent provision of the communications data will have an immediate and positive impact on the investigation or operation. Grade 3 requests are made when matters that are not urgent but, where appropriate, will include specific or time-critical issues such as bail dates; court dates; where persons are in custody; or where there is a specific line of investigation into a serious crime and early disclosure by the telecommunications operator or postal operator will directly assist in the prevention or detection of that crime.
(5) Section 5 of Codes of Practice refers to the application process and Section 6 deals with the authorisation of the application, however there is no practical guidance, such as Authorised Professional Practice Guidance, to assist Forces and their officers, as to how and when applications should be made and authorisations should be given.
(6) In this case a Grade 2 application was submitted almost 24 hours after Ollie was reported missing. Once submitted, Ollie was found within 2 hours and 9 minutes. This application was submitted in writing, however evidence was given that in some circumstances a verbal application for a Grade 2 request can be made if the Grade 2 application is urgent. There is a lack of guidance to police officers nationally as to what would constitute a Grade 2 urgent application and what should be done in writing and what should be done verbally.
(7) I am concerned the circumstances of Ollie’s death could occur again as a result of the lack of practical guidance to Police Forces and their staff as to when and how to make data communication requests pursuant to the Investigatory Powers Act 2016 .
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Lack of practical guidance on authorising communications data applications
Wider context from the report “(1) There is a lack of guidance to assist Police Officers in the practical application of their powers to obtain communications data, whether that be under a Grade 1, 2 or 3 application.
(2) Communications data can be obtained by Police forces in England and Wales pursuant to the Investigatory Powers Act 2016 (the Act). In November 2018 the Home Office issued the Communication Data Codes of Practice (the Codes of Practice) which is a document that extends to 144 pages and relates to the exercise of functions conferred by virtue of Parts 3 & 4 of the Act.
(3) Requests are submitted by police representatives to their Communication Data Investigation Teams to access data, and this will be done in different ways depending on the grading of the request.
(4) Grade 1 requests are made when there is an immediate risk to life. Grade 2 requests are made when there is an exceptionally urgent requirement for the prevention or detection of serious crime; a credible and immediate threat to national security; or a serious concern for the welfare of a vulnerable person where urgent provision of the communications data will have an immediate and positive impact on the investigation or operation. Grade 3 requests are made when matters that are not urgent but, where appropriate, will include specific or time-critical issues such as bail dates; court dates; where persons are in custody; or where there is a specific line of investigation into a serious crime and early disclosure by the telecommunications operator or postal operator will directly assist in the prevention or detection of that crime.
(5) Section 5 of Codes of Practice refers to the application process and Section 6 deals with the authorisation of the application, however there is no practical guidance, such as Authorised Professional Practice Guidance, to assist Forces and their officers, as to how and when applications should be made and authorisations should be given .
(6) In this case a Grade 2 application was submitted almost 24 hours after Ollie was reported missing. Once submitted, Ollie was found within 2 hours and 9 minutes. This application was submitted in writing, however evidence was given that in some circumstances a verbal application for a Grade 2 request can be made if the Grade 2 application is urgent. There is a lack of guidance to police officers nationally as to what would constitute a Grade 2 urgent application and what should be done in writing and what should be done verbally.
(7) I am concerned the circumstances of Ollie’s death could occur again as a result of the lack of practical guidance to Police Forces and their staff as to when and how to make data communication requests pursuant to the Investigatory Powers Act 2016.
” Open source report
Concerns raised 2 Failure to use understandable terminology when questioning members of the public reporting missing persons View source Lack of police staff understanding of the meaning of ‘suicidal ideation’ when responding to missing-person reports View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David John Thompson · 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
David John Thompson went missing from his home on 6 March 2023 after experiencing low mood, previous thoughts of suicide and challenging life events, and was located the following morning. The report raises concerns that police use and understanding of the term “suicidal ideation” led to relevant risk information not being recorded and may have prevented the risk posed by a missing person from being fully appreciated.
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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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to use understandable terminology when questioning members of the public reporting missing persons
Wider context from the report “(1) The inquest heard that when Mr. Thompson’s partner reported him missing to the police, she was repeatedly asked (by both the 999 call handler and the attending police officers) whether he had demonstrated any ‘suicidal ideation’. It was clear that she did not fully understand what that meant, and as a result information which would have been relevant to the consideration of the level of risk presented by Mr. Thompson going missing was not recorded by the police.
(2) Furthermore, I heard evidence that the term ‘suicidal ideation’ was still being widely used by the constabulary when asking questions of members of the public who were reporting missing persons , and I am concerned that a member of the public may not understand what is being asked of them and may not therefore respond appropriately .
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police staff understanding of the meaning of ‘suicidal ideation’ when responding to missing-person reports
Wider context from the report “(3) During the course of the inquest I heard evidence from 5 police officers and 2 members of the police staff. When asked what their understanding of the term ‘suicidal ideation’ was, their answers were vague and inconsistent . There therefore appears to be a lack of understanding by those employed by the police as to what the term means , creating a danger that the risk posed by a missing person is not fully appreciated by staff responding to a missing person report .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue delivering Control Room refresher training on suicidality, fluctuating risk, plain language and broader exploratory questioning.
Verbatim wording from the response “As a Force, we will continue to deliver refresher training to Control Room Staff to further strengthen their understanding of suicidality, associated risks, and the dynamic and fluctuating nature of such incidents.” Source location 2026-0080 - Response from Devon and Cornwall Police
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 Clarify in operational guidance that “suicidal ideation” means thoughts or feelings about suicide.
Verbatim wording from the response “Guidance issued in 2024 clarified that the term ‘suicidal ideation’ refers to thoughts of suicide (with reference to publications within the Lancet, and commentary provided in open-source by the Samaritans within which ‘ideation’ relates primarily to ‘thinking about suicide or could be making a plan to take their own life. This can range from a passing thought to a detailed plan’). This clarification has been further reinforced and incorporated into training and operational guidance that is being issued and delivered throughout 2026 – with specific emphasis on the wide variety of incidents and risks that the term encompasses.” Source location 2026-0080 - Response from Devon and Cornwall Police
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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 operational guides for frontline officers and staff addressing Article 2 risks and suicidality.
Verbatim wording from the response “3. Reinforcement of the above approach to frontline officers and staff through the introduction of operational guidance (Op Guides) relating to incidents involving Article 2 risks and suicidality.” Source location 2026-0080 - Response from Devon and Cornwall Police
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 Issue and deliver reinforced training and operational guidance on the broad spectrum of risk associated with suicidality throughout 2026.
Verbatim wording from the response “Guidance issued in 2024 clarified that the term ‘suicidal ideation’ refers to thoughts of suicide (with reference to publications within the Lancet, and commentary provided in open-source by the Samaritans within which ‘ideation’ relates primarily to ‘thinking about suicide or could be making a plan to take their own life. This can range from a passing thought to a detailed plan’). This clarification has been further reinforced and incorporated into training and operational guidance that is being issued and delivered throughout 2026 – with specific emphasis on the wide variety of incidents and risks that the term encompasses.” Source location 2026-0080 - Response from Devon and Cornwall Police
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 Rigid definitions and scripted questions are not adopted because they may create false reassurance and information loss; plain language and open questioning are preferred.
Verbatim wording from the response “Whilst ‘suicidal ideation’ may be considered a clinical term in some contexts, the Force recognises that in emergency situations and when communicating with members of the public, it is often more appropriate to use plain language that is not prescribed or confined to a single definition. Accordingly, operational practice encourages the use of straightforward terminology such as ‘thoughts or feelings about suicide’ when discussing potential suicide risk.” Source location 2026-0080 - Response from Devon and Cornwall Police
Open published response
Concerns raised 2 Failure of the Firearms Licensing Department to check the PNC record View source Failure of the police process to notify the Firearms Licensing Department of the Environment Agency’s prosecution View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Richard Haddock · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Haddock died on 25 June 2023 after using his shotgun. The report identified concerns that the police process failed to notify the Firearms Licensing Department of an Environment Agency prosecution, and that the Department had not checked his PNC record before returning his firearms. The inquest conclusion was suicide.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the Firearms Licensing Department to check the PNC record
Wider context from the report “(1) The police process which should have ensured that the Firearms Licensing Department was notified of the Environment Agency’s prosecution of Mr. Haddock failed to be effective
(2) The offences with which Mr. Haddock had been charged by the Environment Agency were correctly placed onto Mr. Haddock’s PNC record on 11th October 2021 – a year before the final decision was made to return his shotgun to him in November 2022. The Firearms Licensing Department had not checked his PNC record since 4th August 2021 (more than a year before the final decision to return his guns was made) and were therefore unaware of the prosecution .
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the police process to notify the Firearms Licensing Department of the Environment Agency’s prosecution
Wider context from the report “(1) The police process which should have ensured that the Firearms Licensing Department was notified of the Environment Agency’s prosecution of Mr. Haddock failed to be effective
(2) The offences with which Mr. Haddock had been charged by the Environment Agency were correctly placed onto Mr. Haddock’s PNC record on 11th October 2021 – a year before the final decision was made to return his shotgun to him in November 2022. The Firearms Licensing Department had not checked his PNC record since 4th August 2021 (more than a year before the final decision to return his guns was made) and were therefore unaware of the prosecution.
” 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 Automatically redirect firearms-related Daily Activity File reports to the Continuous Assessment Team inbox for ongoing suitability review.
Verbatim wording from the response “Whenever a PNC record is updated, a so-called Daily Activity File (DAF) report is generated and provided to the relevant police force via an automatic file transfer from PNC Hendon. Any DAF reports that are specific to firearm and shotgun certificate holders in the Devon & Cornwall Police area are assigned a code of ‘50HL’ and forwarded to our Firearms Licensing and Explosives Unit (FLEU) via email.” Source location Response from Devon & Cornwall Police
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 Check the PNC and other databases during initial suitability-review enquiries.
Verbatim wording from the response “1. The FLEU undertake a check on the PNC as a part of their initial enquiries in the aforementioned suitability reviews. More generally, suitability reviews encompass research of other databases.” Source location Response from Devon & Cornwall Police
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 Allocate additional police personnel to the Firearms Licensing and Explosives Unit to increase review capacity.
Verbatim wording from the response “In 2021 there was a significant backlog of outstanding reviews in the FLEU as a result of both the Covid-19 pandemic adversely impacting on the FLEU’s ability to undertake related enquiries, and the Devon & Cornwall Police response to the tragic events of August 2021 in Keyham in Plymouth, which you will be aware of. A significant additional number of police personnel have since been allocated to the FLEU, and there is significant additional senior oversight of the FLEU within Devon & Cornwall Police. In general terms, there has been a significant improvement in the FLEU’s ability to undertake reviews of the type that we are concerned with presently. More specifically in relation to the concern that you raise, the following processes are now in place:” Source location Response from Devon & Cornwall Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require the Continuous Assessment Team to review relevant prosecution reports and record the review as underway in the National Firearms Licensing Management System.
Verbatim wording from the response “• Any DAF reports which reflect a prosecution of the type that Mr Haddock was subject to are subject to a suitability review by the CAT. The National Firearms Licensing Management System (NFLMS) is updated to reflect that this review is underway. The NFLMS is viewable by all police forces and other law enforcement agencies.” Source location Response from Devon & Cornwall Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require an immediate pre-return PNC check after finalising a suitability review, with a further review if relevant new information is identified.
Verbatim wording from the response “• When a suitability review is finalised and a decision is made to return a certificate / licence and firearms to the certificate / licence holder, the CAT are also now required to review the PNC to ensure that it contains no new updates of relevance. If any such updates are identified, a further suitability review takes place.” Source location Response from Devon & Cornwall Police
Open published response
20 Oct 2025 STUART MARTIN FOWKES · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Failure to share known suicide risk between police forces View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
STUART MARTIN FOWKES · 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
STUART MARTIN FOWKES died at his home on 26 May 2025 after travelling from the West Midlands to Cornwall and back while reportedly suicidal and likely under the influence of alcohol. The principal concern was that Devon and Cornwall Police recorded information about a known risk to his life, but this risk was not shared with West Midlands Police; by the time concerns for his safety were raised locally, he was likely already deceased.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to share known suicide risk between police forces
Wider context from the report “(1) DCP had a recorded log entry ref ████████ of a domestic and suicidal report made to DCP by Mr Fowkes’s Mother on 26/5/25 timed at 00:52. Coronerial enquiries elicited a response from a PC ████████ who confirmed the details of that report being from ████████ (Mother of the deceased) who lives in Devon and Cornwall area. She reported her adult son Stuart Fowkes, born 17/6/89 had left her property in a vehicle whilst in drink and suicidal. Prior to leaving, Fowkes had been shouting and swearing at his mum ████████ and whilst close to her, threatened to put his fist in her face. She said she couldn’t stop him leaving as she thought he was going to hurt her. He had told her that if he hadn’t come down to see her tonight, he would have gone to B and O and ████████ harm himself. He had told her that if he hadn’t come down to see her tonight, he would have gone to B and O and ████████ harm himself.
(2) DCP recorded a second reference to Mr Fowkes being suicidal under the same reference ████████ at 00:56 and 01:17 including further information that Mr Fowkes is suicidal and that his father committed suicide 8 years ago in Birmingham.
(3) DCP had recorded a known risk to Mr Fowke’s life.
(4) DCP appear to have been aware of Mr Fowke’s risk of suicide in the early hours of 26 May 2025.
(5) WMP conducted an internal investigation which revealed that no risk to Mr Fowke’s life was shared with West Midlands Police by Devon and Cornwall Police . WMP reported that based on information from DCP, Mr Fowkes was wanted for drink driving and domestic abuse offences. By the time Mr Fowke’s ex-partner raised a concern for his safety and made reference to suicide it is likely Mr Fowkes was already deceased.
” 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 Amend Force Policy DCP-P-051 to require sharing information with relevant forces when risks or vulnerabilities affect people outside Devon and Cornwall.
Verbatim wording from the response “2. In addition, a review of Force Policy has been undertaken and Policy DCP-P-051 referring to grading and deployment is also in the process of being amended, with the addition of the below new section as follows:” Source location Response from Devon & Cornwall Police
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 Brief CRC supervisors and staff on sharing information with other forces to mitigate risks and safeguard vulnerable people.
Verbatim wording from the response “Upon receipt of the PSD Report referred to above, the Devon & Cornwall Police Contact and Resolution Centre (‘CRC’), who are responsible for the contact centre and dispatching to incidents, have taken the following steps to address the learning raised in this matter:” Source location Response from Devon & Cornwall Police
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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 The lack of information sharing was not considered to have contributed to the death, although learning and recommendations were accepted.
Verbatim wording from the response “It is accepted that information regarding Mr Fowkes was not shared by Devon & Cornwall Police with West Midlands Police in this case. It is not suggested, I understand, that the lack of information sharing in this case contributed towards the tragic outcome. However, it is recognised there were recommendations made, and learning taken from this incident to ensure the high level of public service we strive for within this force are met and, where necessary, improved upon.” Source location Response from Devon & Cornwall Police
Open published response
Concerns raised 6 Failure to call an ambulance promptly following a concern for welfare call View source Failure to verify police supervision status when determining ambulance disposition View source Failure to obtain and share complete contact information for ambulance disposition decisions View source Failure to provide police with ambulance arrival estimates and likely delay information View source Failure to contact a police supervisor to discuss options when conveyance may affect local officer availability View source Delays in ambulance attendance View source See 3 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
Lachlan Charles Campbell · 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
Lachlan Charles Campbell died on 1 November 2022 after being found outside a railway station in a distressed and possibly drug-affected state, where he remained for several hours in heavy rain and cold conditions. The report identifies concerns about delays in ambulance attendance, incomplete information sharing between ambulance and police services, and police officers not providing shelter, warmth, or timely medical attention. The inquest concluded that these failures contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to call an ambulance promptly following a concern for welfare call
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours .
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to verify police supervision status when determining ambulance disposition
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached .
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and share complete contact information for ambulance disposition decisions
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide police with ambulance arrival estimates and likely delay information
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options.
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to contact a police supervisor to discuss options when conveyance may affect local officer availability
Wider context from the report “2) Information sharing between SWAST and D&CP.
A number of issues were revealed during the course of the evidence.
a) A concern for welfare call was received by police at circa 00:15. Officers attended on scene at circa 01:00 and chased an ambulance at 01:42 only to find one had not been previously called resulting in an initial delay of nearly 1.5 hours.
b) The initial caller had been a bus driver. His mobile details were not taken and so SWAST was unable to call him back for further information they required. When police officers were asked for their numbers, they provided their shoulder numbers, not their mobile numbers. SWAST thus had incomplete information when considering what disposition was appropriate.
c) Police Officers were advised the call had resulted in a Category 2 disposition but were not provided with an ETA. The target time was 18 minutes but an ambulance did not arrive until 06:15, some 4.5 hours later. Had Officers been aware of the likely delays, their evidence was that they would have considered other options (such as conveying Lachlan to hospital in their car.)
d) In reaching a Category 2 disposition, SWAST understood the Officers were remaining with Lachlan. In the event, they left him to deal with an unresolved domestic violence incident. At inquest, evidence was given that, had this been known to SWAST, a Category 1/2 disposition may have been reached.
e) In the event Officers had concluded there was a need to convey Lachlan to hospital, it would have meant there were no available Officers in the Penzance area. While this is a matter for police to reflect upon, it was notable the Officers’ supervisor was not contacted to discuss options .
f) The inquest heard that in other countries (USA) there are arrangements in place for police to drop victims in need of urgent treatment at hospital (eg stabbings) without being detained for extended periods (current handover for ambulance crews in excess of 2 hours.) If ambulance delays are set to continue and police may need increasingly to convey patients to hospital, is there value in considering whether arrangements of this nature would be beneficial?
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance attendance
Wider context from the report “1) Delays in ambulance attendance . I have written to the Secretary of State separately in this regard and you do not need to address this in your reply.
” 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 Reiterate to frontline personnel the expectation that officers communicate concerns about redeployment and resource availability to supervising officers.
Verbatim wording from the response “It is Devon & Cornwall Police’s expectation that our officers communicate any concerns of this type to their supervising officer (a sergeant, in the present case) at the time. Sergeants are able to make a decision to redeploy other police resources, including in liaison with an inspector and / or the Force Incident Manager (the officer in the control room who is responsible for overseeing the initial force response to incidents) as appropriate. In extreme circumstances, a more senior officer can be contacted by the control room for assistance and support in respect of redeployment. The Assistant Chief Constable with responsibility for local policing in Devon & Cornwall Police has reiterated this expectation in recent messaging to frontline personnel.” Source location Response from Devon and Cornwall Police
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 Require officers using the police control room to explain why they cannot call 999 directly, and train police and ambulance personnel to record relevant information when liaising.
Verbatim wording from the response “If our officers call for an ambulance through the police control room, they are asked if there is a reason that they cannot do this themselves (such as the need to commence CPR, or other environmental factors). Police control room and SWAST personnel are trained to record all relevant information when contacting or otherwise liaising with SWAST.” Source location Response from Devon and Cornwall Police
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 control-room personnel to notify the ambulance service when officers attending an urgent incident are redeployed.
Verbatim wording from the response “The potential for redeployment is particularly acute given the relatively large geographic areas of Devon and Cornwall. Our officers are trained to carefully consider the risk of each situation and liaise with our control room in relation to those decisions. If affected officers redeployed, our control room personnel are trained to ensure that SWAST are notified of the deployment.” Source location Response from Devon and Cornwall Police
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 officers requiring additional medical support to telephone 999 from the scene so operators can liaise directly and allocate resources.
Verbatim wording from the response “As a part of RCRP, if our police officers come across or attend an incident in respect of which they deem that there is a requirement for additional medical support, they are trained to telephone 999 from the scene. This is to seek to ensure that the 999 operator can liaise directly with the person who has the patient with them and can offer appropriate treatment, as well as allocating a resource to attend.” Source location Response from Devon and Cornwall Police
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 through first-aid training that officers may transport patients themselves as a last resort when their risk assessment considers this appropriate.
Verbatim wording from the response “Ordinarily officers are not encouraged to use police vehicles to transport individuals in need of pressing medical attention to hospital. Our position is that the primary service for this must be SWAST as they are better equipped to manage the individual in question in transit, and / or to treat an individual when their condition declines. Police officers are trained in the use of the National Decision Model, which empowers them to risk assess specific scenarios, and (using this) as a last resort are able to make the decision to transport patients themselves to help save life if they consider this appropriate. This is an individual decision by the officer involved. This possibility continues to be reinforced during Devon & Cornwall Police first aid training.” Source location Response from Devon and Cornwall Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SWAST will address ambulance ETA and target-time issues directly in its response to the Regulation 28 report.
Verbatim wording from the response “We understand that the SWAST will be addressing the issue of the ETA and target time with you directly in their response to the Regulation 28 report.” Source location Response from Devon and Cornwall Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SWAST should account for possible police redeployment when conducting its triage and risk assessment for patients needing medical attention.
Verbatim wording from the response “Devon and Cornwall Police understand that SWAST will factor police presence at a scene of someone needing medical attention into their triage / risk assessment process when determining whether to attend such an incident. If our officers are called to an urgent or potentially life-threatening incident, then they could be redeployed. Accordingly, Devon & Cornwall Police’s position is that this possibility should be factored into the aforementioned SWAST triage / risk assessment process.” Source location Response from Devon and Cornwall Police
Open published response
Concerns raised 1 Failure to undertake health-related enquiries in response to potential mental impairment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Michaela Hall · 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
Michaela Hall was stabbed through the eye by her partner on 31 May 2021 and was found deceased the next day; life was formally pronounced extinct on 1 June 2021. The report identified shortcomings in recruitment, pre-sentence reporting and risk assessment, including the partner’s risk being assessed as medium rather than high. It also raised concerns about how Children and Adult Services assessed, recorded, shared and acted on information concerning domestic abuse, safeguarding and potential mental impairment.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake health-related enquiries in response to potential mental impairment
Wider context from the report “Be curious. There were multiple examples of potential mental impairment – a diagnosis of OCD, mentions of suicidality and depression, the Acton email, yet no health-related enquiries appear to have been undertaken .
” Open source report
Concerns raised 6 Delays of over a month in obtaining best evidence through video interview or otherwise View source Lack of formalised, guaranteed funding for long-term therapy and recovery provision View source Failure to extend long-term therapy and recovery provision to domestic abuse and child sexual abuse View source Lack of available DC capacity to progress rape and serious sexual assault complaints View source Failure of the railway bridge parapet to meet statutory obligations View source Delays in long-term therapy and recovery support after sexual violence View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tamsin Ann Dolamore · 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
Tamsin Ann Dolamore died aged 24 after falling from a railway bridge onto railway lines on 8 January 2018; the inquest recorded an Open Conclusion and the medical cause of death as effects of multiple injuries. The substantive concerns included delays in appointing a Sexual Offence Liaison Officer, delays and gaps in mental-health and support services, and insufficient police resources causing delays in progressing rape and serious sexual assault complaints.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Delays of over a month in obtaining best evidence through video interview or otherwise
Wider context from the report “I was informed by ████████ that as of January this year, there were 600 open cases of rape or serious sexual assault. I was told additionally that there are over 20 vacancies for DCs to progress these complaints. One consequence was that it was taking over a month to achieve best evidence through video interview or otherwise .
████████ agreed that the lack of available DCs meant that both the quality and amount of work that could be done were affected.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formalised, guaranteed funding for long-term therapy and recovery provision
Wider context from the report “There are some steps being taken towards the provision of a more joined-up approach through a pენinsula sexual violence pathfinder [funded by NHSE] which brings together commissioners and services across Devon, Cornwall, Plymouth and Torbay to pilot new approaches to longer- term recovery support for those impacted by sexual violence. Locally, a joined- up service called Safer Futures [a partnership between First Light and Barnardos] has been commissioned by Safer Cornwall which includes Cornwall Council, the Integrated Care Board, NHSE and others.
I am concerned that the provision of long-term therapy and recovery for the survivors of rape and sexual violence, which should be extended to include domestic abuse and child sexual abuse, needs to be formalised and provided with a guaranteed level of funding . You may wish to consider if this should be on a statutory basis. No one should have to wait half a year for help after being assaulted.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to extend long-term therapy and recovery provision to domestic abuse and child sexual abuse
Wider context from the report “There are some steps being taken towards the provision of a more joined-up approach through a pენinsula sexual violence pathfinder [funded by NHSE] which brings together commissioners and services across Devon, Cornwall, Plymouth and Torbay to pilot new approaches to longer- term recovery support for those impacted by sexual violence. Locally, a joined- up service called Safer Futures [a partnership between First Light and Barnardos] has been commissioned by Safer Cornwall which includes Cornwall Council, the Integrated Care Board, NHSE and others.
I am concerned that the provision of long-term therapy and recovery for the survivors of rape and sexual violence, which should be extended to include domestic abuse and child sexual abuse , needs to be formalised and provided with a guaranteed level of funding. You may wish to consider if this should be on a statutory basis. No one should have to wait half a year for help after being assaulted.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Lack of available DC capacity to progress rape and serious sexual assault complaints
Wider context from the report “I was informed by ████████ that as of January this year, there were 600 open cases of rape or serious sexual assault. I was told additionally that there are over 20 vacancies for DCs to progress these complaints . One consequence was that it was taking over a month to achieve best evidence through video interview or otherwise.
████████ agreed that the lack of available DCs meant that both the quality and amount of work that could be done were affected .
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the railway bridge parapet to meet statutory obligations
Wider context from the report “Tamsin fell approximately 21.5’ from Menacuddle Hill/North Street railway bridge in St Austell. During the course of the investigation, enquiries were made relating to the parapet at the bridge. Please find attached:
- Report of ████████ at Strange, Strange & Gardner, Consultant Engineers, dated 30/8/18. You will note his view that the parapet does not meet the obligations of the Railway Clause Consolidation Act 1845 ;
- Email from ████████ dated 14/12/18;
- Email from ████████ dated 24/5/19;
- Email from ████████, Cormac, dated 15/7/19.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Delays in long-term therapy and recovery support after sexual violence
Wider context from the report “There are some steps being taken towards the provision of a more joined-up approach through a pენinsula sexual violence pathfinder [funded by NHSE] which brings together commissioners and services across Devon, Cornwall, Plymouth and Torbay to pilot new approaches to longer- term recovery support for those impacted by sexual violence. Locally, a joined- up service called Safer Futures [a partnership between First Light and Barnardos] has been commissioned by Safer Cornwall which includes Cornwall Council, the Integrated Care Board, NHSE and others.
I am concerned that the provision of long-term therapy and recovery for the survivors of rape and sexual violence , which should be extended to include domestic abuse and child sexual abuse, needs to be formalised and provided with a guaranteed level of funding. You may wish to consider if this should be on a statutory basis. No one should have to wait half a year for help after being assaulted .
” 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 Prepare a business case considering an uplift in sexual offences liaison officers to improve timely access to specialist victim interviews.
Verbatim wording from the response “Cornwall currently has 9 sexual offences liaison officers (SOLO) who perform the majority of the specialist video interview role (ABE). DC’s can also complete ABE interviews however they generally rely upon the SOLO for this support. It would be a fair assumption that if there were no DC vacancies then we may be able to use the additional capacity to assist with the ABE backlog. There are no SOLO vacancies, however we are currently preparing a business case to consider an uplift of SOLOs as we are aware of the good practice findings of the national Op Soteria Bluestone project which evidences the value of obtaining early victim accounts by correctly trained staff. The delay in obtaining an ABE account can be due to a number of factors, some of which are outside Police control.” Source location Response from Dorset Police
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 Allocate 76 detective constables to general Criminal Investigation Department crime types, increasing investigative capacity.
Verbatim wording from the response “This figure has improved slightly since CIOS CID have been allocated 76 Detective Constables (‘DC’) to deal with general CID crime types. Rape and other serious sexual offences are two types of the many other serious and complex crimes that we deal with. It has been suggested that RASSO offences account for around 35% to 40% of a Detectives workload. Clearly having vacancies impacts on the average amount of investigations that each investigator will have. Investigators workloads are at levels that have not be seen before and that is a combination of the rising demand from our communities and the vacancies. This high demand also reflects that our communities feel confident to report this type of crime. The vacancy and reducing, however and that is mainly by recruiting Police Officers at the early stages of their careers.” Source location Response from Dorset Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue recruiting police officers to reduce detective constable vacancies and staffing shortfalls.
Verbatim wording from the response “This figure has improved slightly since CIOS CID have been allocated 76 Detective Constables (‘DC’) to deal with general CID crime types. Rape and other serious sexual offences are two types of the many other serious and complex crimes that we deal with. It has been suggested that RASSO offences account for around 35% to 40% of a Detectives workload. Clearly having vacancies impacts on the average amount of investigations that each investigator will have. Investigators workloads are at levels that have not be seen before and that is a combination of the rising demand from our communities and the vacancies. This high demand also reflects that our communities feel confident to report this type of crime. The vacancy and reducing, however and that is mainly by recruiting Police Officers at the early stages of their careers.” Source location Response from Dorset Police
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 Launch Project Synergy to improve the investigative operating model, team resilience and wellbeing, and investigative quality.
Verbatim wording from the response “The Chief Constable has also just agreed to launch Project Synergy which is an initiative to improve our investigative operating model, increase the resilience and wellbeing of our investigative teams and to improve investigative quality. We are currently in the process of recruiting a Detective Chief Superintendent to lead on this project across Devon and Cornwall. Its considerations include formation of investigative hubs whereby investigators will be brought together to increase resilience, enable more specialist officers to be established (including rape investigators) and to introduce investigation support officers to boost the available resource. We are hopeful that this new initiative will increase our capability to deal with the increasing investigative demand.” Source location Response from Dorset Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some delays in obtaining victim video-interview accounts arise from factors outside police control.
Verbatim wording from the response “Cornwall currently has 9 sexual offences liaison officers (SOLO) who perform the majority of the specialist video interview role (ABE). DC’s can also complete ABE interviews however they generally rely upon the SOLO for this support. It would be a fair assumption that if there were no DC vacancies then we may be able to use the additional capacity to assist with the ABE backlog. There are no SOLO vacancies, however we are currently preparing a business case to consider an uplift of SOLOs as we are aware of the good practice findings of the national Op Soteria Bluestone project which evidences the value of obtaining early victim accounts by correctly trained staff. The delay in obtaining an ABE account can be due to a number of factors, some of which are outside Police control.” Source location Response from Dorset Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Staffing levels were not a factor in the death, despite affecting investigators’ workloads and ability to process work.
Verbatim wording from the response “I agree that staff numbers are a factor on our ability to process the work, but our staff provide the best service they can with many competing demands, and it was not a factor in this tragic death. Clearly, I would want us to be fully staffed as that would reduce average workloads and as explained there is ongoing recruitment but that will take time to see the improvement. We have many examples of good work within the teams, and we continue to prosecute RASSO offences in the courts with our CPS colleagues.” Source location Response from Dorset Police
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 Devon & Cornwall Police; 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 Devon & Cornwall Police; 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create FEO portfolios for assessment and performance monitoring.
Verbatim wording from the response “The decision to temporarily remove the decision-making capabilities of FEOs and FEO supervisors articulated during the inquest by Chief Superintendent ████████ provided an immediate response to the issues identified. Following the delivery of the training described above, two additional training related actions have been pursued to augment the decision-making process: the creation of a portfolio for assessing and performance monitoring FEOs, and a comprehensive dip sampling regime involving both the Assistant Chief Constable (Operations) and the Senior Management Team (SMT) within the FELU. This involves the new supervisors within the unit reviewing FEO decisions via an enquiry form, assessing their rationale, and providing feedback to them directly.” Source location Response from Devon and Cornwall Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide replacement training for new FELU starters in cohorts as required until the national qualification is delivered.
Verbatim wording from the response “In order to maintain this standard of training for new starters, Devon and Cornwall Police will re-engage with South Yorkshire Police to provide training to staff in cohorts as and when required. It is envisaged that this process will continue until the new national qualification is delivered through the College of Policing.” Source location Response from Devon and Cornwall Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting development and delivery of the national accredited firearms-licensing training programme with the NPCC and College of Policing.
Verbatim wording from the response “Devon and Cornwall Police fully support the NPCC and the College of Policing (CoP) in developing a national accredited training program for staff involved in making licensing decisions. We agree with the PFD submissions made on behalf of the families during the inquest and will continue to support the national training program as it develops; advocating for sufficient funding to enable this to deliver at pace. We will also support its delivery where requested, ensuring that lessons from Keyham are integrated into the fabric of the course.” Source location Response from Devon and Cornwall Police
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 Revise FELU training and deliver mandatory firearms-enquiry training to all unit staff and relevant decision-makers.
Verbatim wording from the response “As expressed in evidence during inquest, the training provision for the FELU within Devon and Cornwall Police has been completely revised since the incident, creating clear expectations of staff and auditable records of training delivered. There is a clear focus on decision making, risk identification and the implementation of statutory guidance. This has included training to all staff within the FELU, key operational managers who are responsible for making dynamic decisions to revoke licences, and those responsible for making decisions within criminal investigations, known as Evidence Review Officers (EROs).” Source location Response from Devon and Cornwall Police
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 Accredit FELU firearms-enquiry officers internally and maintain qualification records with expiry reminders until national accreditation is available.
Verbatim wording from the response “Until a national qualification is made available through the College of Policing, FEOs are accredited ‘in force’ with a qualification from the course provided by the Licensing Manager from South Yorkshire Police. This process is coordinated internally with individual records maintained, enabling automatic reminders to be sent to staff and their line manager to alert them when this skill is due to expire. At this time there is no formal requirement across England and Wales in relation to either accreditation or refreshing existing skills and learning. We will continue to engage and work closely with the NPCC and College of Policing during 2023 to assist in delivering the national course and in defining a period for reaccreditation which is robust and pragmatic.” Source location Response from Devon and Cornwall Police
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 a three-year continuing professional development programme for FELU staff covering mental health, domestic abuse, risk assessment and decision-making.
Verbatim wording from the response “Following the completion of the mandatory training requirements listed above, we have also started to deliver a three-year continual professional development programme comprising dedicated training to FELU staff from experts in mental health and domestic abuse. This training reflects the core issues examined during the inquest. In addition, we continue to work with the NPCC lead to ensure that these issues are reflected within the national planning for accredited training and annual CPD requirements which are further set out within the NPCC portfolio.” Source location Response from Devon and Cornwall Police
Open published response
Concerns raised 4 Insufficient force funding to meet recurring summer demand View source Inadequate uniformed officer availability for timely summer response View source Failure to answer or respond to calls within adequate timeframes View source Insufficient CMCU staffing for experienced workloads View source See 1 more concern
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. 21
Action
Introduce AACC7 to enable call-backs, a single voice queue and improved 101 answer times.
Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Introduce leaner processes to clarify responsibility and reduce call and follow-up work.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Review shift patterns and move staffing towards peak-demand hours.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Transfer some incoming-contact management from Contact to local BCUs to increase RIMO capacity for 999 calls.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Implement summer wellbeing initiatives addressing financial, physical, psychological and caring responsibilities.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Recruit additional volunteers and Special Constables to increase summer operational capacity.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Refresh and quality-assure contingency plans for demand, deployment and crime allocation.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Open six additional police-station front offices and train staff to handle digital and non-urgent contact.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Implement the agreed new shift pattern for contact handlers.
Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Streamline nine Contact processes, including processes for missing people, Claire’s Law, Sarah’s Law and domestic abuse.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Operate Operation Marnow to coordinate flexible summer resources under a full command structure.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Reduce routine-demand backlogs to improve attendance within response-time targets.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Operate a Demand Reduction team to identify repeat and vulnerable callers and reduce persistent or nuisance contact.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Provide dedicated Human Resources support for staff wellbeing, absence intervention, workplace adjustments and management effectiveness.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Enhance the resource-allocation model using demand, absence, abstraction, workload and performance factors.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Use NICHE and Single Online Home to improve contact processing and public service delivery.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Review identified Contact process improvements to improve service delivery.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Analyse abandoned-call data to understand caller behaviour and contact-channel changes.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Conduct weekly BCU resource planning to maintain required uniformed-officer numbers on each shift.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Regrade the RIMO role and increase its salary to support staff retention.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Run recruitment campaigns to increase CMCU staffing and stabilise retention.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source See 18 more actions
×
AI-generated summary
Daniel Lee Tilley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Lee Tilley was found hanging in Newquay on 7 July 2019 and was later pronounced dead by paramedics. The report identifies concerns about insufficient police staffing and resources, including a four-hour response delay to an emergency call. The inquest concluded that it was possible the delay contributed to the outcome, although the evidence was insufficient to determine whether Daniel intended to take his own life.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient force funding to meet recurring summer demand
Wider context from the report “i. The funding of the force is insufficient to allow it to meet the increase in demand that occurs every summer when tourists come to Devon & Cornwall. I have written separately to the Home Secretary in this regard and a copy of my letter is enclosed for your information. No response is required from you.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate uniformed officer availability for timely summer response
Wider context from the report “ii. a) Staffing levels in the CMCUs (both call handlers and Resource Deployment Officers) in Plymouth and Exeter are insufficient for the workloads experienced.
b) There are an inadequate number of uniformed Officers available to respond in a timely fashion to the demand seen over the summer months.
Let me acknowledge that I recognise these two issues are intertwined. The amount of budget the force receives will dictate what it can afford in terms of police staff and police officers. As Chief Inspector ████████ accepted during the course of this inquest, the police did the best they could with what they had; they simply did not have enough.
My concern in relation to the CMCU is that this problem has existed – on the evidence I heard at inquest – for a decade or so, and it is unresolved today. I am bound to note the recent decision of HMICFRS to move the force into an enhanced level of monitoring with one of the stipulated grounds being: ‘the force does not answer, or respond to, emergency or non-emergency calls within adequate timeframes, and too many calls are abandoned…’
The jury heard from Chief Supt ████████ and ACC Leaper at inquest. They were told that staffing levels for both call handlers and RDOs were still not at the ‘design’ brief advised by BT but that recruitment processes were in hand which, it was hoped, would achieve this. They were told that three separate pieces of software were to be introduced in the New Year which, once fully operational, ought to permit greater efficiencies and speedier call management.
In writing to you, I wanted to bring these matters to your attention so that you can ensure the intended improvements are realised. I understand once you start in your new role you will require a little time to bring yourself up to speed with what will inevitably be a raft of pressing issues, that budgets for 2022/3 are yet to be finalised and, finally, that the recruitment drive and IT upgrades still need to be completed. For those reasons, I have extended the time below for the formal Reply from you.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to answer or respond to calls within adequate timeframes
Wider context from the report “ii. a) Staffing levels in the CMCUs (both call handlers and Resource Deployment Officers) in Plymouth and Exeter are insufficient for the workloads experienced.
b) There are an inadequate number of uniformed Officers available to respond in a timely fashion to the demand seen over the summer months.
Let me acknowledge that I recognise these two issues are intertwined. The amount of budget the force receives will dictate what it can afford in terms of police staff and police officers. As Chief Inspector ████████ accepted during the course of this inquest, the police did the best they could with what they had; they simply did not have enough.
My concern in relation to the CMCU is that this problem has existed – on the evidence I heard at inquest – for a decade or so, and it is unresolved today. I am bound to note the recent decision of HMICFRS to move the force into an enhanced level of monitoring with one of the stipulated grounds being: ‘the force does not answer, or respond to, emergency or non-emergency calls within adequate timeframes, and too many calls are abandoned… ’
The jury heard from Chief Supt ████████ and ACC Leaper at inquest. They were told that staffing levels for both call handlers and RDOs were still not at the ‘design’ brief advised by BT but that recruitment processes were in hand which, it was hoped, would achieve this. They were told that three separate pieces of software were to be introduced in the New Year which, once fully operational, ought to permit greater efficiencies and speedier call management.
In writing to you, I wanted to bring these matters to your attention so that you can ensure the intended improvements are realised. I understand once you start in your new role you will require a little time to bring yourself up to speed with what will inevitably be a raft of pressing issues, that budgets for 2022/3 are yet to be finalised and, finally, that the recruitment drive and IT upgrades still need to be completed. For those reasons, I have extended the time below for the formal Reply from you.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient CMCU staffing for experienced workloads
Wider context from the report “ii. a) Staffing levels in the CMCUs (both call handlers and Resource Deployment Officers) in Plymouth and Exeter are insufficient for the workloads experienced.
b) There are an inadequate number of uniformed Officers available to respond in a timely fashion to the demand seen over the summer months.
Let me acknowledge that I recognise these two issues are intertwined. The amount of budget the force receives will dictate what it can afford in terms of police staff and police officers. As Chief Inspector ████████ accepted during the course of this inquest, the police did the best they could with what they had; they simply did not have enough.
My concern in relation to the CMCU is that this problem has existed – on the evidence I heard at inquest – for a decade or so, and it is unresolved today . I am bound to note the recent decision of HMICFRS to move the force into an enhanced level of monitoring with one of the stipulated grounds being: ‘the force does not answer, or respond to, emergency or non-emergency calls within adequate timeframes, and too many calls are abandoned…’
The jury heard from Chief Supt ████████ and ACC Leaper at inquest. They were told that staffing levels for both call handlers and RDOs were still not at the ‘design’ brief advised by BT but that recruitment processes were in hand which, it was hoped, would achieve this. They were told that three separate pieces of software were to be introduced in the New Year which, once fully operational, ought to permit greater efficiencies and speedier call management.
In writing to you, I wanted to bring these matters to your attention so that you can ensure the intended improvements are realised. I understand once you start in your new role you will require a little time to bring yourself up to speed with what will inevitably be a raft of pressing issues, that budgets for 2022/3 are yet to be finalised and, finally, that the recruitment drive and IT upgrades still need to be completed. For those reasons, I have extended the time below for the formal Reply from you.
” 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 Introduce AACC7 to enable call-backs, a single voice queue and improved 101 answer times.
Verbatim wording from the response “New software and technological changes” Source location Response from Devon & Cornwall Police
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 leaner processes to clarify responsibility and reduce call and follow-up work.
Verbatim wording from the response “In addition, we have been introducing leaner processes to improve clarity of responsibility in turn leading to less time spent on calls and follow up work.” Source location Response from Devon & Cornwall Police
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 shift patterns and move staffing towards peak-demand hours.
Verbatim wording from the response “• We have also reviewed (and will continue to review) the shift patterns to ensure we have more staff working in peak demand hours. In particular, the Incident Resolution Centre (IRC) moved to a new shift pattern as of January 2023. The IRC role is one of managing demand; the team undertakes crime-related tasks and crime screening, with the effect of reducing repeat calls to the organisation and the early resolution of complaints, allegations, and incidents. A new shift pattern has also been agreed for contact handlers and will be implemented in line with the Police Staff Handbook, which we anticipate being implemented in July 2023.” Source location Response from Devon & Cornwall Police
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 Transfer some incoming-contact management from Contact to local BCUs to increase RIMO capacity for 999 calls.
Verbatim wording from the response “• Some management of incoming contact from the public has moved from Contact to local basic command units (BCUs – basically, local policing areas) to free up RIMO time to take 999 calls.” Source location Response from Devon & Cornwall Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement summer wellbeing initiatives addressing financial, physical, psychological and caring responsibilities.
Verbatim wording from the response “We have also increased our focus on the welfare of our personnel and several wellbeing initiatives are implemented during the summer focusing on four key areas: financial vulnerability; physical fitness and health: diet, nutrition, and psychological health; and caring and dependents responsibilities. It is our hope that this will increase our resilience as an organisation during the summer period. Despite the pressure on officers and staff, absence rates in the last summer period remained close to 2019 levels suggesting a positive impact on staff wellbeing of effective management of the issues.” Source location Response from Devon & Cornwall Police
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 Recruit additional volunteers and Special Constables to increase summer operational capacity.
Verbatim wording from the response “• Further volunteers and Special Constables have been taken on.” Source location Response from Devon & Cornwall Police
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 and quality-assure contingency plans for demand, deployment and crime allocation.
Verbatim wording from the response “The force’s contingency plans in relation to demand, deployment and crime allocation policies have been refreshed and quality assured. This enables the force to take a proportionate approach when demand reaches critical levels, and it also allows the force to consider potential early activation of contingency plans to negate other organisational or service risks. An example contingency plan is to stop all training.” Source location Response from Devon & Cornwall Police
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 Open six additional police-station front offices and train staff to handle digital and non-urgent contact.
Verbatim wording from the response “• Finally, we opened an additional six front offices in our police stations in January 2023 (in Tiverton, Truro, Falmouth, Penzance, Newton Abbot and Bude) increasing the provision of front office services. This enables a better service to the public by providing greater connectivity and accessibility. The front office staff will be trained to deal with digital demand and non-urgent contact demand, supported by new technology, significantly expanding the available resource base for Contact.” Source location Response from Devon & Cornwall Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the agreed new shift pattern for contact handlers.
Verbatim wording from the response “• We have also reviewed (and will continue to review) the shift patterns to ensure we have more staff working in peak demand hours. In particular, the Incident Resolution Centre (IRC) moved to a new shift pattern as of January 2023. The IRC role is one of managing demand; the team undertakes crime-related tasks and crime screening, with the effect of reducing repeat calls to the organisation and the early resolution of complaints, allegations, and incidents. A new shift pattern has also been agreed for contact handlers and will be implemented in line with the Police Staff Handbook, which we anticipate being implemented in July 2023.” Source location Response from Devon & Cornwall Police
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 Streamline nine Contact processes, including processes for missing people, Claire’s Law, Sarah’s Law and domestic abuse.
Verbatim wording from the response “Since that work was carried out, process reviews have been undertaken concentrating on areas such as missing people, requests made by the public under Claire’s Law and Sarah’s Law, and domestic abuse. This resulted in nine of our processes being streamlined to improve public service.” Source location Response from Devon & Cornwall Police
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 Operation Marnow to coordinate flexible summer resources under a full command structure.
Verbatim wording from the response “This does mean that daily resourcing is based upon average demand rather than summer demand. Therefore, at peak times such as the summer officers will inevitably, at times, be stretched in terms of capacity. To mitigate this challenge a focused summer policing response is put into place – Operation Marnow – which enables the central coordination of resources using a flexible approach to resourcing across all departments to meet threat, risk and demand on the front line. (See below).” Source location Response from Devon & Cornwall Police
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 Reduce routine-demand backlogs to improve attendance within response-time targets.
Verbatim wording from the response “Last year a focused effort to reduce backlogs in routine demand saw attendance at routine incidents hold steady at above 80% attended within 48 hours, despite the increase in calls for service over the summer. While the percentage responded to within threshold remained below 2019 levels it was higher than 2021.” Source location Response from Devon & Cornwall Police
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 a Demand Reduction team to identify repeat and vulnerable callers and reduce persistent or nuisance contact.
Verbatim wording from the response “• We introduced a Demand Reduction team to identify repeat and vulnerable callers. In addition, this looks to reduce contact from persistent / nuisance callers, utilising partnership work, civil orders, and prosecution where appropriate to reduce this demand. We have seen a similar issue occur with digital contact: for example, one member of the public with mental health issues emailed the force 3,000 times in August. We now have processes in place to help reduce the demand caused by persistent / nuisance emailers.” Source location Response from Devon & Cornwall Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide dedicated Human Resources support for staff wellbeing, absence intervention, workplace adjustments and management effectiveness.
Verbatim wording from the response “• We have increased our focus on maximising the wellbeing of our staff and the support offered to them. We have dedicated Human Resources provision in place to provide enhanced support for individuals through: effective people management; increasing effectiveness of early interventions for absences to avoid unnecessary escalation; effective and timely use of workplace adjustments; empower and increase the confidence of our managers; and potentially an increase in informal performance management processes should managers not undertake their responsibilities effectively. This is with the overall aim of improving performance and retention and thus contribute to an improved service to our communities. Since the introduction of this team in October 2022 sickness levels have reduced from 15% absence rate to 11% in January 2023.” Source location Response from Devon & Cornwall Police
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 Enhance the resource-allocation model using demand, absence, abstraction, workload and performance factors.
Verbatim wording from the response “We have also undertaken a lot of work in relation to how we deploy our resources, to again try and improve our performance during the summer period.” Source location Response from Devon & Cornwall Police
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 Use NICHE and Single Online Home to improve contact processing and public service delivery.
Verbatim wording from the response “New software and technological changes” Source location Response from Devon & Cornwall Police
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 identified Contact process improvements to improve service delivery.
Verbatim wording from the response “• An independent review was carried out in September 2022 by Sopra Steria, who are an external technological consultant. The purpose of this work was to review Contact processes so the force could become more efficient, to better utilise resources and enable people to work more effectively, therefore providing a better quality of service to the public across different methods of contact (for example: 999, 101, email and webchat). Sopra Steria identified process improvements which are now being reviewed with a view to improve our service delivery. These external consultants provided support to understand, by reference to the wider call centre industry, what further process improvements and areas of development should be pursued alongside our ongoing work in this area.” Source location Response from Devon & Cornwall Police
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 Analyse abandoned-call data to understand caller behaviour and contact-channel changes.
Verbatim wording from the response “• The force is working to understand the data behind abandoned calls; for example, whether abandoned calls represent the public abandoning calls altogether, or whether they represent the public moving to a different method of contact that provides a quicker response (such as a 101 call or web chat).” Source location Response from Devon & Cornwall Police
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 weekly BCU resource planning to maintain required uniformed-officer numbers on each shift.
Verbatim wording from the response “The model is based upon the average demand over the past five years and gives an output of officers required per BCU to maintain a ‘24/7’ response. The data and professional judgement are then used to finalise the resource allocation locally to consider local needs and set levels of uniformed police officers. Local planning within BCUs takes place weekly to ensure officer numbers are met on sections on a shift-by-shift basis.” Source location Response from Devon & Cornwall Police
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 Regrade the RIMO role and increase its salary to support staff retention.
Verbatim wording from the response “In addition, the RIMO role has been regraded through a job evaluation process and a salary increase awarded which we anticipate will assist with retention. During exit interviews upon leaving the organisation, our outgoing staff have previously raised the issue of pay as one of the reasons for leaving the police.” Source location Response from Devon & Cornwall Police
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 Run recruitment campaigns to increase CMCU staffing and stabilise retention.
Verbatim wording from the response “As of January 2023, we have 138 Radio Dispatch Officers (now called Resource Incident Management Officers (RIMOs)) against a design of 143 and 191 Contact Officers against a design of 194, which represents an increase in staffing levels since the inquest. These staffing levels were identified by reference to a review by BT, an independent consultant who examined our processes and staffing numbers (as previously shared in the inquest).” Source location Response from Devon & Cornwall Police
Open published response
Concerns raised 2 Failure to euthanise dogs where appropriate to reduce the risks of further and more serious incidents View source Failure to fully investigate reports of dog attacks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Frankie Gray Macritchie · 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
Frankie Gray Macritchie, aged 9, died on 13 April 2019 from injuries inflicted in a dog attack after being left unsupervised with the dog at a caravan park. The concerns included whether previous reports of dog attacks had been fully investigated and whether appropriate action, including euthanasia where appropriate, could reduce the risk of further incidents.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to euthanise dogs where appropriate to reduce the risks of further and more serious incidents
Wider context from the report “That reports of dog attacks are fully investigated and, where appropriate, a dog is euthanised to try and reduce the risks of further and more serious incidents .
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to fully investigate reports of dog attacks
Wider context from the report “That reports of dog attacks are fully investigated and, where appropriate, a dog is euthanised to try and reduce the risks of further and more serious incidents.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Available evidence and legal thresholds meant prosecution or a destruction order for the dog could not realistically have succeeded.
Verbatim wording from the response “In relation to both incidents, enquiries were undertaken but ultimately the police were unable to identify definitive evidence that ████████ had acted in a way that represented an offence; therefore, the owner of ████████ was given words of advice by the police about keeping the dog secure.” Source location 2021-0315-Response-from-Devon-Cornwall-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing procedures and operational practice are considered sufficient for appropriately and robustly handling reports involving dogs posing a risk of serious harm.
Verbatim wording from the response “I understand fully why you have raised this matter under a Regulation 28 report based upon the information available to you at that time, along with the terrible tragedy that resulted in the death of Frankie. In responding to your direction, undertakings by operational and senior leaders including discussions with front line colleagues assures me that Devon and Cornwall Police are dealing with reports appropriately where a dog poses a risk of serious harm. On the basis of these enquiries, I am of the view that we dealt with such reports robustly. This includes having to defend our position through the courts and the media.” Source location 2021-0315-Response-from-Devon-Cornwall-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Limited evidence and the incidents' relatively low seriousness meant seizure was not considered necessary or legally justified at that time.
Verbatim wording from the response “These incidents were concerning, notwithstanding that no physical injury to a person or animal was alleged, with police taking action. I am nevertheless confident that, between the seriousness of these allegations and the lack of evidence available to the police, that a prosecution for a s.3 DDA would not have been possible, nor would have an application for a destruction order (whether following a conviction for a s.3 DDA offence or by complaint to the court under the 1871 Act). In short, I am confident that any attempt by the police to have ████████ destroyed would have been unsuccessful.” Source location 2021-0315-Response-from-Devon-Cornwall-Police_Published
Open published response
Concerns raised 3 Failure to appropriately share targeted ViST data about vulnerable individuals with partner agencies View source Failure to consider the ramifications of bail conditions for vulnerable individuals View source Failure to ensure custody access to and review of CJLDT assessments before bail conditions and release of vulnerable individuals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Darrell Sharples · 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
Darrell Sharples died on 21 July 2018, aged 49. The inquest recorded the medical cause of death as asphyxia due to hanging and concluded that he died by suicide. Concerns included whether information about vulnerable individuals from ViST forms could be appropriately shared with partner agencies, and whether custody staff should access relevant CJLDT assessments before imposing bail conditions and releasing vulnerable individuals.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately share targeted ViST data about vulnerable individuals with partner agencies
Wider context from the report “ViST forms.
These generate a lot of data about potentially vulnerable individuals. I consider deaths may be prevented in the future where that data could be appropriately shared with partner agencies . I have in mind, in particular, Cornwall Partnership Foundation Trust and Kernow Clinical Commissioning Group (on behalf of GPs.)
I recognise there is a need to limit or prioritise the data shared so that it is manageable and targeted to the most vulnerable and/or those at greatest risk of harm or self-harm .
I further recognise that there may well be legitimate concerns about data protection. I was told this may be of concern where a particular individual consents to the sharing of data. Where someone refuses to consent, however, I accept sharing may be more problematic and legal advice may be required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the ramifications of bail conditions for vulnerable individuals
Wider context from the report “Custody Access to CJLDT Assessments and Consideration of Ramifications of Imposing Bail Conditions on Vulnerable Individuals .
At his assessment by CJLDT in May 2018, it had been recognised that ████████ was a strong protective factor keeping Darrell from harming himself.
After his release from custody in July 2018, a bail condition was (correctly) imposed that he was not to contact his wife. This had the unintended consequence of removing that strong protective factor .
In the event those in custody had known of the assessment in the CJLDT records, that may have had an influence on assessing Darrell’s risk to himself at the point of release . It may have led to a request to an HCP or CPFT to re-assess Darrell’s risk to himself.
It may be that the standard questions completed by custody sergeants could be amended to require an Officer to review or have reviewed any assessment in CJLDT prior to the imposition of a bail condition on a vulnerable individual and his release from custody.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure custody access to and review of CJLDT assessments before bail conditions and release of vulnerable individuals
Wider context from the report “Custody Access to CJLDT Assessments and Consideration of Ramifications of Imposing Bail Conditions on Vulnerable Individuals.
At his assessment by CJLDT in May 2018, it had been recognised that ████████ was a strong protective factor keeping Darrell from harming himself.
After his release from custody in July 2018, a bail condition was (correctly) imposed that he was not to contact his wife. This had the unintended consequence of removing that strong protective factor.
In the event those in custody had known of the assessment in the CJLDT records , that may have had an influence on assessing Darrell’s risk to himself at the point of release. It may have led to a request to an HCP or CPFT to re-assess Darrell’s risk to himself.
It may be that the standard questions completed by custody sergeants could be amended to require an Officer to review or have reviewed any assessment in CJLDT prior to the imposition of a bail condition on a vulnerable individual and his release from custody .
” Open source report
23 Mar 2020 Lewis Charles Francis · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum View source Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lewis Charles Francis · 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
Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
Wider context from the report “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies.
” Open source report
Concerns raised 4 Failure to contact ambulance service after caller request View source Insufficient efforts to search and check upon a person's wellbeing when asked to attend the scene View source Failure to grade calls correctly where there is a clear danger to life View source Failure to record ambulance requests on the incident log View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Craig BANKS · 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
Mark Craig Banks, a homeless man with long-term alcohol and mental health problems, died from exposure in an unmade tent near the Tarka Trail in bad weather in the early hours of 23 February 2015; alcohol was a factor. Concerns included failures to contact or correctly grade an ambulance call and insufficient efforts to search for and check on Mr Banks’ wellbeing.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to contact ambulance service after caller request
Wider context from the report “(1) Failure to contact ambulance service after caller request in addition a failure to record the request on the incident log.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient efforts to search and check upon a person's wellbeing when asked to attend the scene
Wider context from the report “(3) RE: ████████ at Page 176 of the Independent Police Complaints Commission report – insufficient efforts to search and check upon Mr Banks’ wellbeing when asked to attend the scene .
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to grade calls correctly where there is a clear danger to life
Wider context from the report “(2) Failure to grade the call correctly when there was a clear danger to Mr Bank’s life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record ambulance requests on the incident log
Wider context from the report “(1) Failure to contact ambulance service after caller request in addition a failure to record the request on the incident log .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update policy D051 to align grading and deployment decisions with national incident-recording and call-handling standards, incorporating the THRIVE risk-assessment tool.
Verbatim wording from the response “In addition, since the death of Mr Banks, the police’s grading and deployment policy (policy D051) and operational practices regarding call grading and incident creation have been reviewed to ensure that they are compliant with the NSIR and National Call Handling Standards (NCHS). D051 was subsequently updated to reflect that good decision-making in terms of grading and deployment required consideration of and compliance with national guidance on log classification; namely, the NSIR and NCHS.” Source location 2017-0271-Response-by-Devon-Cornwall-Police
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 Compile a working practice for auditing incident logs, including audit sampling, quality assurance and reporting to the Force Crime and Incident Registrar.
Verbatim wording from the response “Furthermore, as a part of our ongoing work in this area, the Registrar has directed that a working practice should be compiled to allow for the audit of incident logs to ensure compliance with the NSIR.” Source location 2017-0271-Response-by-Devon-Cornwall-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing grading and deployment policies, audits and working practices are considered sufficient to ensure compliance with national incident-recording and call-handling standards.
Verbatim wording from the response “I am now satisfied that every reasonable effort has been made to ensure that the police’s policies and practices in this respect will be compliant with the required national standards. Furthermore, in order to keep abreast of developments in this area and as a part of a general effort to refine and improve our working practices in this regard, D051 has been reviewed and updated on five occasions following the death of Mr Banks.” Source location 2017-0271-Response-by-Devon-Cornwall-Police
Open published response
Concerns raised 4 Failure to appropriately manage the incident scene and patient safety and dignity View source Delays in attending and transferring emergency patients View source Failure to inform police of road traffic accidents in a timely fashion View source Failure to appropriately triage and manage emergency calls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
William Robert Raymond Nute · 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
William Robert Raymond Nute fell while a car was reversing near a shop on 30 June 2015 and sustained a fractured neck of femur. He later developed pneumonia and died on 2 July 2015. Concerns included delays in ambulance attendance and transfer to hospital, inappropriate triage of emergency calls, and delayed notification of the police, leaving him without effective emergency management while lying on a public highway.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately manage the incident scene and patient safety and dignity
Wider context from the report “That South Western Ambulance did not inform the police of a road traffic accident in a timely fashion resulting in the scene of the incident/patient and late arrival of the ambulance not being managed appropriately . For example the witnesses to the road traffic accident were left waiting a good number of hours for the police to arrive to provide their details to them and there was no one to professionally manage the safety/dignity of Mr Nute who was lying on the highway .
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Delays in attending and transferring emergency patients
Wider context from the report “That the delay in attending and transferring Mr Nute increased his risk of not recovering from his fall/fracture or the trauma of the incident which in turn increasing his risk of death.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform police of road traffic accidents in a timely fashion
Wider context from the report “That South Western Ambulance did not inform the police of a road traffic accident in a timely fashion resulting in the scene of the incident/patient and late arrival of the ambulance not being managed appropriately. For example the witnesses to the road traffic accident were left waiting a good number of hours for the police to arrive to provide their details to them and there was no one to professionally manage the safety/dignity of Mr Nute who was lying on the highway.
” 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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately triage and manage emergency calls
Wider context from the report “That the 999 calls from the public were not triaged by the call handlers at BT or South Western Ambulance appropriately and managed .
” Open source report
24 Jul 2015 Miriam Joyce Smith-Cox · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 1 Failure to receive or act upon safeguarding concerns about accommodation and living conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Miriam Joyce Smith-Cox · 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
Miriam Smith-Cox was found dead on 4 March 2015 at the bottom of stairs, with injuries consistent with a fall. A safeguarding concern about the suitability of her accommodation and living conditions had been raised in December 2014 but was reportedly not received or acted upon, and the reason for her fall was unknown.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to receive or act upon safeguarding concerns about accommodation and living conditions
Wider context from the report “That████████, ████████████████████ with Pluss Work Choice Programme Cornwall raised a safeguarding concern about the suitability of Ms Smith-Cox accommodation and living conditions in December 2014 (see attached letter to ████████ dated 4.12.14 and report) which ████████ gave evidence she did not receive or act upon . ████████ was a key stakeholder in the support of Ms Smith-Cox. Ms Smith-Cox fell down the stairs for unknown reason as raised as a concern by ████████ and this fall led to her death.
” Open source report
12 Dec 2014 Jason Geoffrey PALMER · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1 Failure to make relevant police incident information available to the Firearms Unit for firearms suitability assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jason Geoffrey PALMER · 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
Jason Geoffrey PALMER died from a shotgun injury to the head after consuming a large quantity of alcohol; he and his wife had separated, and the inquest concluded that he had taken his own life. The report raised concerns that information about domestic incidents held in restricted police logs was not available to the Firearms Unit when his shotgun certificate was renewed, limiting the robustness of suitability enquiries.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Failure to make relevant police incident information available to the Firearms Unit for firearms suitability assessment
Wider context from the report “(1) Mr Palmer applied for a shotgun certificate in December 2004. His licence was granted in January 2005. The licence was for renewal in 2009 and the Firearms Officers were aware there had been certain domestic incidents involving Mr Palmer and his wife but were assured by Mr Palmer these were no longer of significance. Mr Palmer's licence was renewed on 19 January 2010.
The Firearms Licensing Operations Officer ████████ commented in a Statement at the Inquest that if he and his colleagues had been aware the number of police incidents relating to Mr Palmer's domestic situation, then they would have made more robust enquiries into the suitability of Mr Palmer to possess shotguns at the time of his renewal . That information was contained within secure Police Logs for the protection of Officers .
Whilst it is understandable for confidentiality reasons and the protection of Officers in circumstances where personal incidents had occurred, if Mr Palmer had been a member of the public, as opposed to a serving Police Officer, then the Firearms Unit would have been aware of these incidents from the Police logs . It may be prudent for such information to be made available to the Firearms Unit and the restricted logs reviewed perhaps at Senior Officer level and if appropriate that information passed to the Firearms Unit for assessment.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review firearms licensing procedures and policies to address restricted incident-log information concerns.
Verbatim wording from the response “A thorough review has been undertaken of the procedures and policies in place to ensure that this concern is addressed.” Source location 2014-0534-Response-by-Devon-Cornwall-Police
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 Use an electronic system to scan police incident logs every ten minutes and immediately alert the Firearms Licensing Unit about logs concerning existing certificate holders.
Verbatim wording from the response “In addition, a significant change has been made to the method by which the Firearms Licensing Unit are alerted to any incident log which relate to an existing certificate holder. An electronic system has now been introduced which “sweeps” all police incident logs every ten minutes. In the event that any log relates to an existing certificate holder, an immediate alert is sent to the Firearms Licensing Unit, where the log content will be checked to identify whether any concern arises as a result of that individual’s suitability to possess a firearm. In the event that the log is restricted, a request can be made to the control room for the log to be reviewed and any relevant information provided.” Source location 2014-0534-Response-by-Devon-Cornwall-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a written working practice formally recording how Firearms Enquiry Officers obtain and use information from restricted incident logs.
Verbatim wording from the response “The process which is followed upon receipt of an application for the granting or renewal of a certificate is that a Firearms Enquiry Officer (FEO) will interrogate the relevant police systems for any incidents of concern, as part of their investigation into the applicant’s suitability to possess firearms. As part of this process, all logs relating to the applicant will be seen by the FEO. This includes the presence of any restricted logs, albeit that the content can only be viewed by an officer of the rank of Inspector or above. The FEO is required to make contact with the Control Room in order that the content of any restricted log is viewed, and any relevant information contained therein is communicated to the FEO for the purposes of any decision regarding the application.” Source location 2014-0534-Response-by-Devon-Cornwall-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing firearms licensing procedures adequately address restricted incident information when assessing applicants’ suitability to possess firearms.
Verbatim wording from the response “The process which is followed upon receipt of an application for the granting or renewal of a certificate is that a Firearms Enquiry Officer (FEO) will interrogate the relevant police systems for any incidents of concern, as part of their investigation into the applicant’s suitability to possess firearms. As part of this process, all logs relating to the applicant will be seen by the FEO. This includes the presence of any restricted logs, albeit that the content can only be viewed by an officer of the rank of Inspector or above. The FEO is required to make contact with the Control Room in order that the content of any restricted log is viewed, and any relevant information contained therein is communicated to the FEO for the purposes of any decision regarding the application.” Source location 2014-0534-Response-by-Devon-Cornwall-Police
Open published response
Concerns raised 1 Risk of drug-related death among future inhabitants of the property View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Daniel COLLINS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel COLLINS occupied a flat in a property in Devonport, Plymouth, and died within one week of another occupant in the same property. The inquest concluded that his death was drug-related, and concern was raised about a history of drug abuse at the property and the risk of future drug-related deaths among its inhabitants.
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 Devon & Cornwall Police; that does not assign responsibility.
PFD Monitor interpretation Risk of drug-related death among future inhabitants of the property
Wider context from the report “1. ████████ appears to be a property in multiple occupation having several flats in the property. The occupants clearly associate and are on speaking terms with one another. It appears there is a history of drug abuse at the property. I am concerned that future inhabitants of that property may suffer a drug related death.
” 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