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.
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 Dorset 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 Dorset 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
8 Jun 2023 Ivan Rumenov Ignatov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Insufficient guidance for custody sergeants assessing detainee risk View source Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services View source Inaccessibility of post-release detainee information due to language or literacy barriers View source Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system View source Lack of guidance for releasing detainees without an address to reside at View source See 2 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
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.
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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for custody sergeants assessing detainee risk
Wider context from the report “ii. There is not sufficient guidance given to custody sergeants on a national basis of how to assess a person’s risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
Wider context from the report “iv. There is a lack of knowledge and/or understanding amongst emergency services and search and rescue services, especially around terminology, process and communication for them to be able to work together when an incident arises without confusion or misunderstanding arising . I would request that consideration is given to further national and local training or guidance across emergency and search and rescue services to ensure communication can be facilitated without delay, and ensure terms and processes are understood to avoid any doubt of what action is being taken when an incident is ongoing.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of post-release detainee information due to language or literacy barriers
Wider context from the report “v. Leaflets given to detainees when released from police custody are not always accessible due to language or literacy barriers and I would request that consideration is given nationally by NHS England and all Police Forces to ensure that any documentation detainees, especially any providing help and assistance, is accessible to them.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system
Wider context from the report “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or others .
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for releasing detainees without an address to reside at
Wider context from the report “iii. There is no guidance, that I am aware of, which addresses what should be done by police forces, and particularly custody sergeants, when a person is to be released without an address to reside at and I would request consideration is given to such guidance being provided.
” 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 Hold joint Dorset Police–Coastguard meetings every six months to review working practices and terminology.
Verbatim wording from the response “A Senior Manager from HMCG also attended the Force Incident Manager and Deployment Manager Continuing Professional Development days in July 2023. These Events are held several times a year to generate discussions about policies, processes, and deployments. These particular sessions served to improve understanding in terms of the respective obligations of Dorset Police and HMCG. This meeting was so positive and productive, that Dorset Police and HMCG have agreed to similar meetings every six months, for the specific purpose of reviewing our working practices and ensuring compliance. We also believe that these meetings will serve to improve the understanding of agency-specific terminology.” Source location Response from Dorset 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 Make custody leaflets printable in any language using Google Translate.
Verbatim wording from the response “The leaflets used by Dorset Police can now be printed in any language following a successful trial of using the Google Translate translation software. It is also the intention of Chief Inspector Neil Phillips, in his capacity as Custody Lead for Dorset Police, to share this development with the National Custody Lead (based at the National Police Chiefs’ Council).” Source location Response from Dorset 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 Remind custody staff through a News Bulletin about the 12 factors indicating increased risk.
Verbatim wording from the response “Additionally, it is our intention to remind Custody Staff of the 12 factors indicating increased risk (as featured in the College of Policing Authorised Professional Practice - in relation to detention and custody risk assessment) by way of News Bulletin, and will then be reviewing, that due consideration is being given to these factors by Custody Staff, by way of dip sampling, as a part of our culture of continuous improvement within the Dorset Police Custody hierarchy.” Source location Response from Dorset 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 Add a Custody Record dropdown menu to capture factors increasing detainee risk.
Verbatim wording from the response “We have updated the Niche system in a way that we believe addresses this concern. A dropdown menu is now included in the Custody Record for every detainee for the purposes of capturing such information.” Source location Response from Dorset 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 Amend Niche occurrence-log Section 2 to prompt consideration of detainee risk and vulnerability.
Verbatim wording from the response “In short, we are in the process of implementing changes to Niche, locally, which will see Section 2 of Occurrence Logs on Niche amended, to prompt the Custody personnel to consider risk and vulnerability regarding the detainee in question.” Source location Response from Dorset 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 Share the multilingual leaflet development with the National Custody Lead.
Verbatim wording from the response “The leaflets used by Dorset Police can now be printed in any language following a successful trial of using the Google Translate translation software. It is also the intention of Chief Inspector Neil Phillips, in his capacity as Custody Lead for Dorset Police, to share this development with the National Custody Lead (based at the National Police Chiefs’ Council).” Source location Response from Dorset 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 National guidance on releasing detainees without an address will be addressed by the College of Policing rather than Dorset Police.
Verbatim wording from the response “The College of Policing have again indicated that they will be addressing this concern with you directly in their response to the report, on the basis that this is also a National issue.” Source location Response from Dorset 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 National guidance on custody risk assessment will be addressed by the College of Policing rather than Dorset Police.
Verbatim wording from the response “In preparing this response, we have been in contact with the College of Policing (who have also received the Regulation 28 report) and, on the basis that this is a National issue, they have indicated to us that they will be addressing this concern with you directly in their response to the Report.” 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.
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. 4
Action
Operate FEO portfolios and comprehensive dip sampling, with supervisors reviewing decisions, assessing rationale and providing direct feedback.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2023. View source
Action
Engage with the NPCC and College of Policing to assist delivery of national accredited training and define robust, pragmatic reaccreditation arrangements.
Stated in progressThe respondent said that this action was in progress when they made their response on 10 March 2023. View source
Action
Provide specialist training on risk assessment, THRIVE, national risk principles and the National Decision Model, and record suitability decisions comprehensively.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2023. View source
Action
Deliver a mandatory, bespoke firearms-licensing training programme covering risk identification, decision making, statutory guidance and relevant operational systems.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2023. View source See 1 more action
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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 Dorset 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 Dorset 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 Dorset 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
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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 Operate FEO portfolios and comprehensive dip sampling, with supervisors reviewing decisions, assessing rationale and providing direct feedback.
Verbatim wording from the response “The decision to temporarily remove the decision-making capability of FEOs and FEO supervisors articulated during the inquest by Devon and Cornwall 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 unit. This involves new and experienced police supervisors within the unit reviewing FEO decisions via an enquiry form, assessing their rationale, and providing feedback to them directly.” Source location Response from Dorset 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 Engage with the NPCC and College of Policing to assist delivery of national accredited training and define robust, pragmatic reaccreditation arrangements.
Verbatim wording from the response “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. Following the inquest, a comprehensive response to the College of Policing was submitted to assist this process, and Dorset’s future policy will reflect the national position and any requirements set by the NPCC and the College of Policing.” Source location Response from Dorset 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 Provide specialist training on risk assessment, THRIVE, national risk principles and the National Decision Model, and record suitability decisions comprehensively.
Verbatim wording from the response “As a result of the work conducted after the incident, we have also received additional training in risk assessments and decision making. This training has been delivered by a barrister who specialises in firearms licensing and focuses on the practical identification of risk through the THRIVE (Threat, Harm, Risk, Investigation, Vulnerability & Engagement) assessment process, as well as the application of the national police risk principles and the use of the NDM in case and appeal management. This training, initiated soon after the incident, is clearly relevant to the matters subjected to appropriate examination at the inquest. Suitability decisions are now recorded on separate documents, including all relevant detail that could affect the suitability of an applicant to hold a certificate. The records are comprehensive and apply the statutory guidance through the use of the NDM.” Source location Response from Dorset 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 Deliver a mandatory, bespoke firearms-licensing training programme covering risk identification, decision making, statutory guidance and relevant operational systems.
Verbatim wording from the response “As expressed in evidence during inquest, the training provision for the Firearms and Explosives Licensing Unit within Dorset 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 unit and key operational managers who are responsible for making dynamic decisions to revoke certificates.” Source location Response from Dorset 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 Existing reviews and the post-incident robust decision-making process are considered sufficient to meet the report's requirements for the covered period.
Verbatim wording from the response “In writing this response, our position is that the date from which the five-year period is considered should be the date of submission of this response. Considering this, it must be noted that the substantial changes implemented in Dorset Police Firearms and Explosives Licensing Unit cover a significant part of this period. As presented at the inquest, following the incident, all decisions were paused until a new leadership structure was created and embedded. This was augmented by a comprehensive training and CPD programme for all staff, a portfolio assessment for FEOs and a robust dip sampling framework (see below). Consequently, all decisions regarding grants, renewals and case reviews since August 2021 have been subject to the new robust process which includes all of the lessons identified through the inquest, and applies a rigour beyond that set within the statutory guidance and APP.” Source location Response from Dorset Police
Open published response
8 Feb 2023 Stephen Robert Wood · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Lack of knowledge and/or understanding of when to report road obstructions 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
Stephen Robert Wood · 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 30 May 2021, Stephen Robert Wood was riding his motorcycle when it entered a 60-metre stretch of grass covering the carriageway, causing him to fall into the path of an oncoming car. He sustained numerous significant and unsurvivable injuries and died. The principal concern was a lack of knowledge about when road obstructions should be reported, meaning hazards may not be removed or warnings provided to other road users.
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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and/or understanding of when to report road obstructions
Wider context from the report “2. I have concerns with regard to the following:
i. That there is a lack of knowledge and/or understanding as to when people should report an obstruction in the road. I would request that consideration is given to making all road users aware of the dangers of obstructions in the road and to encourage them to report any hazards to the local Police force or Local Authority so that it can be removed as soon as possible, or at least other road users be warned of the hazard to prevent a future death.
” Open source report
21 Jul 2022 Gaia Kima Pope-Sutherland · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 12 Failure of Mental Health teams to provide assessment information directly to GPs View source Lack of policy for handling sexual harassment or assault in DHUFT inpatient units View source Lack of police officer knowledge of life-threatening illnesses and their behavioural impact View source Failure to flag key information on DHUFT RiO records View source Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment View source Lack of DHUFT policy for contact with patients’ families View source Failure to create, complete and store Dorset Police records appropriately View source Delay in AMHP feedback of Mental Health Act assessment information to GPs View source Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies View source Lack of resourcing of epilepsy services View source Ambiguity and inconsistency in access to Community Mental Health care processes View source Lack of communication between neurology and psychiatric teams View source See 9 more concerns
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AI-generated summary
Gaia Kima Pope-Sutherland · 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
Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.
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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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Failure of Mental Health teams to provide assessment information directly to GPs
Wider context from the report “x. As per paragraph 1(xiii) above, when a Mental Health Act assessment is undertaken, there is a possibility that information may not be fed back to the GP in the best way or in a timely manner, if it is not fed back by those from the Mental Health team, and I therefore request that consideration is given to the DHUFT representatives forwarding information, directly to the GP, rather than through the discharging team at the acute hospital . This may include their RiO record notes, or their assessment notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for handling sexual harassment or assault in DHUFT inpatient units
Wider context from the report “vi. As per paragraph 1(ix) above, the occurrence of sexual harassment or assault whilst an inpatient at one of DHUFT’s inpatient units could have a detrimental effect on a person’s mental health which could have fatal consequences. I request that consideration is given to a policy being put into place to provide guidance to staff as to how to deal with this situation.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer knowledge of life-threatening illnesses and their behavioural impact
Wider context from the report “iii. As per paragraph 1(iv) above, there could be future deaths due to the lack of knowledge Police Officers in England and Wales have around life threatening illnesses , such as epilepsy and mental health illness, and I request that consideration is given by the College of Policing to providing national training to all staff across all police forces, on illnesses such as epilepsy and mental health illness, and the impact they have on individuals and their behaviour. I also request consideration to be given to these topics forming part of the syllabus for the College of Policing induction training for Police Officers.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Failure to flag key information on DHUFT RiO records
Wider context from the report “viii. As per paragraph 1(xi) above, information could be lost on lengthy RiO records held by DHUFT if there is a significant number of records, and I therefore request that consideration is given to a guidance document dealing with how and what information should be flagged on RiO which could be provided to all staff at DHUFT. I would further request consideration is given to training staff how to record information, so it is flagged on the record.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of DHUFT policy for contact with patients’ families
Wider context from the report “vii. As per paragraph 1(x) above, there is no specific policy in place within DHUFT around how to engage with the family or dealing with the Think Family approach. A lack of contact with family members , who know the patient best, could lead to information gaps, which could lead to future deaths. I request that consideration is given to a policy being created around contact both to, and from, a patient’s family.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Failure to create, complete and store Dorset Police records appropriately
Wider context from the report “v. As per paragraphs 1(vii-viii) above, there is currently a risk that Dorset Police records are not being created, completed or stored in an appropriate way . This could result in a lack of detail, or incorrect information being recorded and relied upon , which could lead to a future death. I therefore request that consideration is given to reviewing how all Dorset Police records are held, to ensure integrity of the information, and that consideration is given to providing a training session on record keeping for all Dorset Police staff, across all areas of the Force.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Delay in AMHP feedback of Mental Health Act assessment information to GPs
Wider context from the report “xi. As per paragraph 1(xiv) above, in respect of the feeding back of information to the GP by the AMHP which is detailed at paragraph 2.10 of Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours . Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideration too.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies
Wider context from the report “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy , and for control room staff only, the call handling, grading and deployment policy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of resourcing of epilepsy services
Wider context from the report “i. As per paragraphs 1(i-iii) above, there could be future deaths locally and across the country due to the lack of resourcing of epilepsy services . I request consideration is given to a review of the nursing resources in epilepsy care locally in Dorset Epilepsy Service, and generally nationally across England and Wales.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Ambiguity and inconsistency in access to Community Mental Health care processes
Wider context from the report “ix. As per paragraph 1(xii) above, I would request that consideration is given to providing training to all staff on the access to Community Mental Health services which could also cover the processes regarding discharge planning from the care of the mental health teams.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between neurology and psychiatric teams
Wider context from the report “ii. Further I am concerned that there could be future deaths as a result of the lack of communication between neurology and psychiatric teams and request that there is consideration as to how to ensure effective lines of communication between the 2 disciplines.
” 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 Include log-keeping and recording in Vulnerability 4 training.
Verbatim wording from the response “The Organisation’s record management system, ‘Niche’ was upgraded in August 2022. The Niche training has been utilised to reinforce the expectations and importance record management and data quality. POLSA and LPSM trained staff have been directed to use Niche to log their decisions and key information. Niche can be accessed remotely via mobile technology and once an entry is made it cannot be amended retrospectively. If information changes or details are recorded in error an additional chronological entry can be made highlighting any amendments and this can be cross referenced to the original entry. Once created, logs are also locked and cannot be amended. As previously noted Vulnerability 4 training will include a session on log keeping and recording.” Source location Response from Dorset Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the adopted missing-person policy changes into working practice.
Verbatim wording from the response “The latest review of the missing person policy was in the process of being finalised during Gaia’s inquest. I enclose a copy of the finalised policy, which is now adopted, and work is ongoing to embed the changes in working practice. I highlight a few aspects of the updated policy that were relevant to the matters explored in the course of Gaia’s inquest:” Source location Response from Dorset Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the concern-for-welfare policy to incorporate current physical and mental ill-health trends and professional guidance.
Verbatim wording from the response “The Dorset Police concern for welfare policy is designed, in consultation with partner agencies, to ensure that the public get the right service to meet their specific needs at the first point of contact. The current version is subject to a review led by the Prevention Department to capture the latest physical and mental ill health trends and guidance from key professionals. The initial draft of the policy is close to completion.” Source location Response from Dorset Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver Vulnerability 4 training on welfare, missing-person and deployment policies to relevant staff and officers.
Verbatim wording from the response “The next stage of the Vulnerability Programme is the ‘Vulnerability 4’ training package, scheduled for delivery between January and April 2023. The Vulnerability 4 training will include updates on the concern for welfare, missing people and the call handling, grading and deployment policies. It will be provided to police officers and staff, including control room call handlers, senior officers up to the rank of Chief Inspector and role-specific training to the ranks above Chief Inspector.” Source location Response from Dorset Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send organisation-wide guidance reminding staff and officers about accurate and transparent record keeping.
Verbatim wording from the response “At the submission of the Organisation’s response to the Preventing Future Deaths Report I propose to send out a further Organisation-wide message to all staff and officers providing a reminder along with guidance about the importance of accurate and transparent record keeping.” Source location Response from Dorset Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement revised call-handling, deployment and grading policies with risk assessment and performance monitoring.
Verbatim wording from the response “The Organisation reviewed and updated the call handling, deployment and grading policy in 2021 and implemented changes in March 2022. The Deployment Policy has been recently reviewed in line with national guidance to ensure that each public contact is risk assessed to inform the appropriate police response. The revised grading of incidents is now a key performance measure with regular reviews and evaluation to ensure compliance. As part of the implementation process, we have now moved to the evaluation stage to understand how the changes in the policy have translated into deployment decision making. The Organisation has commissioned an external audit conducted by the South West Audit Partnership which has been taking place over the summer. A full report is due this Autumn which will inform ongoing developments.” Source location Response from Dorset Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate how revised policies affect deployment decisions and complete the commissioned external audit.
Verbatim wording from the response “The Organisation reviewed and updated the call handling, deployment and grading policy in 2021 and implemented changes in March 2022. The Deployment Policy has been recently reviewed in line with national guidance to ensure that each public contact is risk assessed to inform the appropriate police response. The revised grading of incidents is now a key performance measure with regular reviews and evaluation to ensure compliance. As part of the implementation process, we have now moved to the evaluation stage to understand how the changes in the policy have translated into deployment decision making. The Organisation has commissioned an external audit conducted by the South West Audit Partnership which has been taking place over the summer. A full report is due this Autumn which will inform ongoing developments.” Source location Response from Dorset Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Upgrade Niche and require relevant staff to record decisions and key information in locked, chronological logs.
Verbatim wording from the response “The Organisation’s record management system, ‘Niche’ was upgraded in August 2022. The Niche training has been utilised to reinforce the expectations and importance record management and data quality. POLSA and LPSM trained staff have been directed to use Niche to log their decisions and key information. Niche can be accessed remotely via mobile technology and once an entry is made it cannot be amended retrospectively. If information changes or details are recorded in error an additional chronological entry can be made highlighting any amendments and this can be cross referenced to the original entry. Once created, logs are also locked and cannot be amended. As previously noted Vulnerability 4 training will include a session on log keeping and recording.” Source location Response from Dorset 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 Include epilepsy, psychosis, medical conditions, medication and associated risks in operational first-aid training.
Verbatim wording from the response “The content of Vulnerability 4 will also be built into initial training for Police Officers, Call Handlers and PCSOs to ensure ongoing development of new staff into the Organisation. Furthermore, in 2023, there will be a similar opportunity to raise awareness further in relation to epilepsy, psychosis, medical conditions, medication and the effect of such on and individual and subsequent risks. The Organisation will work with the clinical lead to ensure such are covered in the First Aid Training which is rolled out to operational officers and staff.” Source location Response from Dorset Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the updated missing-person policy and provide recurring contact-centre refresher training.
Verbatim wording from the response “In the meantime, the updated version of the missing person policy has been disseminated locally through Commanders and Inspectors, who are cascading the learning to frontline officers and ensuring the policy has been read and understood. Force Contact Centre training on the new missing person policy begins from the 19th September on the current 10 week cycle for all staff. Every training cycle will include refresher training on missing people and concern for welfare matters for the foreseeable future.” Source location Response from Dorset Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A wholesale review of record keeping across all systems has not been undertaken because targeted improvements are considered a necessary and proportionate response.
Verbatim wording from the response “The Organisation has carefully considered a proportionate and targeted response to the concerns raised through Gaia’s inquest in relation to record keeping. The Organisation holds millions of records and works across multiple systems and processes Organisation-wide, regionally and working with partner agencies. These processes are carefully mapped and overseen by business owners, with some areas inspected by HMICFRS and the Information Commissioner in relation to crime data integrity, record keeping and data protection.” Source location Response from Dorset Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for national training updates on life-threatening illnesses rests with the College of Policing through its clinical governance process.
Verbatim wording from the response “This concern is directed to Chief Constable ████████ at the College of Policing. I wish to formally record my support for the learning from the inquest in relation to life-threatening illnesses to be shared with the College to inform National knowledge and understanding. I have personally written to CC Marsh to offer to support this work and to utilise the Organisation’s learning from Gaia’s inquest to inform and enhance any National training provision. I am aware that any updates to training and information relating to medical issues would go through the College of Policing clinical governance group for appropriate oversight and to ensure guidance was implemented.” Source location Response from Dorset Police
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2 Feb 2022 Carol Patricia Cole · Prevention of Future Deaths report Dorset
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Concerns raised 1 Failure to ensure PPNs reach GPs for Dorset Council residents View source
Responses linked to these concerns
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AI-generated summary
Carol Patricia Cole · 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
Carol Patricia Cole was found collapsed and unresponsive at home on 15 May 2020 after being prescribed medication and having a history including depression, unstable personality disorder and previous overdoses. The inquest concluded that her death was suicide. Concerns were raised that processes for sharing Public Protection Notices in the Dorset Council area may have resulted in the GP not receiving information about concerns regarding her mental health, creating a missed opportunity for assessment, support or treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure PPNs reach GPs for Dorset Council residents
Wider context from the report “iii. In Dorset there are 2 Local Authorities that cover the County, BCP Council and Dorset Council. If MASH receive a PPN about a resident in the BCP Council area the current arrangement is that MASH send the PPN directly to the GP as required. If they receive a PPN about a resident in the Dorset Council area the current process is that they do not send it directly to the GP but send it directly to the Dorset Adult Access team at Dorset Council, who will then send it to the GP .
iv. At the time of her death Carole resided within the Dorset Council area. A PPN was submitted to MASH regarding Carole on 25.4.20 which raised concerns regarding her mental health. The MASH team determined the PNN should be shared with the Dorset Adult Access team to share with the GP in line with the process.
v. At the Inquest the representative from the GP surgery confirmed there was no record of the PNN being received by them , which led to a missed opportunity for Carole to be assessed by her GP.
vi. The process currently in place, which I understand has been agreed by both Dorset Council and Dorset Police, of preventing the MASH team from sending the PNN directly to the GP, may result in the GP not being informed of the contents of the PPN which may result in a person not receiving an assessment, support or treatment. I am not aware of a reason why the MASH team cannot send it directly to the GP, as they do for those residents in BCP council area, to avoid such missed opportunities to take action which may lead to a future death.
2. I have concerns with regard to the following:
i. There could be missed opportunities to share PPNs relating to residents within the Dorset Council area with agencies or professionals due to the current processes in place between Dorset Police and Dorset Council which could lead to a future death. I therefore request that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area.
” 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 Conduct a further review with Health and Social Care partners of PPN-sharing processes, using national best practice to identify improvements.
Verbatim wording from the response “Identification of this risk has prompted a further review with Health partners which is scheduled to commence on 12 April 2022. Police, Health and Social Care will work together to review the current process, what is working well and where improvements can be made based on national best practice from other areas.” Source location 2022-0033-Response-from-Dorset-Police_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review PPN-sharing processes with Dorset and BCP Adult Social Care partners to identify safeguarding risks and consistency improvements.
Verbatim wording from the response “You therefore requested that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area.” Source location 2022-0033-Response-from-Dorset-Police_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police cannot share PPNs with GPs directly because it lacks access to the Dorset Care Record.
Verbatim wording from the response “The review also identified that for the Police to carry out the sharing of PPNs to GPs there would be a requirement for Police to have access to the Dorset Care Record which it currently does not have.” Source location 2022-0033-Response-from-Dorset-Police_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Dorset Council Adult Social Care staff will be responsible for sharing PPNs with GPs using the Dorset Care Record.
Verbatim wording from the response “On 28 March 2022, it was agreed that Dorset Council will fund a member of staff from Adult Social Care to co-locate with Dorset Police in the MASH. This role would be responsible for sharing with GPs and have access to the Dorset Care Record. In the interim I am aware that the Dorset Adult Access Team promptly streamlined their working practices in February 2022 to overcome the issue that resulted in the failure to share the PPN with the GP in the case of Ms Cole.” Source location 2022-0033-Response-from-Dorset-Police_Published
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12 Jan 2021 Cherylan CLULOW · Prevention of Future Deaths report Dorset
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Concerns raised 4 Lack of training and dissemination of information on obtaining fire drop keys View source Failure to provide Police Officers with reliable emergency access to shared accommodation View source Lack of formal information and steps for sourcing fire drop keys View source Lack of general distribution of fire drop keys or key fobs to Police Officers View source See 1 more concern
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AI-generated summary
Cherylan CLULOW · 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
Cherylan Clulow was found semi-conscious at home after police were initially unable to gain access beyond the communal door, and she died in hospital on 30 August 2019 following extensive and multiple strokes. The substantive concerns related to delays in accessing shared accommodation during emergencies, including the lack of formal information, training, and general distribution of fire drop keys or key fobs to police officers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of training and dissemination of information on obtaining fire drop keys
Wider context from the report “(1) The Police Officers who were tasked with the initial attendance could not gain access beyond the communal doors.
(2) The Police Officers did not believe it was proportionate (based on the information which they had) to force entry through the communal doors which required specialist input. They were aware that a colleague had purchased for himself a fire drop key (to be used in emergency situations which could be used to override the communal lock door. There was a delay in gaining access to the address of the deceased.
(3) The Police Officers had no formal information as to where they could source a fire drop key. There was no knowledge of formal steps to be taken to access to a fire drop key particularly as access to communal properties is that more difficult to gain.
(4) There appears to be no general distribution of such keys or key fobs to Dorset Police Officers in order to gain access to shared accommodation by officers in an emergency situation 24 hours a day, 365 days per year.
(5) There appears to be no training or dissemination of information as to how such keys can be obtained.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Police Officers with reliable emergency access to shared accommodation
Wider context from the report “(1) The Police Officers who were tasked with the initial attendance could not gain access beyond the communal doors .
(2) The Police Officers did not believe it was proportionate (based on the information which they had) to force entry through the communal doors which required specialist input. They were aware that a colleague had purchased for himself a fire drop key (to be used in emergency situations which could be used to override the communal lock door. There was a delay in gaining access to the address of the deceased .
(3) The Police Officers had no formal information as to where they could source a fire drop key. There was no knowledge of formal steps to be taken to access to a fire drop key particularly as access to communal properties is that more difficult to gain.
(4) There appears to be no general distribution of such keys or key fobs to Dorset Police Officers in order to gain access to shared accommodation by officers in an emergency situation 24 hours a day, 365 days per year.
(5) There appears to be no training or dissemination of information as to how such keys can be obtained.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal information and steps for sourcing fire drop keys
Wider context from the report “(1) The Police Officers who were tasked with the initial attendance could not gain access beyond the communal doors.
(2) The Police Officers did not believe it was proportionate (based on the information which they had) to force entry through the communal doors which required specialist input. They were aware that a colleague had purchased for himself a fire drop key (to be used in emergency situations which could be used to override the communal lock door. There was a delay in gaining access to the address of the deceased.
(3) The Police Officers had no formal information as to where they could source a fire drop key . There was no knowledge of formal steps to be taken to access to a fire drop key particularly as access to communal properties is that more difficult to gain.
(4) There appears to be no general distribution of such keys or key fobs to Dorset Police Officers in order to gain access to shared accommodation by officers in an emergency situation 24 hours a day, 365 days per year.
(5) There appears to be no training or dissemination of information as to how such keys can be obtained.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of general distribution of fire drop keys or key fobs to Police Officers
Wider context from the report “(1) The Police Officers who were tasked with the initial attendance could not gain access beyond the communal doors.
(2) The Police Officers did not believe it was proportionate (based on the information which they had) to force entry through the communal doors which required specialist input. They were aware that a colleague had purchased for himself a fire drop key (to be used in emergency situations which could be used to override the communal lock door. There was a delay in gaining access to the address of the deceased.
(3) The Police Officers had no formal information as to where they could source a fire drop key. There was no knowledge of formal steps to be taken to access to a fire drop key particularly as access to communal properties is that more difficult to gain.
(4) There appears to be no general distribution of such keys or key fobs to Dorset Police Officers in order to gain access to shared accommodation by officers in an emergency situation 24 hours a day, 365 days per year.
(5) There appears to be no training or dissemination of information as to how such keys can be obtained.
” 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 Procure and issue keys and fobs to all frontline officers for emergency access to local-authority communal buildings.
Verbatim wording from the response “Accordingly, the decision has been made that all frontline Dorset Police officers will now carry keys and fobs when on duty. It is my view that this will serve to avoid delays in sourcing such items and allow for quick access to relevant properties in emergency situations. The process of procuring these items is already underway and I understand that they can be issued to frontline officers quickly (and, I believe, within a month).” Source location 2021-0009-Response-from-Dorset-Police-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify vulnerable residents in privately owned communal premises, obtain relevant keys and fobs, and store access arrangements locally with linked incident-management instructions.
Verbatim wording from the response “To compensate for this, we are in the process of identifying specific vulnerable individuals who live in similar but privately-owned communal premises, with a view to obtaining the relevant keys and fobs to facilitate access to those specific properties where required. Due to the volume of such items, where privately-owned premises are concerned we will store the relevant keys and fobs in a police station local to the address in question, and link instructions for obtaining the relevant item to the record that we hold for the vulnerable individual in question on our police incident management system.” Source location 2021-0009-Response-from-Dorset-Police-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate a reminder to frontline officers on police powers of entry, including lawful forced entry in relevant emergencies.
Verbatim wording from the response “It is my understanding that the keys and fobs are extremely simple to use; essentially, they function as a key. Accordingly, no training should be required. I can however confirm that a reminder on police powers of entry will be circulated to all frontline officers in due course, including on the organisation’s intranet. This will be used as an opportunity to remind frontline police officers of powers available to the police in terms of forcing entry to properties in situations such as that encountered by the colleagues who attended Cheralyn’s address prior to her death.” Source location 2021-0009-Response-from-Dorset-Police-Redacted
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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 variety and volume of keys and fobs make sourcing every item for privately owned premises unrealistic.
Verbatim wording from the response “Our enquiries have led us to conclude that the sheer variety of such items used in privately-owned properties would mean that it is difficult (to the point of being unrealistic) to source every such item. In simple terms, I understand that there is no such item as a ‘skeleton key’ in this context. In this respect, it is of note that, as I understand it, the fire service do not carry or have access to such items on a similar basis, and will instead force entry to such addresses when required.” Source location 2021-0009-Response-from-Dorset-Police-Redacted
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24 Oct 2019 Douglas Paul Oak · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 9 Lack of general awareness of Acute Behavioural Disturbance View source Insufficient frequency and variety of ABD training View source Unsuitability of existing ABD training package for control-room staff View source Failure of Emergency Services to use mutually understood control-room terminology View source Insufficient ABD training for Police and Ambulance Service front-line and control-room staff View source Confusion over Police procedures for requesting Ambulance support View source Absence of Clinical Governance Boards in Police Forces View source Lack of cross-working within the emergency services View source Absence of joint national guidance on Police and Ambulance Service management of ABD View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Douglas Paul Oak · 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 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency services.
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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of general awareness of Acute Behavioural Disturbance
Wider context from the report “i. There is a lack of awareness generally regarding ABD and I would request consideration is given to the inclusion of the signs, symptoms and management of ABD within the First Aid Manual so that all those trained in first aid are able to deal with a patient presenting with ABD.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient frequency and variety of ABD training
Wider context from the report “iv. I also have concerns in relation to the frequency of the delivery of the training referred to in (iii) and I therefore request consideration be given to that training being delivered regularly, at least on an annual basis and with a variety of training techniques, including simulation and role play scenarios.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of existing ABD training package for control-room staff
Wider context from the report “vii. In relation to the training package that has been provided by the College of Policing regarding ABD, although ████████ has recommended this could be rolled out to control room staff, the package is tailored for front-line staff . I would therefore request consideration is given to a specific training package on ABD being designed and rolled out to those working in the control room environment by the College of Policing together with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Services to use mutually understood control-room terminology
Wider context from the report “v. Given that the Police and Ambulance Services work very closely in treating and managing a patient with ABD, and other patients who present with life threatening conditions, it is important that they understand each other. It was clear from this Inquest that there is different terminology used by the different services, the meaning of which is not understood by the other Emergency Services . An example of this was the use of the phrase “on the hurry up”. Although the confusion regarding this terminology was not found to be causative or contributory to Doug’s death, it could be in respect of a future death. I therefore request that consideration is given to the joint national training packages for all Emergency Services, namely the Police Service, Ambulance Service and the Fire Service on the workings within each control room and around the language used in the control rooms.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient ABD training for Police and Ambulance Service front-line and control-room staff
Wider context from the report “iii. I believe it is likely there are persons working within Ambulance Service Trusts and Police Forces, whether it be on the front line or in the control room who are not aware of ABD and the serious risk to life it presents . I therefore request that consideration is given to ensuring all those working on the front line, or in control rooms in Ambulance Service Trusts and Police Forces in England and Wales are trained in ABD.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Confusion over Police procedures for requesting Ambulance support
Wider context from the report “ix. It was clear from the evidence that there appears to be confusion of when Dorset Police Officers should call 999 directly and when they should request assistance through the Police control room . I would request that there is consideration of the redrafting of the current “Police Requesting Ambulance Support” policy within Dorset Police and specifically when Police Officers should dial 999. In addition, I would request consideration of training be provided by Dorset Police to all Police Officers regarding the use of dialling 999 when contacting other Emergency Services. In doing this I would ask that consideration is given to liaising with the other local emergency services regarding their expectations, especially SWAST.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Absence of Clinical Governance Boards in Police Forces
Wider context from the report “viii. Evidence was given that Dorset Police have established a Clinical Governance Board which helps to create an awareness of, and improvement in, medical care provided by those working in the Police Service. This is not something adopted by all Police Forces in England and Wales and I therefore request that consideration is given to setting up a Clinical Governance Board in every Police Force in England and Wales.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-working within the emergency services
Wider context from the report “vi. Extending this point further, evidence was given that there would be benefit in cross working within the emergency services , so for example an Ambulance Clinician working within the Police control room to provide advice. I would therefore request that consideration is given on a national level to cross working within the emergency services.
” 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Absence of joint national guidance on Police and Ambulance Service management of ABD
Wider context from the report “ii. There is no joint national guidance on the management of ABD by those who work for the Police and Ambulance Services, both on the front-line and in the control rooms. They are the people most likely to encounter those suffering with ABD and in most cases work together in the management of these patients. Accordingly, I request consideration is given to providing joint national guidance on the management of ABD patients by the Police and Ambulance Services to include:
• the provision of chemical sedation in pre-hospital care
• the training of all paramedics in administering chemical sedation
• the categorisation of Emergency Service calls relating to ABD
• the transfer of an ABD patient to hospital
” Open source report
25 Jun 2018 John Edward Hill · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Failure to routinely seek information from family members or cohabitants when assessing firearm 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
John Edward Hill · 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
John Edward Hill was found collapsed and unresponsive at home on 26 May 2017, holding a rifle and with a bullet wound to his forehead. The report raised concerns that firearms licensing enquiries did not routinely include family members or others living with the applicant, who might hold important information relevant to the application and prevention of 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 Dorset Police; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely seek information from family members or cohabitants when assessing firearm applications
Wider context from the report “v. Evidence was further given that in the Dorset Police policy entitled “Firearms and Explosive Licensing Risk Management Procedure’ dated the 8th May 2015 there is no reference to such contact with family members, friends or associates and that family members or those living at the same address of the applicant, will not be contacted as standard practice. They may, as above, be contacted where there is evidence of domestic abuse.
vi. Evidence was given that it would be beneficial for the Firearms Unit at Dorset Police to write to those living with the applicant to invite them to raise any concerns they wish to in relation to the application. Although this may not be responded to, at least it gives those close to the applicant an opportunity to raise their concerns. There may be for example domestic violence ongoing at the address that has not been brought to the Police Force’s attention due to lack of reporting. This would be key to the firearm application.
2. I have concerns with regard to the following:
i. When the Police consider a firearm application, there may be valuable information that those close to the applicant may have, in circumstances where there is no domestic abuse or violence. Those living with the applicant may have vital information, which could impact upon the grant of a firearms certificate. This information may therefore be key to preventing a future death.
ii. In view of this I would request that consideration is given to reviewing the national and local guidance in relation to the assessment criteria and enquiries to be considered regarding applications for firearm certificates, and for consideration to be given that those enquiries involve the applicant’s family members, or at the very least those living with the applicant.
” 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