Recipient

Durham Constabulary

First report 21 Oct 2013•Latest report 17 Mar 2026

Recipient record

Reports, concerns and published responses

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

Reports
5

Naming this recipient

Published responses
140%

Found for named reports

Concerns addressed
9

Across all linked responses

Stated actions
32

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

140%published responses found
32stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. County Durham and Darlington

    AI-generated summary

    Natalie Louise AINSWORTH · 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

    Natalie Louise Ainsworth, aged 29, was found deceased on 13 February 2025 at an address in Stanley, County Durham. Police were informed that she had earlier threatened to take her own life, but this information was not known to key officers and was not included in the subsequent risk assessment or response. The report also identified that the risk assessment failed to properly consider known or expected information about her vulnerability and history of mental health issues, self-harm and substance abuse.

    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct an accurate and robust missing-person risk assessment

    Wider context from the report

    “Natalie was a vulnerable missing person considered to be at medium risk. A call was made to Police on the 13th February 2025 at 15:01 hours expressing concern for Natalie's welfare and informing Police of a new address where she may be and informing Police that she had earlier threatened to take her own life. Although the control room recorded that information was passed on to the relevant officer, neither the Inspector who undertook an updated a risk assessment some two hours later, nor the Officer making enquiries, was aware that Natalie had threatened to take her own life. This important information was therefore not part of the risk assessment and not factored into subsequent Police actions, including in terms of whether to force entry to the property which was visited by the Police. Further the risk assessment carried out at 1704 hours was not a robust assessment of the risks which were known, or ought to have been known, by Police at that time. In particular the risk assessment fails to consider Natalie's vulnerability as a person with a history of mental health issues, self harm and substance abuse, records incorrectly that there is no indication that the person is likely to take their own life, records incorrectly that the person has no mental health issues, and records incorrectly that the person has not been involved in a violent incident prior to them disappearing. An accurate and robust assessment of risk is essential to ensure that the nature and extent of any Police response is proportionate, and resources deployed appropriately, particularly when welfare/safety concerns are raised, as they were in Natalie's case. ”
    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate critical missing-person welfare information to relevant officers

    Wider context from the report

    “Natalie was a vulnerable missing person considered to be at medium risk. A call was made to Police on the 13th February 2025 at 15:01 hours expressing concern for Natalie's welfare and informing Police of a new address where she may be and informing Police that she had earlier threatened to take her own life. Although the control room recorded that information was passed on to the relevant officer, neither the Inspector who undertook an updated a risk assessment some two hours later, nor the Officer making enquiries, was aware that Natalie had threatened to take her own life. This important information was therefore not part of the risk assessment and not factored into subsequent Police actions, including in terms of whether to force entry to the property which was visited by the Police. Further the risk assessment carried out at 1704 hours was not a robust assessment of the risks which were known, or ought to have been known, by Police at that time. In particular the risk assessment fails to consider Natalie's vulnerability as a person with a history of mental health issues, self harm and substance abuse, records incorrectly that there is no indication that the person is likely to take their own life, records incorrectly that the person has no mental health issues, and records incorrectly that the person has not been involved in a violent incident prior to them disappearing. An accurate and robust assessment of risk is essential to ensure that the nature and extent of any Police response is proportionate, and resources deployed appropriately, particularly when welfare/safety concerns are raised, as they were in Natalie's case. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a process for directly recording and sharing new or updated missing-person information with investigating officers and reviewing supervisors.

    Verbatim wording from the response

    “Since the issuing of the notice the Force have reviewed processes around the recording of additional information received into the Force Control Room as part of a missing person investigation.”

    Source location

    Response from Durham Constabulary
    Page 1 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the Missing From Home Policy and Guidance to address recognition of vulnerability, risk factors and appropriate responses.

    Verbatim wording from the response

    “In the period between the death of Natalie AINSWORTH and the inquest conclusion the Constabulary had already reviewed it’s Missing From Home Policy and Guidance and provided updated training to those conducting risk assessments. This focused around the recognition vulnerability and other risk factors and determining the appropriate response as a result.”

    Source location

    Response from Durham Constabulary
    Page 1 · response
    Published 26 March 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide updated training for staff conducting missing-person risk assessments on vulnerability, risk factors and appropriate responses.

    Verbatim wording from the response

    “In the period between the death of Natalie AINSWORTH and the inquest conclusion the Constabulary had already reviewed it’s Missing From Home Policy and Guidance and provided updated training to those conducting risk assessments. This focused around the recognition vulnerability and other risk factors and determining the appropriate response as a result.”

    Source location

    Response from Durham Constabulary
    Page 1 · response
    Published 26 March 2026

    Open published response
  2. County Durham and Darlington

    AI-generated summary

    Sophie Ann Louise Cotton · 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

    Sophie Ann Louise Cotton had a long history of mental health problems and previous suicide attempts. On 6 January 2025, after she failed to attend important family contact and could not be contacted, four calls were made to the police requesting a welfare check; shortly afterwards, her family found her hanging by a ligature at home. The principal concerns were refusals or delays in police attendance under the “Right Care, Right Person” procedure, including where callers expressed a real and immediate risk to life and where mental health services could not enter locked premises.

    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Delays caused by supervisory review of negative “Right Care, Right Person” attendance decisions

    Wider context from the report

    “(4) Although there is a procedure in place to have a negative “Right Care, Right Person” decision reviewed by a supervisor, this causes additional delay in circumstances when attendance could be extremely time-sensitive. ”
    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to account for mental health crisis team inability to enter locked premises when directing callers to mental health services

    Wider context from the report

    “(2) During the 16:44 call the “Right Care, Right Person” advice to contact mental health services appears to have disregarded the fact that the mental health crisis team do not have the power to enter locked premises and so would require police attendance to facilitate entry to the premises. ”
    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make a police attendance decision after repeated serious concerns from callers

    Wider context from the report

    “(3) During the 16:57 call there was no decision for police to attend, even though this was the third caller (and second professional caller) that had expressed serious concerns about the Deceased. ”
    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to authorise police attendance despite a reported real and immediate risk to life

    Wider context from the report

    “(1) During the 16:44 call, by following the “Right Care, Right Person” procedure there was a refusal to the request that the police attend, even when a family member was expressing the view that there was a real and immediate risk to life. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Escalate any second call about the same person within 12 hours to a supervisor for immediate further review, with additional calls subject to the same process.

    Verbatim wording from the response

    “On a second call about the same person within a 12 hour period where the answer on the first call was for the police not to attend there will be an immediate escalation to the Supervisor who will carry out a further review as soon as possible.”

    Source location

    Response from Durham Constabulary (2)
    Page 6 · response
    Published 29 May 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement an initial intelligence-check process for every decision not to attend, followed by an expeditious supervisor review where non-attendance remains the decision.

    Verbatim wording from the response

    “Durham Constabulary recognises that there need to be safeguards within the system for speedy and timely reviews of decisions not to attend and 2 specific recommendations have been made to improve the current system. These recommendations have been approved and discussed with the College of Policing who have confirmed that they are in line with the National Toolkit for Right Care, Right Person (RCRP).”

    Source location

    Response from Durham Constabulary (2)
    Page 5 · response
    Published 29 May 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The information supplied during the 16:44 call did not indicate a real and immediate risk to life requiring police attendance.

    Verbatim wording from the response

    “At the time of the 16:44 call ████████ (mother) did express concerns about her daughter relaying information regarding previous incidents. The call handler asked if there had been any threats made on this occasion and was told that there had not been. Mrs Cotton states that she is probably overthinking but is worried about her daughter. There had not been any contact over the weekend and there was no new information from the previous call. Mrs Cotton confirms that her son is going to go back to the address again. It is confirmed to Mrs Cotton that on the information provided at that time that it is not considered that there is a real and immediate risk and that the police will not be attending. It is confirmed that the call will be subject to review by a supervisor as standard practice. All calls are assessed based upon the information supplied at the time of the call.”

    Source location

    Response from Durham Constabulary (2)
    Page 1 · response
    Published 29 May 2025

    Open published response
  3. County Durham and Darlington

    AI-generated summary

    Sylvia Margaret Louisa SAVAGE · 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

    Sylvia Margaret Louisa Savage died on 25 April 2023 at the University Hospital of North Durham from bronchopneumonia, following a fall from her bed at Redwell Hills Care Home on 18 March 2023 and subsequent injuries and decline in health. The concerns included unclear fall-reporting arrangements, ineffective monitoring of her mobilisation, inadequate post-fall medical assessment, missing or insufficient care records, and failure to promptly reassess her care plan after falls.

    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear and timely internal and external fall reporting

    Wider context from the report

    “1. There was I heard no clear definition of when to report falls externally & internally - this to me is perhaps the reason why the fall Mrs Savage suffered on 1/2/23 was not recorded internally, all be it CQC were notified on this occasion. The fall on 18/3/23 was not reported to CQC and whilst I understand staff at the care home did not know the outcome of Mrs Savage's treatment in hospital - she left the home by ambulance and did not return. This seems an occurrence worthy of reporting – It strikes me some clearer reporting structure is necessary - timely and accurate reporting both internally and to regulators allows for those concerned to assess the care home and decide on whether there are risks/issues that need addressing and protect residents. I would suggest over reporting is preferable to under reporting. ”
    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to clearly document medical advice obtained after resident falls

    Wider context from the report

    “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an incident. ”
    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to promptly re-evaluate and amend care plans after significant events

    Wider context from the report

    “5. The evidence I have heard is after Mrs Savage's fall on 1/2/23 and when it became clear the sensor mat was not working as intended - this should have prompted staff to return to the care plans and re-evaluate them - it did not. Indeed one care home witness stated as Mrs Savage had not had 3 falls in 3 months no change to her plan was needed. Given the second fall Mrs Savage had some weeks later gave her injuries that led to her death this approach appears flawed. Whilst I acknowledge work is ongoing in this area it appears that prompt re-evaluation of the care plans after events such as a fall are necessary to prevent injury and death - I would ask for some reassurance that significant events are captured by staff and in turn their significance is carefully considered and if necessary changes made to care. ”
    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide effective, individually tailored monitoring measures for residents at high risk of falls

    Wider context from the report

    “2. The evidence is clear that the provided sensor mat was not an efficient way of monitoring Mrs Savage when she attempted to mobilise. It was well known in the home that Mrs Savage defeated it's purpose by moving or unplugging it. There seems to have been a lack of thought as to an alternative measure. The wall mounted sensor, for example was seen by the expert as a reasonable measure - the home manager said he could consider them and the regional manager indicated they were used in the company, but not at the care home where Mrs Savage was residing. It seems to me the council should have an armoury of measures to pick from to tailor to the needs of the individual resident not just limited to one particular measure. The risk of death is obvious to others if persons at high risk of falls are not known to be moving by those charged with looking after 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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain timely medical advice after a resident fall

    Wider context from the report

    “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an incident. ”
    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain accessible and retained resident records

    Wider context from the report

    “4. The absence of records has hindered my investigation into Mrs Savage's death. The expert in her evidence made it clear - good recording keeping allows staff to monitor changes in condition, allows new staff or those returning from time off to reacquaint themselves with residents condition and allows clinicians to make diagnosis - without access to good records I can see a clear risk to the care of residents. It is also surprising to me the complete reliance on paper records which in Mrs Savage’s case have been lost. I would have expected to see electronic recording of information and electronic storage of it. I note the roll out of this in the company has been paused whilst the company is awaiting sale and my concern is whether the electronic recording and storage will be implemented - to me immediate access to records of a resident or the absence of them creates a concern. ”
    Open source report
  4. Plymouth, Torbay and South Devon

    AI-generated summary

    Maxine Betty Davison and 4 others · Prevention of Future Deaths report

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

    Report summary

    On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to condition firearms licensing delegation on adequate training

    Wider context from the report

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

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

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

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of nationally accredited training for firearms licensing staff

    Wider context from the report

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

    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 annual approved-practice training and continuing professional development, with tutoring and mentoring for new firearms licensing staff.

    Verbatim wording from the response

    “Whilst I welcome the important work being done by Chief Constable ████████ that addresses national standardisation, formal accreditation and training for firearms licensing staff, all of Durham Constabulary’s Firearms Enquiry Officer’s currently receive training/CPD in approved practice on an annual basis. New staff joining the department are further supported throughout this process by a period of tutorship, mentoring and CPD to ensure they are both confident and competent within the role. In January 2021, Durham Constabulary’s Firearms FEOs were the first in the country to successfully complete the online Mowbray Partner’s training package, aligned to the College of Policing learning outcomes. The use of this online training has evolved, with all members of the firearms licensing team completing a training package for their respective roles, supported by additional in-house CPD.”

    Source location

    Response from Durham Constabulary
    Page 3 · response
    Published 10 March 2023

    Open published response
  5. County Durham and Darlington

    AI-generated summary

    Robert Wilkinson · Prevention of Future Deaths report

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

    Report summary

    Robert Wilkinson, a firearms and shotgun certificate holder with a terminal illness, intentionally took his own life using one of his firearms the day after being discharged from hospital. The report raised concerns that there had been no face-to-face meeting with him before the decision to revoke his certificates and that the revocation letter had not been personally served, meaning he retained access to the firearm used.

    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct face-to-face meetings with certificate holders when making revocation decisions

    Wider context from the report

    “(1) As part of the process leading to the decision to revoke, although there had been contact with the deceased/his family/medical practitioner, there had not been a face to face meeting between a member of the firearms licensing team and the deceased. Such a meeting would have provided better quality of information to enable those considering the issue of revocation to have made the decision on the best possible information. ”
    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 Durham Constabulary; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to clearly and directly communicate revocation decisions to certificate holders

    Wider context from the report

    “(2) The revocation letter was never personally served. The deceased was in hospital for some of the time. Contact had been made with the deceased's family, in particular his son, and whilst it may not have been said in clear terms, the inference clearly was that the deceased was to have his certificates revoked and it was the deceased's son who communicated this information to his father and not the Police. Further consideration needs to be given as to the most appropriate means by which a decision to revoke should be made known to the certificate holder. It is accepted that this was a difficult case for the Police to manage, but clearly if the deceased had not had access to his guns on the day that he shot himself then he would not have been able to take his own life in the way that he did on the day that he did. Thus, an objective review how this case was managed should be undertaken so that improvements to the system might be identified with the result that similar fatalities in the future might be avoided. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Include value-adding face-to-face meetings with certificate holders in the structured firearms licensing review process.

    Verbatim wording from the response

    “1. The benefit of a face to face meeting between a certificate holder and a member of the Firearms Licensing Team. I acknowledge that such a meeting could provide better quality of information to enable more informed decision making. Indeed I am aware that Chief Inspector ████████ acknowledged this point in his evidence before you, on the 18th October 2013. I would confirm that when such a meeting”

    Source location

    2013-0269-Response-by-Durham-Constabulary
    Page 1 · response
    Published 21 October 2013

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A face-to-face meeting is not considered necessary where it would add no value to a firearms certificate refusal or revocation.

    Verbatim wording from the response

    “would add value to any review of a shotgun/firearms certificate holder then this will be undertaken and now forms part of the structured review process. I would add that it is important that such a meeting should have a specific aim in view of the numbers of reviews currently undertaken by Durham Constabulary.”

    Source location

    2013-0269-Response-by-Durham-Constabulary
    Page 2 · response
    Published 21 October 2013

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

140%
140%All other recipients 58%
0%100%

How actions were described at the time

This respondent
66%12%19%3%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

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

Types of action described in responses

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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026