2 Feb 2026 Scott Darren TAYLOR · Prevention of Future Deaths report Essex
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Concerns raised 7 Failure to remove arm and leg restraints from unconscious patients during conveyance to hospital View source Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint View source Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage View source Lack of a national ambulance response standard for Acute Behavioural Disturbance with active restraint View source Discrepancy in Acute Behavioural Disturbance recognition and alert training for Police Officers and Special Constables View source Confusing terminology for Acute Behavioural Disturbance in ambulance triage training materials View source Failure to apply consistent ambulance response coding based on clinical presentation rather than sectioning status View source See 4 more concerns
Responses linked to these concerns
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AI-generated summary
Scott Darren TAYLOR · 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
Scott Darren Taylor died at Basildon Hospital on 13 August 2022 following multiorgan failure and rhabdomyolysis associated with cocaine use, physical exertion, prone restraint and Neuroleptic Malignant Syndrome. The report raised concerns about inconsistent ambulance response categorisation for acute behavioural disturbance with active restraint, terminology and training, police training, and the removal of restraints during conveyance.
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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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to remove arm and leg restraints from unconscious patients during conveyance to hospital
Wider context from the report “b. Whilst it would not have changed the outcome for Mr Taylor, arm and leg restraints were not removed by police officers in this case when it was understood that Mr Taylor was unconscious and when Mr Taylor was being conveyed to hospital . Police officers who gave evidence were not clear that this was a requirement of the 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Inconsistent ambulance response categorisation for Acute Behavioural Disturbance with active restraint
Wider context from the report “b. The East of England Ambulance NHS Trust provide ambulance services across 6 counties and that also includes police/healthcare professionals reporting Acute Behavioural Disturbance and active police restraint. There is concern that there is a different response applied and that this discrepancy between Category 1 and Category 2 responses is significant and could affect the survival of patients . Evidence heard from police trainers and expert witnesses is that Acute Behavioural Disturbance has a high rate of fatality and requires an urgent response, particularly where police officers with training in this condition are reporting to ambulance service and with active restraint.
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly link Acute Behavioural Disturbance and active restraint to Category 1 ambulance triage
Wider context from the report “a. Members of the public were restraining Scott Taylor on arrival of the police who quickly became concerned that Mr Taylor was exhibiting signs of Acute Behavioural Disturbance and made an emergency call to the ambulance service. The police, during the 999 call, were put on hold on three occasions by the ambulance service and became increasingly concerned about Mr Taylor’s deteriorating condition over an 18 minute period and confirmation that this remained a Category 2 call despite active police restraint with suspected Acute Behavioural Disturbance. Police decided to ‘scoop and run’ and urgently convey Mr Taylor to hospital due to the severity of their concerns. The EEAST Standard Operating Procedure requires escalation to Category 1 where there is active restraint, but this is not linked to Acute Behavioural Disturbance and remains unclear and may continue to cause confusion during triage by contact call handlers .
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a national ambulance response standard for Acute Behavioural Disturbance with active restraint
Wider context from the report “a. It was agreed in evidence that the set of symptoms consistent with Acute Behavioural Disturbance amount to a medical emergency with a significant mortality risk. The evidence was that the Association of Ambulance Chief Executives set the Categories nationally that dictate the required classification for ambulance response to emergencies, however in some ambulance localities the required response is allocated Category 2 and in others Category 1 . This means that there is not a national standard for response Acute Behavioural Disturbance with active restraint .
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Discrepancy in Acute Behavioural Disturbance recognition and alert training for Police Officers and Special Constables
Wider context from the report “a. Whilst it was not causative of Mr Taylor’s death, there appears to be a discrepancy in the training for Police Officers and Special Constables in the potential recognition and actions for Acute Behaviours Disturbance . Special Constables are a valuable resource for police forces and may often be first on scene as in this case and should receive the same training in the potential recognition and alert of potential life-threatening conditions.
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Confusing terminology for Acute Behavioural Disturbance in ambulance triage training materials
Wider context from the report “d. The EEAST documents continue to use the term ‘Excited Delirium’ interchangeable in some of the training materials and this may lead to confusion with contact handlers triaging calls .
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to apply consistent ambulance response coding based on clinical presentation rather than sectioning status
Wider context from the report “c. The EEAST updated training on Acute Behavioural Disturbance, active restraint and reports received from police and correct coding remains confusing with the policy and training handouts in December 2023 with discrepancies between those who are sectioned and those who are not. Persons confirmed with Acute Behavioural disturbance and in active police restraint being coded as Category 2 and those in the same circumstances and ‘sectioned’ will require a Category 1 response . The difference appears to be one related to the Mental Health Act and not the presentation or clinical requirements of the person .
” 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 Update restraint guidance to require removal where safe and appropriate, informed by circumstances and the National Decision Model.
Verbatim wording from the response “You also expressed concern that police officers did not remove handcuffs or leg restraints when Mr Taylor appeared unconscious, and that officers did not appear clear that the relevant policy required them to do so. The policy in place at the time contained an absolute instruction to “remove all methods of restraint,” in the case of unconsciousness which, when considered against the operational realities of ABD and the unpredictable nature of such presentations, was not sufficiently aligned with safe decision-making or with the principles of the National Decision Model.” Source location Response from Essex 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 Incorporate the updated restraint policy into initial and regular refresher training for all officers.
Verbatim wording from the response “Following review at the inquest and subsequent policy analysis, Essex Police has updated this guidance to provide officers with clearer, more realistic direction. The revised policy now states that officers must remove restraints where it is considered safe and appropriate to do so, and that this decision must be informed by the prevailing circumstances and assessed through the National Decision Model. This updated wording removes the absolute instruction that did not reflect the operational complexities faced by officers, and instead reinforces the requirement for a considered, risk-assessed approach that is consistent with officer training and the realities of managing individuals experiencing ABD.” Source location Response from Essex 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 Standardise Acute Behavioural Disturbance training for regular officers and Special Constables across initial and refresher training.
Verbatim wording from the response “In relation to ABD, you noted that Special Constables may not have received the same depth of training as regular officers. Essex Police acknowledges the importance of ensuring that all officers, regardless of role, are equipped to identify life-threatening medical emergencies and respond consistently. As a result, all officers—regular and Special Constabulary—now receive the same level of training in relation to ABD.” Source location Response from Essex Police
Open published response
13 Jan 2026 Heidi Audrey Diana WILLIAMS · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1 Failure to investigate suspected tablet-supply activity referred by another police force 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
Heidi Audrey Diana WILLIAMS · 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
Heidi Williams died at her home on 14 December 2024, and the stated cause of death was opioid and bromazolam toxicity. A review of her mobile phone indicated that she had been ordering tablets from a number linked to banking details and a suspect in Essex. Northamptonshire Police asked Essex Police to investigate, but the report states that Essex Police had refused to do so at that time; the investigation and inquest had not concluded.
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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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate suspected tablet-supply activity referred by another police force
Wider context from the report “A review of her mobile phone showed that she was ordering a large number of tablets from a mobile number which also supplied banking details. These details resolved back to a suspect ████████ with two addresses linking back to him within the Essex area. This gentleman also has two addresses known on PNC within the Essex area. Northamptonshire Police have been in correspondence with Essex Police asking that Essex Police look into this matter. At the present time Essex police have refused so to do.
” Open source report
26 Nov 2025 Aminata Coulibaly · Prevention of Future Deaths report Essex
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Concerns raised 4 Failure to share relevant police contacts with the mental health Trust View source Failure to record relevant police contacts on Athena View source Failure to seek clarification of changed welfare circumstances View source Failure to record relevant welfare information reported by the mental health Trust View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Train Contact Management staff in Right Care, Right Person, incident recording, National Decision Model, THRIVE, escalation and supervisory requirements through recruit and continuing-development programmes.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2025. View source
Action
Develop Mental Health Risk Management Briefings to bring relevant agencies together to manage risks involving people experiencing mental ill health.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2025. View source
Action
Update investigation policy and procedure to require safeguarding reassessment, referrals, referral documentation, outcomes and recorded justification before case closure.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2025. View source
Action
Establish a Mental Health Triage team within the Strategic Vulnerability Centre to improve police, health and social-care safeguarding pathways and information sharing.
Stated completedThe respondent said that this action was complete when they made their response on 1 December 2025. View source See 1 more action
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AI-generated summary
Aminata Coulibaly · 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
Aminata Coulibaly died at home between the evening of 24 June and the morning of 25 June 2022 from acute alcohol toxicity, with respiratory depression as the mechanism; the manner in which the alcohol entered her system could not be determined. The report identifies concerns about safeguarding, information-sharing and recording by Essex Police and the mental health trust, including failures relating to her expressed suicidal thoughts and the handling of the hate crime investigation.
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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant police contacts with the mental health Trust
Wider context from the report “(1) Essex Police were aware that Aminata Coulibaly was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime. Essex Police did not update the mental health Trust that Aminata Coulibaly sent 2 emails on 22 June 2022 in response to her being informed (incorrectly) that the Hate Crime investigation by Essex Police had been closed:
i. to the officer in the case, setting out elements of how she is being treated, elements of the hate crime and that she is not happy with the decisions made by Essex Police and she feels like taking her life.
ii. to the Quality Service Team that was forwarded to the Hate Crime police sergeant on 23 June 2022, stating that Aminata Coulibaly wants to contest the decision made by the officer to close the case and that she is facing suicidal thoughts, anxiety and depression.
These were not uploaded to Athena or the shared with the mental health Trust .
2. Aminata made a very distressed phone call to the officer in the case on 24 June 2022 and this was not placed on Athena or shared with the mental health Trust .
3. On 26 June 2022 the mental health Trust called Essex Police reporting concerns for Ms Coulibaly’s welfare. The Essex Police contact handler did not record important information reported by the mental health Trust that:
a. Aminata had suffered assault and racial abuse by her neighbours
b. The mental health Trust had texted Aminata Coulibaly to say that if they did not hear from her by 5pm then they would contact the police for a welfare check.
c. Aminata Coulibaly has been having strong thoughts to end her life.
4. On 26 June 2022 a different Essex Police contact handler contacted the mental health Trust to update them on the outcome of their concern for welfare that the police would not attend as it did not meet the criteria. The contact did not ask for clarification when the mental health Trust nurse raised concern when informed that the decision was made that police were not going to attend when he asked, “even though it is life and limb?”. The contact handler did not clarify if there had been any update in the circumstances, these words had not been used by the Trust nurse in the first call.
The evidence from the Force Control Room Inspector was that the contact handlers should have recorded relevant information and sought further clarification that this should have been relayed back to her. This would not have made a difference for Aminata Coulibaly as she was probably deceased but is relevant to prevent a future death and ensure that the Inspector has all relevant information when applying THRIVE to assess risk and response.
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record relevant police contacts on Athena
Wider context from the report “(1) Essex Police were aware that Aminata Coulibaly was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime. Essex Police did not update the mental health Trust that Aminata Coulibaly sent 2 emails on 22 June 2022 in response to her being informed (incorrectly) that the Hate Crime investigation by Essex Police had been closed:
i. to the officer in the case, setting out elements of how she is being treated, elements of the hate crime and that she is not happy with the decisions made by Essex Police and she feels like taking her life.
ii. to the Quality Service Team that was forwarded to the Hate Crime police sergeant on 23 June 2022, stating that Aminata Coulibaly wants to contest the decision made by the officer to close the case and that she is facing suicidal thoughts, anxiety and depression.
These were not uploaded to Athena or the shared with the mental health Trust.
2. Aminata made a very distressed phone call to the officer in the case on 24 June 2022 and this was not placed on Athena or shared with the mental health Trust.
3. On 26 June 2022 the mental health Trust called Essex Police reporting concerns for Ms Coulibaly’s welfare. The Essex Police contact handler did not record important information reported by the mental health Trust that:
a. Aminata had suffered assault and racial abuse by her neighbours
b. The mental health Trust had texted Aminata Coulibaly to say that if they did not hear from her by 5pm then they would contact the police for a welfare check.
c. Aminata Coulibaly has been having strong thoughts to end her life.
4. On 26 June 2022 a different Essex Police contact handler contacted the mental health Trust to update them on the outcome of their concern for welfare that the police would not attend as it did not meet the criteria. The contact did not ask for clarification when the mental health Trust nurse raised concern when informed that the decision was made that police were not going to attend when he asked, “even though it is life and limb?”. The contact handler did not clarify if there had been any update in the circumstances, these words had not been used by the Trust nurse in the first call.
The evidence from the Force Control Room Inspector was that the contact handlers should have recorded relevant information and sought further clarification that this should have been relayed back to her. This would not have made a difference for Aminata Coulibaly as she was probably deceased but is relevant to prevent a future death and ensure that the Inspector has all relevant information when applying THRIVE to assess risk and response.
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to seek clarification of changed welfare circumstances
Wider context from the report “(1) Essex Police were aware that Aminata Coulibaly was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime. Essex Police did not update the mental health Trust that Aminata Coulibaly sent 2 emails on 22 June 2022 in response to her being informed (incorrectly) that the Hate Crime investigation by Essex Police had been closed:
i. to the officer in the case, setting out elements of how she is being treated, elements of the hate crime and that she is not happy with the decisions made by Essex Police and she feels like taking her life.
ii. to the Quality Service Team that was forwarded to the Hate Crime police sergeant on 23 June 2022, stating that Aminata Coulibaly wants to contest the decision made by the officer to close the case and that she is facing suicidal thoughts, anxiety and depression.
These were not uploaded to Athena or the shared with the mental health Trust.
2. Aminata made a very distressed phone call to the officer in the case on 24 June 2022 and this was not placed on Athena or shared with the mental health Trust.
3. On 26 June 2022 the mental health Trust called Essex Police reporting concerns for Ms Coulibaly’s welfare. The Essex Police contact handler did not record important information reported by the mental health Trust that:
a. Aminata had suffered assault and racial abuse by her neighbours
b. The mental health Trust had texted Aminata Coulibaly to say that if they did not hear from her by 5pm then they would contact the police for a welfare check.
c. Aminata Coulibaly has been having strong thoughts to end her life.
4. On 26 June 2022 a different Essex Police contact handler contacted the mental health Trust to update them on the outcome of their concern for welfare that the police would not attend as it did not meet the criteria. The contact did not ask for clarification when the mental health Trust nurse raised concern when informed that the decision was made that police were not going to attend when he asked, “even though it is life and limb?”. The contact handler did not clarify if there had been any update in the circumstances , these words had not been used by the Trust nurse in the first call.
The evidence from the Force Control Room Inspector was that the contact handlers should have recorded relevant information and sought further clarification that this should have been relayed back to her. This would not have made a difference for Aminata Coulibaly as she was probably deceased but is relevant to prevent a future death and ensure that the Inspector has all relevant information when applying THRIVE to assess risk and response.
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record relevant welfare information reported by the mental health Trust
Wider context from the report “(1) Essex Police were aware that Aminata Coulibaly was under the care of the crisis mental health team and that the exacerbation of her mental health crisis was linked to a matter that was being investigated as a Hate Crime. Essex Police did not update the mental health Trust that Aminata Coulibaly sent 2 emails on 22 June 2022 in response to her being informed (incorrectly) that the Hate Crime investigation by Essex Police had been closed:
i. to the officer in the case, setting out elements of how she is being treated, elements of the hate crime and that she is not happy with the decisions made by Essex Police and she feels like taking her life.
ii. to the Quality Service Team that was forwarded to the Hate Crime police sergeant on 23 June 2022, stating that Aminata Coulibaly wants to contest the decision made by the officer to close the case and that she is facing suicidal thoughts, anxiety and depression.
These were not uploaded to Athena or the shared with the mental health Trust.
2. Aminata made a very distressed phone call to the officer in the case on 24 June 2022 and this was not placed on Athena or shared with the mental health Trust.
3. On 26 June 2022 the mental health Trust called Essex Police reporting concerns for Ms Coulibaly’s welfare. The Essex Police contact handler did not record important information reported by the mental health Trust that:
a. Aminata had suffered assault and racial abuse by her neighbours
b. The mental health Trust had texted Aminata Coulibaly to say that if they did not hear from her by 5pm then they would contact the police for a welfare check.
c. Aminata Coulibaly has been having strong thoughts to end her life.
4. On 26 June 2022 a different Essex Police contact handler contacted the mental health Trust to update them on the outcome of their concern for welfare that the police would not attend as it did not meet the criteria. The contact did not ask for clarification when the mental health Trust nurse raised concern when informed that the decision was made that police were not going to attend when he asked, “even though it is life and limb?”. The contact handler did not clarify if there had been any update in the circumstances, these words had not been used by the Trust nurse in the first call.
The evidence from the Force Control Room Inspector was that the contact handlers should have recorded relevant information and sought further clarification that this should have been relayed back to her. This would not have made a difference for Aminata Coulibaly as she was probably deceased but is relevant to prevent a future death and ensure that the Inspector has all relevant information when applying THRIVE to assess risk and response.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train Contact Management staff in Right Care, Right Person, incident recording, National Decision Model, THRIVE, escalation and supervisory requirements through recruit and continuing-development programmes.
Verbatim wording from the response “To ensure these procedures are understood and consistently delivered by operational officers and staff in our Control Centre, the following has been implemented:” Source location Response from Essex 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 Develop Mental Health Risk Management Briefings to bring relevant agencies together to manage risks involving people experiencing mental ill health.
Verbatim wording from the response “• The Essex Police Mental Health Triage team have developed Mental Health Risk Management Briefings (MHRMB) which can be requested by police or partners. The aim of this meeting is to bring all agencies involved with the subject together, or introduce agencies to the process, that need to have some involvement to manage the risk that the subject poses to themselves or the wider public.” Source location Response from Essex 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 Update investigation policy and procedure to require safeguarding reassessment, referrals, referral documentation, outcomes and recorded justification before case closure.
Verbatim wording from the response “• Essex Police has updated policy and procedure to direct action to be taken to investigate crime, support victims, and share information. Of key importance is procedure B0602 Investigation of Crime, updated in September 2025 which states at 3.7:” Source location Response from Essex 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 Establish a Mental Health Triage team within the Strategic Vulnerability Centre to improve police, health and social-care safeguarding pathways and information sharing.
Verbatim wording from the response “Since 2022, Essex Police have established a Mental Health Triage team to improve safeguarding pathways and referrals. They are a strategic department within our Strategic Vulnerability Centre (SVC) that works with partners to provide a holistic overview of mental health across Essex and exists to bridge the gap between the police and partner agencies. They work with partners regarding mental health policies and procedures to ensure they are collaborative and fit for purpose. This has been achieved by:” Source location Response from Essex 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 Where police are not primarily responsible, incidents should be referred or directed to the appropriate agency, subject to specified police duties.
Verbatim wording from the response “• The Concern for Welfare policy which was detailed during the inquest hearing and sets out the police response to such calls has been superseded by the Right Care, Right Person (RCRP) policy D 0800 and procedures D 0801 to 803. These came into effect in early 2024 and follows national guidance which was developed with partner agencies including the NHS. These procedures establish that the right agency deals at first point of contact, and then throughout an incident. This provides clarity to Essex Police officers and staff to make operational decisions when responding to call for service involving medical support, physical, and mental health, from members of the public or partner agencies.” Source location Response from Essex 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.
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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 Essex 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 Essex 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a joint Essex and Kent lesson plan to enhance firearms licensing professional development and maintain current knowledge.
Verbatim wording from the response “Local development events in the form of classroom days are regular, varied, and relevant to the role. All new team members are given bespoke inhouse training delivered and monitored by their supervisor and with the exception of two new members of staff my team have all attended the training course in West Yorkshire. Essex and Kent Police have a collaborated Learning and Development Command, who are developing a lesson plan to further enhance professional development and ensure currency of knowledge. I anticipate this will be in place by the end of August 2023.” Source location Response from Essex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate with national policing and professional bodies in developing a national firearms licensing training package.
Verbatim wording from the response “Essex Police are engaged with the NPCC Lead, Chief Constable ████████ and College of Policing in the development of the national training package. We have delivered local training to ensure continuous professional development, including an input on the Home Office Guide on Firearms Licensing Law in November 2022 and the updated Statutory Guidance for Chief Officers of Police on Firearms Law in February 2023, as well as risk matrix development, National Decision Making model, Keyham Inquiry recommendations and impact, ‘Managing Risk and Firearms Licensing’, Domestic Abuse and Stalking inputs and Welfare and Counselling Support guidance.” Source location Response from Essex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Restrict decisions to return certificates after suitability reviews to the Superintendent for Armed Policing.
Verbatim wording from the response “I am satisfied that, in the absence of a national accredited training product that a local training programme is in place to ensure all member of staff and supervisors to whom decision making authority is delegated have received, and will continue to receive, adequate local training. Since September 2021, all decisions to return certificates following a suitability review are made by the Superintendent for Armed Policing.” Source location Response from Essex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and deliver a local firearms licensing training programme for staff and supervisors exercising delegated decision-making authority.
Verbatim wording from the response “Essex Police are engaged with the NPCC Lead, Chief Constable ████████ and College of Policing in the development of the national training package. We have delivered local training to ensure continuous professional development, including an input on the Home Office Guide on Firearms Licensing Law in November 2022 and the updated Statutory Guidance for Chief Officers of Police on Firearms Law in February 2023, as well as risk matrix development, National Decision Making model, Keyham Inquiry recommendations and impact, ‘Managing Risk and Firearms Licensing’, Domestic Abuse and Stalking inputs and Welfare and Counselling Support guidance.” Source location Response from Essex Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing local training is considered adequate for firearms licensing staff and supervisors despite the absence of nationally accredited training.
Verbatim wording from the response “I am satisfied that, in the absence of a national accredited training product that a local training programme is in place to ensure all member of staff and supervisors to whom decision making authority is delegated have received, and will continue to receive, adequate local training. Since September 2021, all decisions to return certificates following a suitability review are made by the Superintendent for Armed Policing.” Source location Response from Essex Police
Open published response
27 Jan 2023 Jayden Andrew Booroff · Prevention of Future Deaths report Essex
View report summary
Concerns raised 6 Lack of a senior single point of contact for ongoing communications with emergency services across shift changes View source Failure of risk assessments to capture key risk information before ward observation levels are reduced View source Failure to communicate self-harm risks to emergency services searching for an absent patient View source Miscommunication between mental health, police and other emergency services View source Lack of understanding of the distinction between an unauthorised absence after section 17 leave and an escape from a detained ward patient View source Failure to establish the changed risk and immediacy of serious or fatal harm when a patient escapes from a secure mental health ward View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jayden Andrew Booroff · 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
Jayden Andrew Booroff died after absconding from The Linden Centre and being struck by a train on 23 October 2020. The report identified concerns about risk assessments, observation levels, ward security, absconsion procedures, record keeping, medication, and communication between healthcare professionals and 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a senior single point of contact for ongoing communications with emergency services across shift changes
Wider context from the report “(4) Lack of an Essex Partnership NHS Foundation Trust senior single point of contact for communications with emergency services who would provide any further information or receive updates and how this could be managed across change of shifts .
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of risk assessments to capture key risk information before ward observation levels are reduced
Wider context from the report “(1) Essex Partnership NHS Foundation Trust risk assessments missed key risk information that led to a reduction in observations levels on the ward .
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate self-harm risks to emergency services searching for an absent patient
Wider context from the report “(2) There is a lack of understanding at Essex Partnership NHS Foundation Trust level about the difference between:
a. a patient who has been granted section 17 leave under the Mental Health Act who does not return from a period of authorised leave, and
b. a patient who being subject to detention under the Mental Health Act, who has escaped from the confines of the ward and who has not been granted section 17 leave by the Responsible Clinician
and therefore, there is a concern as to how this information is then communicated to emergency services searching for the patient of the risks of self-harm .
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Miscommunication between mental health, police and other emergency services
Wider context from the report “(3) Miscommunication between:
a. Essex Partnership NHS Foundation Trust to emergency services
b. Essex Police to Essex Partnership NHS Foundation Trust
c. Essex Police to other emergency services
In seeking further information, how a risk managed within the confines of a secure mental health ward may change for an escaped patient and whether there is real and immediate risk of serious or fatal harm to self or others, rather than assumptions that language is being used in the same way by different 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the distinction between an unauthorised absence after section 17 leave and an escape from a detained ward patient
Wider context from the report “(2) There is a lack of understanding at Essex Partnership NHS Foundation Trust level about the difference between :
a. a patient who has been granted section 17 leave under the Mental Health Act who does not return from a period of authorised leave , and
b. a patient who being subject to detention under the Mental Health Act, who has escaped from the confines of the ward and who has not been granted section 17 leave by the Responsible Clinician
and therefore, there is a concern as to how this information is then communicated to emergency services searching for the patient of the risks of self-harm.
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the changed risk and immediacy of serious or fatal harm when a patient escapes from a secure mental health ward
Wider context from the report “(3) Miscommunication between:
a. Essex Partnership NHS Foundation Trust to emergency services
b. Essex Police to Essex Partnership NHS Foundation Trust
c. Essex Police to other emergency services
In seeking further information, how a risk managed within the confines of a secure mental health ward may change for an escaped patient and whether there is real and immediate risk of serious or fatal harm to self or others , rather than assumptions that language is being used in the same way by different services .
” 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 Progress collaborative implementation of the national framework for adults missing from health and care settings through multi-agency planning and a Task and Finish group.
Verbatim wording from the response “b. This team are also working towards the implementation of ‘The multi-agency response for adults missing from health and care settings - A national framework for England’. This is collaborative guidance produced by the Home Office, NPCC, and the Missing Persons charity. The team held a multi-agency collaborative conference in September 2022 with Essex Local Authorities, local Integrated Care Boards, and third sector organisations and achieved buy-in to a Task & Finish group looking at how to roll out this framework in Essex.” Source location Response from Essex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Align Missing Persons Procedure B1601 with national guidance and require contact with BTP when suicide-risk information is marked on the PNC.
Verbatim wording from the response “As detailed by Chief Inspector Scott-Haynes during the inquest, immediate action was taken to align our Missing Persons Procedure B1601 with the College of Policing guidance. The Procedure is now clear that contact must be made with the British Transport Police (“BTP”) if BTP has placed a suicide risk or related information marker on the Police National Computer (“PNC”).” Source location Response from Essex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share national guidance on restricted patients who abscond with Essex Police and relevant external agencies.
Verbatim wording from the response “3. Essex Police’s Strategic Vulnerability Centre is a department that oversees and co-ordinates the force’s activity across a number of areas of vulnerability. It includes non-operational thematic strands relating to missing persons and Mental Health. Through the work of the Strategic Vulnerability Centre:” Source location Response from Essex Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed dedicated constable and inspector liaison capacity at the Linden Centre to improve local identification, information sharing, partnership working and strategic oversight.
Verbatim wording from the response “10. At a more local level, Essex Police have embedded dedicated police liaison working within the Linden Centre in Chelmsford. This liaison role is resourced by a constable, with an Inspector providing a local strategic overview.” Source location Response from Essex Police
Open published response
23 Sep 2021 Anthony James Preston · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Uncertainty about whether the Police Missing Person Policy is fit for purpose 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
Anthony James Preston · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony James Preston died at home on 16 November 2020 after being found suspended by a ligature. The report describes his attendance at A&E after an apparent attempted hanging, his disappearance before a mental health assessment, and his later discovery deceased at home. The substantive concern was whether the Police Missing Person Policy was fit for purpose.
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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about whether the Police Missing Person Policy is fit for purpose
Wider context from the report “That the Police Missing Person Policy should be looked at to see if it is fit for purpose.
” Open source report
24 Nov 2020 Sharon Louise Kelly · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Insufficiently clear communication lines and operating arrangements between EEAS and Essex Police for potential joint attendance at a risk-marked property View source Lack of sufficiently clear EEAS training on communicating relevant recorded information to ambulance crews for dynamic risk assessments View source Lack of sufficiently clear EEAS training on identifying relevant flag markers for appropriate police attendance at a property View source Lack of sufficiently clear Essex Police Comms Officer training on when a blue lights response should be mandated View source Failure to maintain adequate arrangements for convening an urgent MHS assessment with social services View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sharon Louise Kelly · 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
Sharon Louise Kelly, who had a long history of mental health and alcohol problems and frequent suicide attempts, informed a family member that she would kill herself on the anniversary of her baby son’s death. On 27 June 2019, an ambulance attended her property but did not enter while awaiting delayed police attendance; when services eventually entered, Ms Kelly was deceased. The concerns included delays and communication between ambulance and police services, risk assessment and police response procedures, and arrangements for urgent mental health assessments.
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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear communication lines and operating arrangements between EEAS and Essex Police for potential joint attendance at a risk-marked property
Wider context from the report “Whether lines of communication and the modus operandi between EEAS and Essex Police are sufficiently clear in relation to a potential joint attendance at a property where there is a risk marker (given the delays on 27 June 2019)
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficiently clear EEAS training on communicating relevant recorded information to ambulance crews for dynamic risk assessments
Wider context from the report “Whether there is sufficiently clear training at EEAS in relation to (1) identifying relevant flag markers to ensure police attendance at a property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019)
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficiently clear EEAS training on identifying relevant flag markers for appropriate police attendance at a property
Wider context from the report “Whether there is sufficiently clear training at EEAS in relation to (1) identifying relevant flag markers to ensure police attendance at a property where appropriate and 2) communicating relevant information from relevant records to ambulance crews to ensure that dynamic risk assessments take place on the basis of all relevant information (in light of decision making and delays on 27 June 2019)
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficiently clear Essex Police Comms Officer training on when a blue lights response should be mandated
Wider context from the report “Whether there is sufficient clarity in the training for Essex Police Comms Officers as to the circumstances in which a blue lights response should be mandated (in light of the evidence of Insp ████████ as to the response on 27 June 2019)
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate arrangements for convening an urgent MHS assessment with social services
Wider context from the report “Whether EPUT can review its arrangements for convening an urgent MHS assessment, in conjunction with social services . (in light of the jury’s findings with regard to the MHA assessment in June 2019)
” Open source report
5 Apr 2019 Raymond Alan Knight · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Failure to provide CCTV coverage inside holding cells 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
Raymond Alan Knight · 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
Raymond Alan Knight was arrested on suspicion of possessing illicit drugs with intent to supply, taken to Grays Police Station, and collapsed in a holding cell before being pronounced dead at hospital. Toxicological analysis indicated high levels of cocaine in his blood, and the inquest concluded that the death was drug related. The report raised concern that CCTV did not cover the individual holding cells, leaving no photographic record of what happened inside them when officers were not present.
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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide CCTV coverage inside holding cells
Wider context from the report “The CCTV camera positioned in the holding area at Grays Police Station did not include, within its range, sight into the individual holding cells. As a result, there was no photographic record of exactly how Mr Knight was and what he was doing while he was in the holding area . It is essential to be able to see what is happening within the holding cells when a prisoner is detained within one of them. The court was told that a police officer would be required to be at the cell at all times but, if for any reason, there were to be no officer in attendance, a CCTV record of within the cell is essential. The introduction of discrete camera coverage of the holding areas may well prevent future deaths, of whatever cause, in those specific locations.
” Open source report
14 Aug 2017 Terence Joseph Pimm · Prevention of Future Deaths report Essex
View report summary
Concerns raised 11 Insufficient guidance View source Insufficient coordination between the police, hospital Trust and probation service View source Failure of call handling at The Lakes View source Insufficient training View source Failure of mental health assessors to seek family input in appropriate circumstances View source Failure of police call handlers to assess whether an individual is objectively at immediate risk View source Failure of record-keeping at the police custody suite View source Failure of call handling at the police custody suite View source Failure of record-keeping at The Lakes View source Failure of mental health clinicians to understand the effect of warrants on their ability to assess and treat View source Insufficient information sharing between the police, hospital Trust and probation service View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terence Joseph Pimm · 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
Terence Joseph Pimm died after leaping from the seventh floor of a car park on 26 August 2016, following recent threats to jump and contact with police, hospital and probation services. The substantive concerns included call handling and record-keeping, guidance and training, assessment of immediate risk, involvement of family members in mental health assessments, information sharing and coordination, and clinicians’ understanding of warrants.
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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance
Wider context from the report “3). The sufficiency of guidance and training.
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient coordination between the police, hospital Trust and probation service
Wider context from the report “6). The sufficiency of information sharing and coordination between the police, hospital Trust and probation service .
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of call handling at The Lakes
Wider context from the report “1). Call handling and record-keeping at The Lakes
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient training
Wider context from the report “3). The sufficiency of guidance and training.
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health assessors to seek family input in appropriate circumstances
Wider context from the report “5). To mental health assessors as to the circumstances in which the input of family Members should be sought .
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of police call handlers to assess whether an individual is objectively at immediate risk
Wider context from the report “4). To police call handlers as to whether an individual is, objectively, at an “immediate” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of record-keeping at the police custody suite
Wider context from the report “2). Call handling and record-keeping at the police custody suite
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of call handling at the police custody suite
Wider context from the report “2). Call handling and record-keeping at the police custody suite
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of record-keeping at The Lakes
Wider context from the report “1). Call handling and record-keeping at The Lakes
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health clinicians to understand the effect of warrants on their ability to assess and treat
Wider context from the report “7). Training/guidance for mental health clinicians in relation to persons who are subject to a warrant . The evidence pointed to a lack of understanding as to the effect of a warrant upon the clinician’s ability to assess and treat .
” 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 Essex Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient information sharing between the police, hospital Trust and probation service
Wider context from the report “6). The sufficiency of information sharing and coordination between the police, hospital Trust and probation service.
” 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 Raise the Prevention of Future Deaths report at the scheduled health-partner meeting to reinforce the importance of the proposed information-sharing agreements.
Verbatim wording from the response “• Information Sharing Agreements, including Standard Operating Procedures, between Essex Police and our partners in Health are currently being developed. The final drafts were submitted to the Health lead on the 1st September and a meeting is scheduled to take place on 23rd November 2017. One of the proposed Standard Operating Procedures includes provision for Health to make a request for information to Essex Police (or vice versa) “where Health Professionals are working with a patient or planning to work with a patient and it is identified that the police are likely to hold information relating to the patient, which would indicate they pose a risk of serious harm to:” Source location 2017-0217-Response-by-Essex-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop information-sharing agreements and standard operating procedures with health partners for reciprocal disclosure of serious-harm risk information.
Verbatim wording from the response “The sufficiency of information sharing and co-ordination between the police, Hospital Trust and probation service” Source location 2017-0217-Response-by-Essex-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Supplement Force Control Room call-handler training with guidance on assessing immediacy, welfare risks, and when to seek advice.
Verbatim wording from the response “The sufficiency of guidance and training to police call handlers as to whether an individual is, objectively, at an ‘immediate’ risk” Source location 2017-0217-Response-by-Essex-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require custody-suite telephone calls to be handled by police personnel, relevant detainee information recorded, and unrelated calls transferred to the Force Control Room.
Verbatim wording from the response “Essex Police have taken the following action;” Source location 2017-0217-Response-by-Essex-Police
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations