15 Mar 2026 Ruslans Burkevics · Prevention of Future Deaths report Manchester West
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Concerns raised 1 Lack of regular refresher training in mental health first aid for frontline officers View source
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AI-generated summary
Ruslans Burkevics · 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
Ruslans Burkevics died after sustaining multiple injuries in a likely unwitnessed fall from an open 12th-floor bedroom window at his home, after police had escorted him home the previous evening. The report raised concern that frontline officers receive no regular refresher training in mental health first aid, despite evidence of the deceased’s mental health difficulties and substance use contributing to episodes of crisis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of regular refresher training in mental health first aid for frontline officers
Wider context from the report “3 - It was reflected in evidence that whilst front line officers must receive regular refresher training on first aid, no such provision for mental health first aid training is currently being provided, on a regular and refreshing basis . There was evidence that no direct training on mental health is provided apart from initial training . Mental Health may be a topic within other qualifications and development courses as a peripheral issue of that subject, but no dedicated mental health first aid type refresher is provided at present .
” 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 Complete the review and redevelopment of mental health training provision, informed by frontline officers and partner organisations.
Verbatim wording from the response “As part of our organisational development under the post-Right Care Right Person operating model, GMP’s mental health portfolio underwent a change of strategic ownership in March 2026. This transition has initiated a comprehensive review and refresh of the entire portfolio to ensure that our approach to policing mental health-related demand is consistent, professional and aligned to modern policing standards. This work is intended to strengthen the organisation’s capability to manage increasingly complex and high-risk situations involving mental ill-health.” Source location Response from Greater Manchester Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess opportunities to introduce a cyclical dedicated mental health first-aid refresher product for officers.
Verbatim wording from the response “The overarching aim of this refreshed training approach is to ensure that all GMP officers receive appropriate, relevant and contemporary input that enhances their understanding of mental health vulnerabilities, improves their confidence in managing crisis situations, and ultimately strengthens the safety and safeguarding of the public. This includes exploring opportunities to introduce a dedicated mental health first-aid refresher product delivered on a cyclical basis, complementing existing first-aid requirements and ensuring officers remain informed in an area where societal needs and clinical understanding continue to evolve.” Source location Response from Greater Manchester Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue refresher materials and updated mental health guidance to frontline officers through established internal communication channels as required.
Verbatim wording from the response “During this period, GMP will continue to deliver its existing mental health-related training products to ensure officers retain a baseline level of knowledge and capability. In addition, refresher materials and updated guidance will be issued to frontline officers through established internal communication channels as required, particularly where emerging themes, operational learning or partnership insight identify areas where immediate reinforcement or clarification would enhance understanding.” Source location Response from Greater Manchester Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation While mental health first-aid training is reviewed, existing guidance and MHUT access provide officers with professional advice for managing mental health crises.
Verbatim wording from the response “In addition to this ongoing review of mental health first aid provision, it is important to note that GMP officers are not mental health professionals but lay persons operating within a policing context. As part of their existing training and operational guidance, officers are explicitly directed to seek specialist mental health advice through the Mental Health Urgent Triage (MHUT) service when incidents involve elements of mental ill health. MHUT provides officers with access to qualified mental health professionals who are able to offer expert advice, supported by access to relevant patient records and the wider health system, thereby informing proportionate and lawful decision making.” Source location Response from Greater Manchester Police
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Concerns raised 4 Failure to audit use of police handover forms View source Failure to update policies supporting handover-form implementation View source Failure to appropriately communicate key information in police handovers for people detained under the Mental Health Act View source Failure to clearly record police handovers View source See 1 more concern
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AI-generated summary
Roger Gary Leadbeater · 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
Roger Gary Leadbeater died on 9 August 2023 from multiple stab wounds inflicted by a patient detained under the Mental Health Act who had absconded from escorted leave. The report identified concerns about inadequate and poorly recorded handovers between police forces and the mental health trust, which meant significant risk information was not clearly communicated and may have affected decisions to grant leave. It also noted that, as of January 2026, relevant policies and auditing arrangements had not been updated to support the use of new handover forms.
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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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to audit use of police handover forms
Wider context from the report “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died.
The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation.
On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use.
I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to update policies supporting handover-form implementation
Wider context from the report “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died.
The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation.
On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use.
I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately communicate key information in police handovers for people detained under the Mental Health Act
Wider context from the report “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died.
The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation.
On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use.
I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated . This is turn may affect risk assessments and decisions around patients being granted leave.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record police handovers
Wider context from the report “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died.
The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation .
On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use.
I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave.
” 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, test and release the Form 1157 mobile app with the revised structure and mandatory risk-information fields.
Verbatim wording from the response “To ensure the amended Form 1157 is fully embedded into frontline practice, GMP is also updating the digital version of the form used on officers’ mobile devices. An initial meeting to scope the required changes to the 1157 mobile app took place on 23rd February 2026, during which the technical and operational requirements were agreed. The final sign off for the project is due to take place on 16th March 2026 after which development work will begin. It is estimated that it will take 3 months for the completion of testing and for full release of the app to take place.” Source location 2026-0041 - Response from Greater Manchester Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require PRISM Care Plan triage staff to verify Form 1157 completion and attachment before closing relevant Care Plans.
Verbatim wording from the response “In addition, completion of the 1157 has now been incorporated into the new PRISM app used by District Safeguarding Teams (MASH). Officers and staff triaging Care Plans must confirm that the Form 1157 has been completed and attached before a Care Plan can be closed. This creates a clear check-and-balance within the system and prevents closure where the correct safeguarding paperwork has not been provided.” Source location 2026-0041 - Response from Greater Manchester 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 Produce and publish a mental-health missing-persons CPD video covering risk assessment, conveyance responsibilities and structured hospital handovers.
Verbatim wording from the response “This learning will also be integrated into the Sergeants’, Inspectors’ and Superintendents’ Skills Courses delivered to all newly promoted officers. In addition, the Vulnerability CORE within the Public Protection Division is producing a short CPD training video focused on mental health considerations in Missing Person cases. The video will outline expectations around risk assessment, conveyance responsibilities, and the structured handover of pertinent risk information to receiving hospitals, including the completion of Form 1157.” Source location 2026-0041 - Response from Greater Manchester 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 Run a monthly comparison of hospital-originating missing-person episodes against Form 1157 submissions to identify missing documentation.
Verbatim wording from the response “The Missing Person Safeguarding Unit within the Public Protection Division will run a monthly report identifying all Missing Person episodes originating from hospitals. This will be shared with the Prevention Hub to compare against their 1157 submissions via the updated app, ensuring that the required documentation has been completed for every relevant incident.” Source location 2026-0041 - Response from Greater Manchester Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend Form 1157 and the supporting policy to mandate structured recording and handover of risk information across specified mental-health conveyances.
Verbatim wording from the response “To address the issues that presented in Mr Leadbeater’s case, GMP has amended Form 1157 and moreover extended the circumstances in which the form is mandated for completion. The form must now be completed whenever officers take or convey (or assist in conveying) a person to hospital under any of the following circumstances:” Source location 2026-0041 - Response from Greater Manchester Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrate case learning on risk identification, documentation and information sharing into Missing Person CPD and promoted-officer skills courses.
Verbatim wording from the response “GMP is embedding the learning arising from this case into its wider professional development framework. The circumstances and lessons identified will be incorporated into Missing Person Continual Professional Development (CPD), ensuring that all officers receive consistent guidance on risk identification, documentation and effective information sharing.” Source location 2026-0041 - Response from Greater Manchester Police
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1 Dec 2025 Lewis Bates · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Lack of guidance for call handlers on reasonable public enquiries concerning missing persons View source Failure to correctly distinguish between missing-person reporting and the Right Person Right Care initiative View source Failure to account for healthcare information-disclosure constraints when directing callers to make enquiries View source
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AI-generated summary
Lewis Bates · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lewis Bates was reported missing after leaving his mother and stepfather’s house, having previously expressed an intention to end his life if he could not see his children. His body was found approximately two hours and 21 minutes after the missing-persons report. Concerns included the absence of guidance for call handlers about reasonable enquiries, advice to contact healthcare providers, and apparent confusion about the applicable police response process.
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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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for call handlers on reasonable public enquiries concerning missing persons
Wider context from the report “1. A detailed report by an officer from the force’s Professional Standards Branch which reviewed the handling of the 999 call was finalised on 10th June 2025. In the intervening time, whilst some individual learning has been recommended for the individual call handler, it is a matter of concern that no consideration appears to have been given to the systems issue raised by the report’s findings, namely that no guidance currently exists for call handlers as to what constitutes ‘reasonable enquiries’ by a member of the public in relation to a person reported as missing .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly distinguish between missing-person reporting and the Right Person Right Care initiative
Wider context from the report “3. Having considered the audio recording and transcript of the 999 call with the utmost care, I am concerned that the call handler appears confused as to whether she was dealing with the call as a missing persons report or under the Right Person Right Care initiative . I am concerned such confusion was a relevant factor in the appropriate police response to the 999 call not being provided on this occasion.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to account for healthcare information-disclosure constraints when directing callers to make enquiries
Wider context from the report “2. In the context of the advice given by the call handler, I am concerned that the additional enquiries the caller was asked to undertake included contacting Mr Bates’s GP surgery and the local hospital , notwithstanding the potential legal constraints on healthcare providers disclosing information to a concerned member of the public .
” 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 Issue formal guidance defining unreasonable enquiries for informants and setting out lawful alternatives when healthcare or sensitive information is relevant.
Verbatim wording from the response “By the end of February 2026, GMP will issue formal guidance for call handlers clearly outlining:” Source location Response from Greater Manchester Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the FCCO Sherlock guidance system with revised instructions for distinguishing Missing Person and RCRP procedures.
Verbatim wording from the response “Alongside the re-publication of amended policies, the Public Protection Division will work closely with the Force Contact, Crime and Operations (FCCO) Branch to ensure that revised guidance is made available to all call handlers and their supervisors. This will be delivered to respective teams and police staff via additional training. This measure is designed to prevent any further confusion and ensure consistency in decision-making.” Source location Response from Greater Manchester Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Missing Person and RCRP policies, consult stakeholders, and progress senior-officer sign-off to clarify their distinction and reduce operational confusion.
Verbatim wording from the response “GMP will conduct a full review of both the Missing Person and RCRP policies to identify areas of overlap and potential confusion. Following this review and wherever appropriate:” Source location Response from Greater Manchester Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate a reminder to call handlers through bespoke correspondence and FCCO digital wallboards that members of the public should not be asked to contact GP surgeries for information.
Verbatim wording from the response “To prevent any future mistakes, bespoke correspondence has been forwarded to Call Handlers; and internal FCCO digital wallboards have been updated with a reminder that this does not constitute a reasonable enquiry for a member of the public reporting a concern for welfare and/or a potential missing person.” Source location Response from Greater Manchester Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver enhanced call-handler and supervisor training on vulnerability assessment, complex cases, escalation decisions, and supervisory quality assurance.
Verbatim wording from the response “Rather than imposing rigid lists, GMP will strengthen decision-making through enhanced training and guidance for call handlers. This will include:” Source location Response from Greater Manchester Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The request for callers to contact GP surgeries appears to be an isolated individual-learning incident, not a problem in existing tools or training.
Verbatim wording from the response “The Call Handler responsible has been given organisational learning feedback regarding this incident which will be filed in their personal records.” Source location Response from Greater Manchester Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A mandatory checklist for call handlers cannot be adopted because it could create confusion, restrict judgment, and increase risks.
Verbatim wording from the response “Missing person cases are rarely straightforward. They range from a child late home from a party to a vulnerable adult leaving a hospital ward. Each situation carries its own complexities, and what is reasonable in one context may be entirely inappropriate in another. For example, a care home with multiple staff might be able to conduct room checks and contact known associates, whereas a single parent caring for other young children cannot safely leave the house to search the local area. Similarly, staff in supported accommodation often lack access to personal records, making it difficult to carry out meaningful enquiries.” Source location Response from Greater Manchester Police
Open published response
20 Aug 2025 Masood Hamid · Prevention of Future Deaths report Manchester North
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Concerns raised 4 Ineffective investigation of deaths of detained patients View source Lack of coordinated planning for least-distressing patient transport View source Ineffective learning from deaths of detained patients View source Ineffective communication between police and ambulance services during transport assistance View source See 1 more concern
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AI-generated summary
Masood Hamid · 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
Masood Hamid, who had dementia and multiple physical health conditions, died on 24 December 2024 shortly after being transferred under restraint from Shawside Care Home to hospital. The report identified concerns about inadequate planning for the transfer, ineffective communication between GMP and NWAS that delayed assistance, and an ineffective investigation into his death.
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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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Ineffective investigation of deaths of detained patients
Wider context from the report “2. There was an ineffective investigation into the death of a patient who died in the care of the state whilst detained under the Mental Health Act 1983 . As a result, the findings in the SWARM huddle document contradicted evidence of key witnesses. A lack of effective investigation in such cases means there is ineffective learning in order to prevent 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of coordinated planning for least-distressing patient transport
Wider context from the report “1. There was a lack of planning or consideration between all those involved in his care as to the best time and the least distressing way in which Mr Hamid could be transported to the hospital . This in full knowledge that any move would likely cause distress to a patient with dementia and physical health issues.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Ineffective learning from deaths of detained patients
Wider context from the report “2. There was an ineffective investigation into the death of a patient who died in the care of the state whilst detained under the Mental Health Act 1983. As a result, the findings in the SWARM huddle document contradicted evidence of key witnesses. A lack of effective investigation in such cases means there is ineffective learning in order to prevent 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication between police and ambulance services during transport assistance
Wider context from the report “3. There was ineffective communication between GMP and NWAS between 21:28 hours and 23:45 which delayed the deployment of officers to assist NWAS staff with the transportation of the deceased. This delay meant a prolonged period of distress and agitation which contributed to the stress placed on the deceased.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct ongoing knowledge-sharing visits between FCCO staff and NWAS control rooms, with designated SPOCs cascading learning.
Verbatim wording from the response “• Knowledge-Sharing Visits: Since 14 July 2025, GMP FCCO staff have been visiting NWAS control rooms to foster mutual understanding and collaboration. These visits include first and second-line leaders, with designated SPOCs responsible for cascading learning across teams.” Source location Response from Greater Manchester Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the developed mental-health protocol briefing to all frontline officers force-wide.
Verbatim wording from the response “• Training for District Officers: A briefing item has been developed by GMP’s Prevention Branch for all frontline officers. This includes guidance on the Northwest Regional Mental Health Capacity Act Joint Protocol 2023, specifically regarding police support to NWAS in restraining or transporting patients lacking capacity and requiring emergency treatment. This will be delivered force wide imminently.” Source location Response from Greater Manchester Police
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce daily operational huddles between GMP dispatch managers and NWAS managers to improve real-time coordination.
Verbatim wording from the response “• Daily Operational Huddles: Daily briefings between GMP dispatch managers and NWAS managers have been introduced to improve real-time coordination.” Source location Response from Greater Manchester Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communication between GMP and NWAS occurred and was constructive, disputing the concern that communication was ineffective.
Verbatim wording from the response “Following careful consideration of your Regulation 28 report, I provide the following formal response regarding the concerns raised. The primary issue identified relates to the alleged ineffective communication between Greater Manchester Police (GMP) and Northwest Ambulance Service (NWAS) between 21:28 and 23:45 hours on 23 December 2024, which is understood to have delayed the deployment of police officers to assist NWAS staff with the transportation of Mr Hamid.” Source location Response from Greater Manchester Police
Open published response
7 Jul 2025 Elaine TARBUCK · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 5 Lack of clarity about lawful authority and responsibility for forced entry View source Sub-optimal information gathering and evaluation of emergency category View source Failure to accurately evaluate concern-for-welfare emergencies requiring forced entry View source Failure of emergency-service first-responder allocation to provide appropriate care for concern-for-welfare emergencies View source Poor training of emergency call handlers View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Provide continuing THRIVE training, refresher training and monitoring to improve risk assessment and decision-making.
Stated completedThe respondent said that this action was complete when they made their response on 16 July 2025. View source
Action
Implement and operate the RCRP policy and partner-agency pathways for assessing concern-for-welfare calls and directing responses.
Stated completedThe respondent said that this action was complete when they made their response on 16 July 2025. View source
Action
Deliver initial and refresher RCRP training to relevant staff, including guidance on risk, response protocols and partner-agency referrals.
Stated completedThe respondent said that this action was complete when they made their response on 16 July 2025. View source
Action
Audit staff understanding of the RCRP policy and provide subject-matter-expert support where misunderstandings or ambiguity are identified.
Stated in progressThe respondent said that this action was in progress when they made their response on 16 July 2025. View source
Action
Develop and test an upgraded RCRP assessment tool integrating thematic pathways and presenting relevant guidance during questioning.
Stated in progressThe respondent said that this action was in progress when they made their response on 16 July 2025. View source
Action
Review and amend the existing RCRP assessment tools, including question wording, ordering and NWAS definitions, to improve information gathering and risk identification.
Stated in progressThe respondent said that this action was in progress when they made their response on 16 July 2025. View source
Action
Implement the inter-agency Gaining Entry Memorandum of Understanding defining responsibility for forced entry when NWAS requires access.
Stated completedThe respondent said that this action was complete when they made their response on 16 July 2025. View source
Action
Circulate targeted RCRP communications, including case studies, audit findings and pathway reminders, through supervisors, managers and digital wallboards.
Stated completedThe respondent said that this action was complete when they made their response on 16 July 2025. View source
Action
Establish enhanced FCCO scrutiny, performance audits, dip sampling, performance plans and dashboard monitoring for RCRP compliance and signposting accuracy.
Stated completedThe respondent said that this action was complete when they made their response on 16 July 2025. View source
Action
Use Nearpod modular RCRP training to upskill staff while the upgraded assessment tool is trialled.
Stated completedThe respondent said that this action was complete when they made their response on 16 July 2025. View source See 7 more actions
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AI-generated summary
Elaine TARBUCK · 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
Elaine TARBUCK died after an accidental fall at home, sustaining a head injury and exsanguinating before she was found unresponsive on 29 March 2025. The report identified concerns about the assessment and information gathering by emergency services, delays in arranging forced entry, and the application of the ‘Right Care, Right Person’ policy.
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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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about lawful authority and responsibility for forced entry
Wider context from the report “4. There was lack of understanding as to whether the forced entry would be lawful, a matter for the police, or a matter for Fire and Rescue Services in circumstances that the next-of-kin, if asked, would have agreed readily to there being forced entry at the outset and well before their arrival.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Sub-optimal information gathering and evaluation of emergency category
Wider context from the report “5. There was accepted sub-optimal information gathering and evaluation of the category of this emergency with an example of poor training resulting in inappropriate language being used by a call handler.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately evaluate concern-for-welfare emergencies requiring forced entry
Wider context from the report “3. In fact, calls to the non-emergency 101 and 999 emergency lines evaluated that this was a non-critical emergency and a presumed medical event . This created a significant delay before it was appreciated that entry would need to be forced and the Fire and Rescue Service were requested to attend.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency-service first-responder allocation to provide appropriate care for concern-for-welfare emergencies
Wider context from the report “6. The emergency response had come about because of a new ‘Right Care, Right Person’ policy applied by emergency services that, in fact, delivered as a first responder, the wrong person delivering the wrong care to the deceased’s residence .
7. Prior to the implementation of ‘Right Care, Right Person’ this ‘concern for welfare’ emergency would have been dealt with by the attendance of the police on the scene as first responders who would have been likely to have achieved entry as a result of the concern for welfare.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Poor training of emergency call handlers
Wider context from the report “5. There was accepted sub-optimal information gathering and evaluation of the category of this emergency with an example of poor training resulting in inappropriate language being used by a call handler .
” 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 continuing THRIVE training, refresher training and monitoring to improve risk assessment and decision-making.
Verbatim wording from the response “Relevant staff have received additional training around the THRIVE model to ensure consistent and effective risk assessment and decision-making across all RCRP-related incidents. Initial THRIVE training was delivered to all staff between August 2023 and February 2024, and all new staff continue to receive THRIVE training as part of their induction. This model underpins GMP’s approach to prioritising incidents and allocating resources, ensuring that responses are proportionate, appropriate, and aligned with the principles of RCRP. Where audit findings identify issues with the application of THRIVE assessments, staff are required to undertake refresher training and are subsequently monitored and supported to ensure compliance and a clear understanding of the model.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and operate the RCRP policy and partner-agency pathways for assessing concern-for-welfare calls and directing responses.
Verbatim wording from the response “GMP’s RCRP project was developed under the oversight of Greater Manchester’s Deputy Mayor. Each thematic response pathway was agreed prior to launch with relevant partners including (but not limited to) local authorities, health services (including NWAS) and mental health service providers. RCRP was launched in Greater Manchester on the 30th September 2024.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver initial and refresher RCRP training to relevant staff, including guidance on risk, response protocols and partner-agency referrals.
Verbatim wording from the response “Right Care, Right Person training” Source location Response from Greater Manchester 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 Audit staff understanding of the RCRP policy and provide subject-matter-expert support where misunderstandings or ambiguity are identified.
Verbatim wording from the response “• RCRP policy re-read - To reinforce policy understanding, the FCCO is currently conducting an audit of all staff who have a role within the RCRP processes, including staff and supervisors within call handling, crime recording, customer enquiry unit and radio dispatch to ensure there is a record confirming they have read and understood the RCRP policy. All relevant staff have been given protected time to read the RCRP policy and subsequently confirm this has been completed via a Microsoft Form. This audit is expected to be completed by the end of August 2025.” Source location Response from Greater Manchester 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 and test an upgraded RCRP assessment tool integrating thematic pathways and presenting relevant guidance during questioning.
Verbatim wording from the response “To support improved information gathering a new RCRP assessment tool was developed in early 2025. This new assessment tool was developed with the aim of supporting call handlers to better navigate the often-complicated nature of CFW calls and their interdependencies with other areas of business. This new assessment tool is currently undergoing testing within the FCCO.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and amend the existing RCRP assessment tools, including question wording, ordering and NWAS definitions, to improve information gathering and risk identification.
Verbatim wording from the response “Whilst testing of the new RCRP assessment tool is ongoing, GMP’s RCRP project team is currently reviewing the current assessment tool to ascertain if amendment can be made to better support call handlers in understanding the nature of concern and to ensure they are professionally curious when managing CFW calls. This work is currently focusing on the wording and order of the question scripts as well as considering whether further questions can be added to the assessment tool to improve service delivery.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the inter-agency Gaining Entry Memorandum of Understanding defining responsibility for forced entry when NWAS requires access.
Verbatim wording from the response “Gaining entry on behalf of NWAS” Source location Response from Greater Manchester 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 Circulate targeted RCRP communications, including case studies, audit findings and pathway reminders, through supervisors, managers and digital wallboards.
Verbatim wording from the response “• Communication strategy - Wider communication has been circulated to supervisors and managers within the FCCO as a reminder about expectations, standards and behaviour particularly addressing the key risks. Communication strategies have been reinforced through digital wallboards and regular messaging to supervisors and managers. These communications are designed to maintain awareness of key RCRP principles and support continuous improvement. Recent examples include the use of case studies from live incidents and inquests to highlight learning points, the sharing of audit findings to identify areas for improvement, and reminders about correct pathway usage under the RCRP framework. These targeted messages ensure that staff remain informed, aligned, and equipped to apply the policy consistently.” Source location Response from Greater Manchester 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 Establish enhanced FCCO scrutiny, performance audits, dip sampling, performance plans and dashboard monitoring for RCRP compliance and signposting accuracy.
Verbatim wording from the response “As such, a number of measures have been implemented to address these concerns.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Nearpod modular RCRP training to upskill staff while the upgraded assessment tool is trialled.
Verbatim wording from the response “To support the ongoing understanding of RCRP, further training has been developed that will align with the proposed assessment tool. This training has been created within the Nearpod system. Nearpod is a third-party training platform which allows users to access modular training relevant to their training needs and provides bite-sized yet informative inputs, available when required to upskill staff. This training is currently being utilised, pending the trial of the new assessment tool.” Source location Response from Greater Manchester 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 The existing gaining-entry memorandum clearly allocates responsibilities and provides entry support through GMFRS or, if necessary, GMP.
Verbatim wording from the response “These measures were agreed by all three organisations (GMFRS, NWAS and GMP) and ensure that support to force entry can be provided to NWAS by either GMFRS or GMP when required.” Source location Response from Greater Manchester 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 GMFRS is the primary agency to force entry when NWAS leads a concern-for-welfare incident and requests assistance.
Verbatim wording from the response “In April 2024, GMP, NWAS and GMFRS signed the “Gaining Entry Memorandum of Understanding”. The purpose of the MoU is to outline a process to guide NWAS in circumstances whereby they need to gain entry into premises to assess patients who require an emergency clinical assessment. Under this MoU, GMFRS are the primary agency to support NWAS when forced entry is required at a premises. GMFRS will utilise their powers under the Fire and Rescue Service Act 2004, specifically Part 2 section 11, which notes:” Source location Response from Greater Manchester 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 NWAS is responsible for remotely assessing physical-health concerns and ordinarily providing the appropriate response.
Verbatim wording from the response “GMP are not the most appropriate agency to respond to physical health matters. Call Handlers are trained to use the RCRP assessment tool which assists them in identifying whether an incident involves a real and immediate risk to life or risk of serious harm, but they are not trained to triage physical health concerns or identify a suitable operational response to such concerns.” Source location Response from Greater Manchester 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 Despite inadequate questioning, signposting the caller to NWAS was consistent with Right Care, Right Person principles.
Verbatim wording from the response “It is acknowledged that the questioning and identification of risk was sub-optimal, meaning there was insufficient evidence or good reason to confirm either a location or a physical health need (both of which are required deployment criteria for NWAS). As the caller and Mrs Tarbuck’s daughter believed she had indeed fallen and/or was deceased within her home address, however, further questioning by the police call handler would likely have identified the evidence to support the notion that NWAS was the most appropriate emergency agency to attend to address a medical concern. As as such, the advice to contact NWAS was in line with RCRP principles.” Source location Response from Greater Manchester Police
Open published response
4 Mar 2025 Alfie Lawless · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Delays in recognising deaths or serious injuries within the meaning of s12 Police Reform Act 2002 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alfie Lawless · 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
Alfie Lawless died by hanging after suspending himself by the neck with a ligature. His mental health had deteriorated following an incident on 18 May 2024, and he had used cocaine before his death. The principal concern was the length of time Greater Manchester Police took to recognise his death as a Death or Serious Injury under section 12 of the Police Reform Act 2002.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising deaths or serious injuries within the meaning of s12 Police Reform Act 2002
Wider context from the report “The court heard evidence from a Detective Sergeant from Greater Manchester Police’s Professional Standards Branch (‘PSB’) as to valuable learning which has been identified following her review and critical analysis of the police response to the initial 999 call made on 18th May 2024 and the subsequent police investigation.
In the light of this, I am concerned as to the length of time it took for Mr Lawless’s death to be recognised by Greater Manchester Police as a Death or Serious Injury within the meaning of s12 Police Reform Act 2002 : something which appears only to have occurred after a statement for the purposes of the inquest was requested from a senior officer asked to review previous police contact with Mr Lawless .
” 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 Ensure mandatory DSI referrals are made within the Police Regulations timescales and Appropriate Authorities attend formal DSI training.
Verbatim wording from the response “The PSD will adhere to Police Regulations by ensuring that mandatory referrals are made, without delay, and in any case not later than the end of the day after the day it first becomes clear that it is a matter which must be referred. This will also ensure that AA’s attend formal training in relation to DSI, which is provided by an external company.” Source location Response from GMP
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 Use a standard DSI assessment form recording decision rationale and considered material, circulated to Appropriate Authorities for immediate use.
Verbatim wording from the response “To ensure that a common standard is applied to this assessment, a new form has been designed requiring the AA to not only include their rationale behind the decision around whether the DSI criteria had been met, but also what material they have considered in order to make this decision. This form was designed in consultation with the AA’s within the PSD and the final version has been circulated to the AA’s within the Directorate for their immediate use.” Source location Response from GMP
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 Undertake monthly dip sampling to ensure the revised DSI assessment process becomes embedded.
Verbatim wording from the response “The PSD Senior Leadership Team will undertake a period of monthly dip sampling in order to ensure that this process is embedded.” Source location Response from GMP
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 internal processes for assessing Death or Serious Injury incidents.
Verbatim wording from the response “The Professional Standards Directorate has reviewed its internal processes for when assessing incidents relating to Death or Serious Injury (DSI).” Source location Response from GMP
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 monthly DSI input on the Detective Sergeant and Detective Inspector dealing-with-death course at the GMP training school.
Verbatim wording from the response “The PSD AA’s also provide a monthly input on the Detective Sergeant / Detective Inspector dealing with Death course at GMP’s training school specifically relating to DSI and what is expected when referring a case into the PSD.” Source location Response from GMP
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 Roll out force-wide DSI awareness training through internal articles explaining DSI definitions and referral requirements.
Verbatim wording from the response “There will be a roll out of DSI awareness training both internally and across the Greater Manchester Police (GMP) in order to raise awareness and understanding. This will take the form of force intranet articles which will outline the definition of a DSI and when to refer into the PSD.” Source location Response from GMP
Open published response
2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure carers are informed of Mental Health Act admissions within 24 hours View source Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository View source Failure to provide mental health patients with access to an independent mental health advocate View source Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks View source Failure to determine when police are the appropriate agency for mental health-related enquiries View source Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Sean Heath · 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
Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carers are informed of Mental Health Act admissions within 24 hours
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate;
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository
Wider context from the report “The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide mental health patients with access to an independent mental health advocate
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate ;
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature , the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry;
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to determine when police are the appropriate agency for mental health-related enquiries
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry ;
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill ;
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists
Wider context from the report “That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care ; and
” 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 Finalise and sign the partnership agreement clarifying agency responsibilities for mental-health concerns and police responses.
Verbatim wording from the response “A partnership agreement has been drafted between GMP – GMMH – Pennine Care (not yet signed, expected by end of 2024) which clearly sets out each agency’s responsibility in relation to mental health concerns; i.e. mental health concerns that are of a real and immediate risk to life or risk of serious harm will continue to see a policing response. This agreement will clearly set out expectations within GM and drive a consistent approach.” Source location Response from GMP
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 Agree a forced-entry memorandum assigning Greater Manchester Fire and Rescue Service as the primary responder for specified medical-concern cases.
Verbatim wording from the response “Memorandum of Understanding
On 2nd April 2024, Greater Manchester agreed a forced entry Memorandum of Understanding which specifies that Greater Manchester Fire and Rescue Service are the primary responder to force entry on behalf of North West Ambulance Service in cases of a medical concern. This reflects common practice in other areas of the country.” Source location Response from GMP
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 RCRP through the assessment toolkit, THRIVE risk assessment, response grading and vulnerability assessment requirements.
Verbatim wording from the response “Right Care, Right Person (RCRP) had not been formally launched in GMP at the time of Michael’s death. RCRP is a national, Government approved, framework for assisting police with decision-making about when they should be involved in responding to reported incidents involving people with mental health needs. It was launched in Greater Manchester on 30th September 2024.” Source location Response from GMP
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 clinical mental-health advice, incident-call reviews and GP referrals through the Mental Health Tactical Advice Service.
Verbatim wording from the response “GMP’s Mental Health Co-Ordination Unit (MHCU) have confirmed that a 3.5 hours long Mental Health Awareness input has been delivered face to face to over 2500 officers during 2024 and this has included a sixty minute input from the Clinical Lead of the Mental Health Tactical Advice Service (MHTAS), based in the Force Contact Centre to include common presentations and risks. MHTAS support officers making decisions relating to mental health concerns and will also review any mental health related incident/call for service at the request of a FCCO supervisor. MHTAS forward a GP referral for every individual they review.” Source location Response from GMP
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance and introduce quality-assurance systems supporting RCRP decision-making and continuing professional development.
Verbatim wording from the response “• Training and development strategy and evaluation criteria defined” Source location Response from GMP
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory mental health awareness training to officers and relevant contact-centre staff.
Verbatim wording from the response “Mandatory Mental Health Awareness (GMP)
In GMP, this is delivered in accordance with the CoP Approved Professional Practice (APP) for policing duties. The introduction to this APP states: “All police decision making on the most appropriate course of action under any circumstances should be guided and structured using the national decision model (NDM). Decision making concerning health care matters should be made by clinically trained professionals and not police officers”. Although police officers and staff are not expected to be able to identify the specific symptoms of mental ill health or learning disabilities or attempt to diagnose illness, it is important that their training enables them to recognise indicators of mental health problems so that these can be taken into consideration. This recognition can occur at any point in their interaction with people.” Source location Response from GMP
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 Revisit mental-health training to reinforce RCRP deployment and police-involvement requirements.
Verbatim wording from the response “All mental health training is being revisited with the implementation of Right Care, Right Person (RCRP) in terms of reinforcing the policy on deployment and Police involvement at mental health incidents.” Source location Response from GMP
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 Monitor and review RCRP assessment decisions and adverse outcomes, reporting findings to senior command and partner governance.
Verbatim wording from the response “In respect of Greater Manchester, learning from other forces who had already implemented RCRP was that staff and officers may find it difficult to make the decision that the police will not be attending a call. This is because they may be concerned about the consequences of adverse outcomes or criticism of their decision making, when not attending. It is accepted that these are incredibly difficult decisions to make, especially in a pressurised environment and when complex legislation comes into play. The RCRP assessment tool is there to support staff to evidence their decision making and will continue to be subject to review and monitoring by GMP and its partners.” Source location Response from GMP
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide RCRP assessment and decision-making training through role-specific courses and an accredited e-learning package.
Verbatim wording from the response “Call handlers and Crime Recording and Resolution Officers (CRRO) will use the RCRP Assessment Toolkit and refer to GMP service standards and ask further questions in order to be satisfied as to the exact nature of the call and assess the requirement for police deployment. They are guided to recognise any identified risk and if necessary be ‘professionally curious’ to ensure understanding. GMP’s Incident Response Policy requires that, in order to ensure an appropriate response to the contact’s needs, incident priority is determined by a THRIVE risk assessment³, response grading in accordance with the THRIVE assessment and a consideration of the GMP Vulnerability Assessment Framework (VAF). The aim is to ensure that the appropriate police response for every call is initiated from the outset.” Source location Response from GMP
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 Police powers of entry do not extend to welfare concerns alone; they require a real risk to life or serious injury.
Verbatim wording from the response “Reference is made to the Police being the right agency to respond to mental health enquiries because of their powers of entry. GMP has never had a written policy document in respect of routinely attending ‘welfare checks’ because that ‘duty’ is not reflected in legislation. The police power of entry pursuant to Section 17 (1) (e) of the Police and Criminal Evidence Act 1984, is to “save life and limb”. The extent of this power was examined in the stated case of Syed v DPP (2010) and the court determined that a ‘concern for welfare’ is too low a threshold to force entry.” Source location Response from GMP
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 Greater Manchester Fire and Rescue Service is the primary responder for forced entry in medical-concern cases; police assist only if unavailable.
Verbatim wording from the response “Memorandum of Understanding
On 2nd April 2024, Greater Manchester agreed a forced entry Memorandum of Understanding which specifies that Greater Manchester Fire and Rescue Service are the primary responder to force entry on behalf of North West Ambulance Service in cases of a medical concern. This reflects common practice in other areas of the country.” Source location Response from GMP
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 Routine police attendance at welfare checks is not undertaken because legislation does not impose that duty.
Verbatim wording from the response “Reference is made to the Police being the right agency to respond to mental health enquiries because of their powers of entry. GMP has never had a written policy document in respect of routinely attending ‘welfare checks’ because that ‘duty’ is not reflected in legislation. The police power of entry pursuant to Section 17 (1) (e) of the Police and Criminal Evidence Act 1984, is to “save life and limb”. The extent of this power was examined in the stated case of Syed v DPP (2010) and the court determined that a ‘concern for welfare’ is too low a threshold to force entry.” Source location Response from GMP
Open published response
29 May 2024 Elizabeth Sarah Jayne McCann · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 19 Inadequate management structure and oversight in the health and wellbeing college View source Failure to comply with GDPR in the health and wellbeing college View source Inadequate safeguarding provisions in health and wellbeing colleges View source Insufficient probation staffing capacity View source High proportion of probation officers with limited service and experience View source Limited information-sharing protocols between probation and partner services View source Lack of professional curiosity by senior GMP officers View source Poor-quality GMP investigations and reports View source Insufficient staffing of sexual offender management units View source Poor-quality investigations failing to generate organisational learning View source Failure to provide adequate supervision and support to newly qualified probation staff View source Insufficient professional curiosity among staff dealing with high-risk offenders View source Ineffective information-sharing protocols in health and wellbeing colleges View source Sexual offender management caseloads exceeding safe levels View source Insufficiently clear and understood risk-management protocols in health and wellbeing colleges View source Failure to escalate investigation reports for senior consideration View source Referrals to health and wellbeing services without risk-management protocols View source Inadequate systems for managing risk in the health and wellbeing college View source Lack of an information-sharing protocol between the health and wellbeing college and probation View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Review and redistribute offender-manager caseloads to balance risk profiles, prioritising balanced workloads over geographical boundaries and repeating the exercise as demand and risk change.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Revise the Police Internal Management Review process, brief Detective Inspectors, reinforce senior leadership compliance and track review timeliness and quality.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Discuss case learning with Sex Offender Management Unit staff and incorporate it into initial offender-manager training and continuing professional development.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Increase the Specialist Offender Manager team to transfer administrative work from community offender managers and enable greater focus on active management, risk assessments and visits.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Implement the Operation Maidera recovery plan and invest force resources to reduce registered sex offender caseload ratios for offender managers.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Increase the Sex Offender Management Unit establishment by 18 full-time-equivalent staff, including additional offender managers, a criminal investigation team and a proactive intelligence function.
Stated plannedThe respondent said that this action was planned when they made their response on 31 May 2024. View source
Action
Strengthen Police Internal Management Reviews through independent quality assurance and improved connectivity with the Strategic Organisational Learning Board.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Introduce daily management meetings and senior-led silver reviews to identify learning, improve information sharing, revise risk plans and commission Police Internal Management Reviews where required.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source
Action
Refresh staff training to embed professional curiosity, information sharing, multi-agency challenge, risk assessment triggers and MAPPA learning, including refresher training for existing staff.
Stated completedThe respondent said that this action was complete when they made their response on 31 May 2024. View source See 6 more actions
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AI-generated summary
Elizabeth Sarah Jayne McCann · 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
Elizabeth Sarah Jayne McCann was raped and murdered on 25 August 2022 at the home address of her murderer. The report identifies failures in risk assessment, information sharing, safeguarding, and management of a high-risk offender by the Health and Wellbeing College, Probation, and Greater Manchester Police. It also identifies concerns about excessive caseloads, inadequate staffing, supervision, recording, and organisational learning.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate management structure and oversight in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight , lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to comply with GDPR in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate safeguarding provisions in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient probation staffing capacity
Wider context from the report “1. The inquest heard evidence that the probation staff were carrying significant caseloads . This was due to challenges in recruiting sufficient staff . The evidence was that there is still a national shortage of probation officers . Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation High proportion of probation officers with limited service and experience
Wider context from the report “1. The inquest heard evidence that the probation staff were carrying significant caseloads. This was due to challenges in recruiting sufficient staff. The evidence was that there is still a national shortage of probation officers. Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Limited information-sharing protocols between probation and partner services
Wider context from the report “4. Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited . Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be shared .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of professional curiosity by senior GMP officers
Wider context from the report “8. There was no evidence before the inquest of any professional curiosity by senior GMP officers as to the role of GMP and if lessons could be learnt . It was unclear as to why senior officers were unsighted .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Poor-quality GMP investigations and reports
Wider context from the report “7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report. The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing of sexual offender management units
Wider context from the report “5. The inquest was told that nationally a significant number of police forces were struggling to adequately staff their Sexual Offender Management Units . As a consequence, the level of supervision of sex offenders in the community was being risk managed posing a risk to communities.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Poor-quality investigations failing to generate organisational learning
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed . This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate supervision and support to newly qualified probation staff
Wider context from the report “2. The evidence before the inquest was that it was important that newly qualified probation staff were closely supervised and supported by their managers . Without that supervision performance issues identified by the trackers were not being tackled . Ensuring this had been and was challenging as the number of staff line managed by senior probation officers had been too high . This was being addressed but was only achievable if sufficient senior staff were retained.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional curiosity among staff dealing with high-risk offenders
Wider context from the report “9. It was accepted that there needed to be a level of professional curiosity by staff dealing with high-risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Ineffective information-sharing protocols in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Sexual offender management caseloads exceeding safe levels
Wider context from the report “6. In the case of Greater Manchester Police, the staffing issues had been known by senior managers for a number of years (many years before Covid) and a decision taken to risk mange far below the appropriate staffing numbers taken. The consequence was that the staff in the unit could not effectively manage their caseloads that were far in excess of the recommended level . The numbers in the unit were increasing but the caseloads were still high.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Insufficiently clear and understood risk-management protocols in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place . There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate investigation reports for senior consideration
Wider context from the report “7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report . The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Referrals to health and wellbeing services without risk-management protocols
Wider context from the report “3. Evidence before the inquest was that if probation referred clients under supervision to places such as the Health and Wellbeing College this would, if not implemented effectively pose a significant risk to vulnerable users of such institutions. If referrals were made without a protocol being in place that dealt with managing risk then the risk posed increased further.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate systems for managing risk in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of an information-sharing protocol between the health and wellbeing college and probation
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation , the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 Review and redistribute offender-manager caseloads to balance risk profiles, prioritising balanced workloads over geographical boundaries and repeating the exercise as demand and risk change.
Verbatim wording from the response “A review and redistribution of caseloads is now complete. This has been a beneficial process as it has re-balanced risk levels across teams i.e., all Offender Managers now carry a similar percentage profile of Very High and High Risk RSOs in their caseload, and balanced caseloads now take priority over tight geographical boundaries. This exercise will be repeated on a regular basis, including when vacancies arise, to ensure there is fluidity in moving resources around to respond to changing demand and risk.” Source location Response from GM 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 Revise the Police Internal Management Review process, brief Detective Inspectors, reinforce senior leadership compliance and track review timeliness and quality.
Verbatim wording from the response “Following leadership changes within the Public Protection Division the PIMR process has been fully revised by the new Head of SOMU to comply with APP. All Detective Inspectors have been briefed on their responsibilities in relation to timeliness and the quality of PIMRs and compliance with review has been reinforced with the senior leadership team and is tracked by the Head of Public Protection.” Source location Response from GM 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 Discuss case learning with Sex Offender Management Unit staff and incorporate it into initial offender-manager training and continuing professional development.
Verbatim wording from the response “Furthermore, the specifics of this case and the learning from it have been discussed with all SOMU staff and added to the initial training for Offender Managers and ongoing continuous professional development inputs.” Source location Response from GM 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 Increase the Specialist Offender Manager team to transfer administrative work from community offender managers and enable greater focus on active management, risk assessments and visits.
Verbatim wording from the response “Investment has also been made into increasing the Specialist Offender Manager team responsible for RSOs held on remand in prisons and hospitals. This will take away significant proportions of largely administrative workload meaning Offender Managers can focus on those who need more active management, risk assessments and visits in the community.” Source location Response from GM 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 Implement the Operation Maidera recovery plan and invest force resources to reduce registered sex offender caseload ratios for offender managers.
Verbatim wording from the response “In April 2023, following changes to the Chief Officer team this policy was reversed resulting in the formulation of a recovery plan, Operation Maidera. The Gold Strategy was set by Assistant Chief Constable ████████ who made a significant investment of force resources, reducing RSO to Offender Manager ratios from 1:85 to 1:56.” Source location Response from GM 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 Increase the Sex Offender Management Unit establishment by 18 full-time-equivalent staff, including additional offender managers, a criminal investigation team and a proactive intelligence function.
Verbatim wording from the response “However, as GMP’s sex offender register is forecasted to increase by 7-10% annually in line with national predictions, Chief Officers have taken the decision to further increase the establishment of the SOMU by 18 full time equivalent staff, representing an investment of c.£1m of additional resources. This will not only increase the number of Offender Managers from 76 to 80 to maintain effective ratios as the register grows but will also formally establish a dedicated criminal investigation team and a pro-active intelligence function to significantly enhance the support to Offender Managers with their retained workloads.” Source location Response from GM 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 Strengthen Police Internal Management Reviews through independent quality assurance and improved connectivity with the Strategic Organisational Learning Board.
Verbatim wording from the response “The PIMR process has also been further strengthened via independent quality assurance by the force Investigation and Safeguarding Review Team, which in turn provides better connectivity to the Strategic Organisational Learning Board.” Source location Response from GM 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 Introduce daily management meetings and senior-led silver reviews to identify learning, improve information sharing, revise risk plans and commission Police Internal Management Reviews where required.
Verbatim wording from the response “The new Head of SOMU has introduced a daily management meeting which tracks any further offences committed by RSOs in order to identify any learning opportunities, ensure effective information sharing and revise risk management plans. Where a serious further offence has been committed a senior officer (Chief Inspector or above) now chairs a silver review meeting and commissions PIMRs as required. Compliance with APP, including senior officer oversight, is then tracked via the branch’s monthly performance meeting, which is chaired by the Head of Public Protection.” Source location Response from GM 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 Refresh staff training to embed professional curiosity, information sharing, multi-agency challenge, risk assessment triggers and MAPPA learning, including refresher training for existing staff.
Verbatim wording from the response “The need for professional curiosity and the learning from this case have been further embedded into the completely refreshed training delivered to all new staff, along with portfolio completion. Refresher CPD training on PIMRs has been delivered to existing staff.” Source location Response from GM 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 A discretionary MAPPA Serious Case Review was not considered necessary because police and probation internal management reviews would provide the relevant findings.
Verbatim wording from the response “Due to ████████ being managed at MAPPA Level 1, the Deputy Chair of the MAPPA Strategic Management Board (Detective Superintendent) determined the case did not meet the criteria for a mandatory SCR. Consideration was given to commissioning a discretionary SCR, however, owing to tandem Police and Probation Internal Management Reviews (PIMRs) being commissioned it was determined that a discretionary SCR would not add additional value to the findings of the PIMR as outlined in national MAPPA guidance (paragraph 20.5).” Source location Response from GM 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 Health and Wellbeing College risk management, safeguarding and information-sharing matters are for the Department of Health and Social Care to address.
Verbatim wording from the response “This is a matter for the Department of Health and Social Care to reply on behalf of the Pennine Care NHS Foundation Trust.” Source location Response from GM Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National police staffing and community supervision of registered sex offenders are primarily matters for the Home Office to address.
Verbatim wording from the response “This is primarily a matter for reply by the Home Office on behalf of all police forces, however, it is worth noting that the provenance for the evidence presented at inquest is the Independent Review into the Police-led Management of Registered Sex Offenders in the Community, authored by Mick Creedon QPM which was published in 2022. In particular, paragraphs 26 to 28 outline the implications on policing of volume changes, the proliferation of the internet, increased societal and criminal justice awareness around sexual offending and the introduction of new offences.” Source location Response from GM 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 Probation staffing, supervision, referral risk management and information-sharing matters are primarily for the Ministry of Justice to address.
Verbatim wording from the response “These four matters are primarily for the Ministry of Justice to reply to on behalf of the Probation Service, however, to promote effective communication between agencies and improve awareness of any challenges, the Head of Public Protection at Greater Manchester Police and the Head of Public Protection at Greater Manchester Probation service commenced monthly meetings in 2023.” Source location Response from GM Police
Open published response
23 Apr 2024 Ashley Crews · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of a local policy for handcuff use when executing arrest warrants 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
Ashley Crews · 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
Ashley Crews died on 20 February 2024 from injuries sustained in a fall from height after police officers attended his ninth-floor flat to execute an arrest warrant. The principal concern was that there was no local policy governing the use of handcuffs when executing an arrest warrant.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a local policy for handcuff use when executing arrest warrants
Wider context from the report “1. There is no local policy for the use of handcuffs when executing an arrest warrant.
” Open source report
19 Feb 2024 Samuel Curless (Sam) · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to provide adequate classroom-based or on-the-job training on sudden death response View source Lack of institutional learning, reflection or training following reported-death call handling incidents View source Inadequate training of attending officers to preserve the life of a hanging casualty View source Failure to provide timely First Aid refresher training on Basic Life Support for hanging casualties View source See 1 more concern
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
Samuel Curless (Sam) · 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
Samuel Curless died in hospital on 24 October 2022 after being found suspended from a ligature and receiving delayed life-support intervention. The concerns included failures to call an ambulance promptly, delays in checking vital signs and removing the ligature, and possible inadequacies in police training and refresher training for responding to hanging casualties.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate classroom-based or on-the-job training on sudden death response
Wider context from the report “3. I heard evidence from Detective Superintendent ████████ that both attending officers were part of a cohort of at least 650 officers within GMP (and a larger cohort nationally) who received their initial police training entirely online . I am concerned that both officers’ training on Sudden Death (and the training of others) was delivered as one of over 15 online modules on a given day and that at the time of the inquest, they had not received any classroom based or on the job training . I am concerned that they are not the only officers within GMP who have received this level/method of training input and therefore there is a risk that other officers on duty have inadequate training on this issue .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of institutional learning, reflection or training following reported-death call handling incidents
Wider context from the report “1. That in respect of GMP Call Handler’s being required to call an ambulance to attend the scene, even where it is reported that someone is “dead” there has been no institutional learning following this incident . I asked ████████ if there had been any learning, reflection or training since this incident. He said that there hadn’t on this issue .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of attending officers to preserve the life of a hanging casualty
Wider context from the report “2. That the training delivered to the first two attending officers did not adequately prepare them for responding to a scene where someone is found hanging in a way which is consistent with their priority to preserve life of a hanging casualty .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely First Aid refresher training on Basic Life Support for hanging casualties
Wider context from the report “4. There was evidence given to me by Detective Superintendent ████████ that there is an unknown number of GMP officers who are not meeting the expectation of receiving First Aid refreser training within 12 months , which since May 2022 has included training on how to resuscitate a hanging casualty. I am therefore concerned that there remains a cohort of officers who have not had the post May 2022 training that includes how to provide Basic Life Support to this kind of casualty until the arrival of an ambulance .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include ligature-removal training in Module 1 and 2 initial and refresher first-aid courses.
Verbatim wording from the response “GMP uses the FALP as the core syllabus for its first aid training but in addition to the core syllabus supplementary elements or scenarios are incorporated into the training based upon operational risks and/or learning derived from incidents that have occurred in Greater Manchester or nationally. From April 2022 one of the supplementary elements GMP introduced into the Module 1 and 2 initial and refresher training courses was ligature removal. This training will continue in place moving forward.” Source location Response from Greater Manchester 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 Present Dealing with Death learning at the monthly Tutor Constable Forum and quality-assure delivery through periodic classroom observations.
Verbatim wording from the response “To support the implementation of this learning, dealing with death has been presented at GMP’s monthly Tutor Constable Forum to support those who tutor students on District whilst responding to incidents. Finally, our training Sergeants undertake periodical in-class observations to quality assure both the training content and that the delivery is in line with best practice.” Source location Response from Greater Manchester 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 Raise inquest learning at the Tactical Organisational Learning Board to share learning and reinforce preservation-of-life messages.
Verbatim wording from the response “This case has also been raised at the Tactical Organisational Learning Board (TOLB). The TOLB is attended by representatives from across GMP with a view to sharing the learning and reinforcing the key messages around preservation of life.” Source location Response from Greater Manchester 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 Audit similar incidents to assess call-handler compliance with ambulance-contact procedures.
Verbatim wording from the response “As a result of the issues identified in this case GMP commissioned an audit of 33 similar incidents. The purpose of the audit was to understand whether call handlers were following the correct processes and taking the required action when dealing with these types of incidents or whether the issue identified in this case was a symptom of a broader issue across the department. The result of the audit identified one case where the call handler hadn’t contacted the Northwest Ambulance Service (NWAS) or asked a colleague to assist in making a call to NWAS. The call handler in question has received individual feedback on the issue. The other 32 calls examined each resulted in call handlers either asking colleagues to call NWAS or the call handler calling NWAS themselves when the initial call had concluded.” Source location Response from Greater Manchester 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 Reinforce call-handler requirements to call an ambulance through force-wide email and team briefing-site messages.
Verbatim wording from the response “While the result of the audit undertaken following the inquest doesn’t indicate a broader issue across the branch, the Force Contact, Crime and Operations Branch will further reinforce the requirements on call handlers to call an ambulance when faced with a scenario such as that which presented in the case of Mr Curless. This will be achieved by way of an email being sent to all call handlers and by including an item on each call handling team’s briefing site.” Source location Response from Greater Manchester 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 Strengthen first-aid training governance through monitoring, regular attendance-data sharing, monthly governance oversight and compliance accountability.
Verbatim wording from the response “GMP has also improved the governance around first aid training to ensure that officers remain up to date with their training requirements. The numbers are monitored by People & Development Branch Learning Services Team and reported to the Clinical Governance Panel. Attendance data is shared with GMP Districts and Branches on a regular basis, including individual officer details and course booking dates. In addition, First Aid Training is a standing item at GMP’s monthly Major Incident Response Governance Board (MIRGB) meeting which is chaired by the Deputy Chief Constable (DCC). At the monthly meeting the DCC holds Districts and Branches to account in respect of their compliance with the first aid training requirements. First Aid training will remain a focus of the MIRGB moving forward.” Source location Response from Greater Manchester 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 Disseminate Dealing with Death learning across the force through intranet, bulletins, organisational-learning meetings and local learning leads.
Verbatim wording from the response “To further reinforce police officer and staff understanding of the Dealing with Death Policy and the expected actions of those at the scene I have tasked the Organisational Learning Hub to disseminate learning across the Force, using a variety of established communications channels, which will include the following:” Source location Response from Greater Manchester 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 Review student-officer training on the Dealing with Death Procedure.
Verbatim wording from the response “GMP’s Police Education Qualifications Framework (PEQF) Learning Support Team has reviewed the training provided to student officers in relation to the Dealing with Death Procedure.” Source location Response from Greater Manchester 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 The audit did not indicate a broader call-handling issue across the branch, although one individual failure was identified and feedback provided.
Verbatim wording from the response “As a result of the issues identified in this case GMP commissioned an audit of 33 similar incidents. The purpose of the audit was to understand whether call handlers were following the correct processes and taking the required action when dealing with these types of incidents or whether the issue identified in this case was a symptom of a broader issue across the department. The result of the audit identified one case where the call handler hadn’t contacted the Northwest Ambulance Service (NWAS) or asked a colleague to assist in making a call to NWAS. The call handler in question has received individual feedback on the issue. The other 32 calls examined each resulted in call handlers either asking colleagues to call NWAS or the call handler calling NWAS themselves when the initial call had concluded.” Source location Response from Greater Manchester 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 There is nothing to suggest that online training created a broader force-wide issue, although learning from the inquest was disseminated.
Verbatim wording from the response “While the officers’ actions in this case have given rise to questions in relation to the adequacy of the training delivered via online methods there is nothing to suggest that this is a broader Force-wide issue. However, in line with normal practice, the learning arising from the inquest has been raised at the TOLB to ensure that learning is shared, and key messages are disseminated across the force.” Source location Response from Greater Manchester Police
Open published response
8 Dec 2023 Claire Nicole Briggs · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses View source Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service 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
Claire Nicole Briggs · 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
Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses .
” 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 Brief FCCO staff on the agreed Joint Operating Procedure before its implementation, including its purpose, relevance and required use.
Verbatim wording from the response “Once the JOP has been agreed for launch in Greater Manchester, and before the implementation stage, there will be a process within the FCCO to ensure that all staff are made aware of the document and that they understand its purpose and aims, its relevance to GMP, and how it should be used by them. This message will be distributed by the senior leadership team within the FCCO to all supervisors within the branch for further cascading to all staff members.” Source location Response from GMP
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 Continue working with Northwest partners to agree and implement a Joint Operating Procedure aligned with Right Care, Right Person.
Verbatim wording from the response “Further progress has been made to finalise, agree, and implement the JOP since the inquest touching upon the death of Claire Briggs concluded. Version 1.0 of the JOP went live on 12 October 2023 with four of the five North West police forces, namely Cheshire Constabulary, Cumbria Constabulary, Lancashire Constabulary and Merseyside Police.” Source location Response from GMP
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Greater Manchester partnership agreement defining police and ambulance roles and expectations for physical-health Concern for Welfare incidents.
Verbatim wording from the response “GMP is currently working closely with NWAS in respect of the RCRP project. Work is ongoing in relation to the response to be provided by police and ambulance resources to incidents of a physical health concern. To ensure an appropriate response is provided by both blue light services, a partnership agreement specific to Greater Manchester is currently in development. This partnership agreement will formally outline each organisation’s roles and expectations at incidents of Concern for Welfare (‘CFW’) where the primary or sole nature of the incident relates to a physical health concern, and will ensure that GMP’s response to matters of physical health concern, in conjunction with NWAS, is aligned to the principles of RCRP and the regional JOP and that organisations meet their legal obligations under ECHR legislation.” Source location Response from GMP
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 Maintain agreed police–ambulance escalation processes for obtaining information, escalating delays, cancelling ambulances and resolving operational concerns.
Verbatim wording from the response “In November 2022, communication was distributed throughout the FCCO outlining the escalation process between GMP and NWAS. This message was reinforced in June 2023 via internal messaging and is recirculated, as necessary, to ensure consistent compliance. What was initially introduced as an interim measure in 2022 is now considered “business as usual” and, through regular liaison with NWAS, is regarded as appropriate practice for both organisations. These escalation processes are outlined below:” Source location Response from GMP
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing GMP-NWAS escalation processes are considered appropriate and sufficient while work continues to implement the Joint Operating Procedure.
Verbatim wording from the response “In November 2022, communication was distributed throughout the FCCO outlining the escalation process between GMP and NWAS. This message was reinforced in June 2023 via internal messaging and is recirculated, as necessary, to ensure consistent compliance. What was initially introduced as an interim measure in 2022 is now considered “business as usual” and, through regular liaison with NWAS, is regarded as appropriate practice for both organisations. These escalation processes are outlined below:” Source location Response from GMP
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 Ambiguous lead-agency wording prevents agreement to the Joint Operating Procedure until responsibilities and deployment expectations are clarified.
Verbatim wording from the response “Other partner organisations, including GMP, have yet to agree to the JOP. GMP considers the wording contained within the section on ‘Identifying the Lead Agency’ creates ambiguity and could cause confusion. The current wording is not clear as to which organisation would be the lead agency in certain circumstances, particularly in instances when there may be scene safety concerns, and what such a designation would mean in practical terms. This section of the JOP also suggests that two organisations could be considered the lead agency at the same incident for different purposes (“the lead for the policing purpose would be the Police, NWAS would remain the Lead Agency for the health matter”).” Source location Response from GMP
Open published response
15 May 2023 Rebecca Alice Fisher · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of understanding of how to apply golden hour guidance and its required timescales View source Poor-quality documentation and information sharing between officers and supervision View source Lack of monitoring of effective Aide Memoire use and implementation View source Unclear effectiveness of missing-person training in supporting high-risk assessments View source Lack of understanding that short periods away from mental health units do not preclude high-risk status when a patient fails to return View source Poor understanding of the high-risk status of voluntary mental health ward patients who fail to return View source Lack of understanding of how to access mobile phone data such as cell site data View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Review whether further supervisor training on missing-person investigations, risk assessment, Golden Hour principles, communications data, and costs should be provided and determine its form.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023. View source
Action
Include Golden Hour guidance, cell-siting costs, family updates, and mental-health learning in operational briefings, then verify completion across districts.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023. View source
Action
Disseminate guidance that mobile-phone tracing and cell-site enquiries should be considered for medium- and high-risk missing persons, with rationale recorded when not pursued.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Create and distribute a communications-data guide covering Cycomms, mobile-phone enquiries, and access for medium- and high-risk missing persons.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Re-circulate the Missing from Home Policy 2022 and Aide Memoires through existing continuous professional development channels.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023. View source
Action
Develop and disseminate a seven-minute briefing on mental-health terminology, associated risk, Golden Hour principles, communications data, costs, and Aide Memoire use.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023. View source
Action
Determine and implement a method to measure staff understanding and the briefing’s effectiveness.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023. View source
Action
Monitor completion of the actions identified in the Regulation 28 response through the Strategic Learning Board.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023. View source
Action
Circulate an interim memorandum to District Commanders for dissemination on mental-health terminology, risk, Golden Hour tasks, and mobile-phone data access.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Review the Missing from Home Policy wording on medium-risk Golden Hour timescales and consider clarification.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 May 2023. View source See 7 more actions
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AI-generated summary
Rebecca Alice Fisher · 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
Rebecca Alice Fisher was found deceased by her family on 15 April 2022 after being reported missing from a mental health ward following unescorted leave. A post-mortem found a fatal dose of drugs, including pregabalin. The principal concern was that Greater Manchester Police did not assess her as a high-risk missing person, resulting in delays to mobile telephone enquiries and specialised input; concerns also included gaps in staff understanding, documentation, information sharing, and the implementation of training and guidance.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of how to apply golden hour guidance and its required timescales
Wider context from the report “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included:
1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return;
2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return;
3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and
4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit.
The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them.
Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Poor-quality documentation and information sharing between officers and supervision
Wider context from the report “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included:
1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return;
2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return;
3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and
4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit .
The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them.
Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring of effective Aide Memoire use and implementation
Wider context from the report “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included:
1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return;
2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return;
3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and
4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit.
The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them .
Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Unclear effectiveness of missing-person training in supporting high-risk assessments
Wider context from the report “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included:
1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return;
2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return;
3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and
4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit.
The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them.
Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding that short periods away from mental health units do not preclude high-risk status when a patient fails to return
Wider context from the report “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included:
1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return;
2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return ;
3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and
4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit.
The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them.
Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Poor understanding of the high-risk status of voluntary mental health ward patients who fail to return
Wider context from the report “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included:
1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return ;
2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return;
3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and
4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit.
The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them.
Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of how to access mobile phone data such as cell site data
Wider context from the report “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included:
1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return;
2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return;
3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site ; and
4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit.
The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them.
Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review whether further supervisor training on missing-person investigations, risk assessment, Golden Hour principles, communications data, and costs should be provided and determine its form.
Verbatim wording from the response “To further address this issue across the organisation, the professional standards branch referred the matter to GMP’s training school, as it was recognised that supervisors who have been substantive for a long period of time may not have had any recent training or continuous professional development (CPD) with regards to investigating missing persons, Golden Hour tasks and risk assessments.” Source location Response from Greater Manchester 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 Include Golden Hour guidance, cell-siting costs, family updates, and mental-health learning in operational briefings, then verify completion across districts.
Verbatim wording from the response “The MPSU are also sending a notification to all operational Superintendents across the Force to state that the Golden Hour principles guidance is included within operational briefings alongside information regarding the cost of cell siting. The briefings will also include a reminder to operational Sergeants to keep the next of kin and family of the missing person updated, as per the concern raised in point four and include details of this case as an example of the importance of correct risk assessment and understanding of mental health terminology.” Source location Response from Greater Manchester 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 Disseminate guidance that mobile-phone tracing and cell-site enquiries should be considered for medium- and high-risk missing persons, with rationale recorded when not pursued.
Verbatim wording from the response “Specifically on the Stockport District, the Senior Leadership Team have already circulated a notification to all response supervisors to ensure that they are aware that cell citing, and mobile phone enquiries should be considered for medium risk missing persons, as well as high risk missing persons if relevant. If supervisors are not going to pursue an avenue of investigation, they should have a proper rationale to explain why it is not a proportionate enquiry and this should be recorded on the MFH report. This was also sent out to all District Commanders by the MPSU.” Source location Response from Greater Manchester 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 Create and distribute a communications-data guide covering Cycomms, mobile-phone enquiries, and access for medium- and high-risk missing persons.
Verbatim wording from the response “Cycomms, cell siting, and mobile phone enquiries should be considered for medium and high-risk missing persons. A notification is also being sent out on the Organisation Learning Hub Top three bulletin June 2023 edition. Item one of the bulletin is regarding analysing communications data, and this covers the use of Cycomms and Mobile phone enquiries. A comprehensive guide has been created to address the learning around a lack of knowledge of this area. The bulletin will specifically detail that all communications data can be sought for medium and high risk missing, and a guide will direct officers on how to do this. The Organisation Learning Hub Top three bulletin goes to every member of staff and officer within GMP.” Source location Response from Greater Manchester 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 Re-circulate the Missing from Home Policy 2022 and Aide Memoires through existing continuous professional development channels.
Verbatim wording from the response “GMP are in the process of re-circulating the MFH Policy 2022 and Aide Memoires. These have already been shared through the CPD sessions that have been provided by the MPSU.” Source location Response from Greater Manchester 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 and disseminate a seven-minute briefing on mental-health terminology, associated risk, Golden Hour principles, communications data, costs, and Aide Memoire use.
Verbatim wording from the response “GMP want to ensure that its staff and officers understand the terminology used by mental health services for voluntary mental health patients and for those who have unescorted leave. To address this, I have asked the Organisational Learning Development Group (OLDG) to produce a seven-minute briefing. A seven-minute briefing is widely used across organisations as research suggests that seven minutes is an ideal time span to concentrate and learning is more memorable, as it is simple and not clouded by other issues and pressures. It is delivered in a flow chart form, in person by supervisors. This format also allows the recipients to ask questions following the briefing to confirm their understanding.” Source location Response from Greater Manchester 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 Determine and implement a method to measure staff understanding and the briefing’s effectiveness.
Verbatim wording from the response “I want to ensure that officers and staff understand the new information being presented to them within the briefing and that they can effectively apply this in their everyday role when investigating a missing person. To achieve this, the OLDG are currently exploring the most effective way to monitor their understanding. There are several options available which are being considered.” Source location Response from Greater Manchester 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 Monitor completion of the actions identified in the Regulation 28 response through the Strategic Learning Board.
Verbatim wording from the response “GMP is committed to constantly improving its response to Missing People. It is vital we learn lessons in such tragic cases. The strategic lead for safeguarding will put out immediate instructions to all district leads regarding the learning in this case and highlight the Golden Hour tasks that must be completed by all staff.” Source location Response from Greater Manchester 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 Circulate an interim memorandum to District Commanders for dissemination on mental-health terminology, risk, Golden Hour tasks, and mobile-phone data access.
Verbatim wording from the response “Whilst this briefing package is being designed by the OLDG, GMP have, in the short term, circulated a memorandum to all District Commanders explaining the issues highlighted from this inquest and an explanation of the terminology used in mental health settings and previous misconception of risk. The notification also includes the information detailed within the response to point three below regarding golden hour tasks and a lack of understanding around the cost of accessing mobile phone data. The District Commanders will then disseminate this to their divisional supervisors and colleagues.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Missing from Home Policy wording on medium-risk Golden Hour timescales and consider clarification.
Verbatim wording from the response “I have consulted with the MPSU, and they are going to consider this terminology and will be explaining it further to aid the officers understanding of what time frame this refers to.” Source location Response from Greater Manchester 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 Cost to GMP must never justify not using mobile phone data for medium- or high-risk missing persons.
Verbatim wording from the response “The cost to GMP to access mobile phone data and using cell siting should never be a reason as to why it is not used. The inquest highlighted a lack of understanding from some officers about this being a reason as to why GMP may not use cell siting. This is incorrect. Operational Superintendents will be informed of this via the notification from the Missing Person Safeguarding Unit and they will be asked to disseminate this information to their respective supervisors and teams across all districts to ensure that officers and staff are not considering this as a factor in their decision making. This would also ensure it is not cited as a reason to members of the public as to why GMP would not utilise mobile phone data.” Source location Response from Greater Manchester Police
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maxine Betty Davison and 4 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester 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 Greater Manchester 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 Greater Manchester 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 Provide the Firearms Licensing Manager and Detective Sergeant with additional firearms-licensing decision-maker training.
Verbatim wording from the response “The current Firearms Licensing Manager has completed training, procured through an external partner Mowbray Partners, this training is titled “Firearms Licensing – Decision Makers”. The Firearms Licensing Manager and Detective Sergeant will additionally be attending a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. Furthermore, the Firearms and Explosives Licensing Unit (FELU) have all reviewed the new 2023 Home Office Statutory Guidance and 2023 College of Policing Approved Professional Practice. The Detective Sergeant will complete the training “Firearms Licensing” with external training partner Mowbray Partners. They will additionally complete the training “Firearms Licensing – Decision Makers” by the end of April 2023.” Source location Response from Greater Manchester 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 Permit only trained personnel to make firearms-licensing decisions under the updated statutory guidance.
Verbatim wording from the response “To reassure you further, only those trained personnel above are permitted to make decisions in line with the updated statutory guidance.” Source location Response from Greater Manchester 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 Attend a two-day continuous professional development event on firearms licensing for the Firearms Licensing Manager and Detective Sergeant.
Verbatim wording from the response “The current Firearms Licensing Manager has completed training, procured through an external partner Mowbray Partners, this training is titled “Firearms Licensing – Decision Makers”. The Firearms Licensing Manager and Detective Sergeant will additionally be attending a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. Furthermore, the Firearms and Explosives Licensing Unit (FELU) have all reviewed the new 2023 Home Office Statutory Guidance and 2023 College of Policing Approved Professional Practice. The Detective Sergeant will complete the training “Firearms Licensing” with external training partner Mowbray Partners. They will additionally complete the training “Firearms Licensing – Decision Makers” by the end of April 2023.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver firearms-licensing training to all Firearms Enquiry Officers through an external training partner.
Verbatim wording from the response “All Firearms Enquiry Officers (FEO) have completed training with an external partner, Mowbray Partners titled “Firearms Licensing”. FEO’s are the frontline of the Firearms Licensing Unit and make all initial decisions based on the current legislation, statutory and non-statutory guidance and Approved Professional Practice. The training by Mowbray addresses these fundamental issues.” Source location Response from Greater Manchester 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 Only personnel who have completed relevant firearms licensing training are permitted to make decisions under the updated statutory guidance.
Verbatim wording from the response “The current Firearms Licensing Manager has completed training, procured through an external partner Mowbray Partners, this training is titled “Firearms Licensing – Decision Makers”. The Firearms Licensing Manager and Detective Sergeant will additionally be attending a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. Furthermore, the Firearms and Explosives Licensing Unit (FELU) have all reviewed the new 2023 Home Office Statutory Guidance and 2023 College of Policing Approved Professional Practice. The Detective Sergeant will complete the training “Firearms Licensing” with external training partner Mowbray Partners. They will additionally complete the training “Firearms Licensing – Decision Makers” by the end of April 2023.” Source location Response from Greater Manchester Police
Open published response
21 Dec 2022 Angeline Marie Phillips · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure of police officers to attend incidents within policy timescales View source Lack of policy controls preventing transfer of incident attendance responsibility to third-party agencies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Angeline Marie Phillips · 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
Angeline Marie Phillips died at her home on 30 January 2021 after police and ambulance services were contacted following concerns about her welfare and previous suicide attempts. The principal concern was that police did not attend within the required response time and responsibility was passed to a third party, with concerns that the policy could allow similar delays and risks to 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure of police officers to attend incidents within policy timescales
Wider context from the report “1) During the Inquest evidence was heard that: -
a) The Greater Manchester Police Incident Response Policy governed the grading of an Incident in relation to priority and the response time to an Incident.
b) In relation to the grading of the Incident relating to the Deceased, which was reported at 18.09 hours on the 29th of January 2021, the incident was graded correctly as a Grade 2 Priority Response with a response time of 1 hour but a police officer only attended more than 8 hours after the report of the Incident with the Incident having been referred to NWAS without a police officer attending.
c) The Greater Manchester Police Incident Response Policy makes no reference of an option to refer the Incident to a 3rd Party, such as NWAS, but there is no specific reference in the Policy that the attendance must be by a police officer and that the responsibility to attend must not be passed to a 3rd party or any other agency.
d) I am concerned that unless the Greater Manchester Police Incident Response Policy is reviewed police officers will not attend Incidents within the timescales referred to in the Policy and there will be an opportunity to pass the responsibility to 3rd party agencies, which may lead to a risk that future deaths could occur unless action is taken.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of policy controls preventing transfer of incident attendance responsibility to third-party agencies
Wider context from the report “1) During the Inquest evidence was heard that: -
a) The Greater Manchester Police Incident Response Policy governed the grading of an Incident in relation to priority and the response time to an Incident.
b) In relation to the grading of the Incident relating to the Deceased, which was reported at 18.09 hours on the 29th of January 2021, the incident was graded correctly as a Grade 2 Priority Response with a response time of 1 hour but a police officer only attended more than 8 hours after the report of the Incident with the Incident having been referred to NWAS without a police officer attending.
c) The Greater Manchester Police Incident Response Policy makes no reference of an option to refer the Incident to a 3rd Party, such as NWAS, but there is no specific reference in the Policy that the attendance must be by a police officer and that the responsibility to attend must not be passed to a 3rd party or any other agency .
d) I am concerned that unless the Greater Manchester Police Incident Response Policy is reviewed police officers will not attend Incidents within the timescales referred to in the Policy and there will be an opportunity to pass the responsibility to 3rd party agencies , which may lead to a risk that future deaths could occur unless action is taken.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Incident Response Policy to address incident attendance and agency responsibility concerns.
Verbatim wording from the response ““A review of the Greater Manchester Police Incident Response Policy to consider specific reference in the policy that the attendance must be by a police officer and that the responsibility to attend must not be passed to a 3rd party or another agency”” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide and maintain IRP and THRIVE training for FCC officers and staff through initial instruction, audits, briefings, and new-joiner programmes.
Verbatim wording from the response “Force-wide training on the IRP was provided to GMP officers and staff during its initial implementation, to ensure all of those who are required to follow the policy are clear about their responsibilities so that the appropriate grade is applied to each incident.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the current Incident Response Policy incorporating THRIVE risk assessment for incident grading and response decisions.
Verbatim wording from the response “As a result, on 1st February 2022, GMP implemented the current IRP which incorporates the nationally recognised risk assessment approach to incident grading known as THRIVE (Threat, Harm, Risk, Investigation, Vulnerable and Engagement). The THRIVE process has been implemented since the tragic death of Ms Phillips and represents a significant change from the procedures that were in place at that time.” Source location Response from Greater Manchester 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 Where another agency is better placed to respond, responsibility may transfer to that agency or proceed through a joint response.
Verbatim wording from the response “GMP undertakes a THRIVE risk assessment for all incidents. The THRIVE assessment process informs the appropriate response. GMP will deploy to an incident where it has been identified that a police response is required. However, there are incidents where GMP is not the most appropriate agency to respond to, or lead on the response to, an incident. Where the THRIVE risk assessment identifies that the response may be better provided by another agency, GMP liaises with that agency to determine how the response will be progressed. This can lead to the other agency taking over the incident or, if appropriate, a joint response may follow. THRIVE risk assessments and the liaison and decision-making in relation to deployments are documented on police systems.” Source location Response from Greater Manchester 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 A further review requiring police attendance at all incidents is unnecessary because the current IRP provides robust risk assessment and appropriate agency attendance.
Verbatim wording from the response “GMP has reflected on the concerns raised within the Regulation 28 report and considers that a review of the IRP to direct police attendance at all incidents would not provide the best level of service to the public. The IRP has been reviewed in the period following Ms Phillips’ death. The system that is in place now provides a robust risk assessment process which results in attendance by the most appropriate agency.” Source location Response from Greater Manchester Police
Open published response
12 Aug 2022 Brandon James Pryde and David Ernest Faulkner · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to verify transfer of Command and Control between police supervisors View source Failure of GMP Force Duty Supervisors to recognise their authority to perform Command and Control on the motorway network View source Failure of the Command and Control protocol to operate effectively throughout pursuits View source Failure to communicate clearly whether Command and Control has been taken View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brandon James Pryde and David Ernest Faulkner · 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
Brandon Pryde and David Faulkner died at the scene after a stolen BMW, driven by Brandon Pryde, travelled against the flow of traffic on the M60 and collided with David Faulkner’s vehicle at high speed. Concerns arose that the protocol for transferring command and control of police pursuits between GMP and NWMPG did not operate in practice, resulting in no effective command and control during the pursuit.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to verify transfer of Command and Control between police supervisors
Wider context from the report “I received evidence in both inquests that there is a Protocol between GMP and NWMPG (which is based at the Cheshire Constabulary) dated June 2015 in accordance with the College of Police Authorised Professional Practice for Police Pursuits, for the Command and Control of pursuits. That Protocol is intended to provide a mechanism for Command and Control to be undertaken and transferred between GMP and NWMPG when pursuits move between the normal road network and the motorway network, so that Command and Control is maintained throughout. The Supervising Officer in the control room has the authority to direct that a pursuit be discontinued if they assess that it is right to do so, having regard to all of the circumstances which are known to them, which may include information not immediately available to the police officer(s) involved in the pursuit.
Although I found that the absence of any control-room Command and Control had not contributed to either death in this case, the following matters gave rise to concern, having regard to the inherent risk of pursuits, which are likely to move between ordinary road and motorway networks in the Greater Manchester area;
(1) The GMP Force Duty Supervisor assumed that the NWMPG Supervisor had taken Command and Control when they had not done so ;
(2) The NWMPG Supervisor did not communicate whether they had taken Command and Control clearly;
(3) The GMP Force Duty Supervisor did not consider that they had any authority to perform Command and Control of the pursuit once it had entered the motorway network; and
(4) The Protocol did not operate in practice so that there was no effective Command and Control at any point during the pursuit.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure of GMP Force Duty Supervisors to recognise their authority to perform Command and Control on the motorway network
Wider context from the report “I received evidence in both inquests that there is a Protocol between GMP and NWMPG (which is based at the Cheshire Constabulary) dated June 2015 in accordance with the College of Police Authorised Professional Practice for Police Pursuits, for the Command and Control of pursuits. That Protocol is intended to provide a mechanism for Command and Control to be undertaken and transferred between GMP and NWMPG when pursuits move between the normal road network and the motorway network, so that Command and Control is maintained throughout. The Supervising Officer in the control room has the authority to direct that a pursuit be discontinued if they assess that it is right to do so, having regard to all of the circumstances which are known to them, which may include information not immediately available to the police officer(s) involved in the pursuit.
Although I found that the absence of any control-room Command and Control had not contributed to either death in this case, the following matters gave rise to concern, having regard to the inherent risk of pursuits, which are likely to move between ordinary road and motorway networks in the Greater Manchester area;
(1) The GMP Force Duty Supervisor assumed that the NWMPG Supervisor had taken Command and Control when they had not done so;
(2) The NWMPG Supervisor did not communicate whether they had taken Command and Control clearly;
(3) The GMP Force Duty Supervisor did not consider that they had any authority to perform Command and Control of the pursuit once it had entered the motorway network ; and
(4) The Protocol did not operate in practice so that there was no effective Command and Control at any point during the pursuit.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the Command and Control protocol to operate effectively throughout pursuits
Wider context from the report “I received evidence in both inquests that there is a Protocol between GMP and NWMPG (which is based at the Cheshire Constabulary) dated June 2015 in accordance with the College of Police Authorised Professional Practice for Police Pursuits, for the Command and Control of pursuits. That Protocol is intended to provide a mechanism for Command and Control to be undertaken and transferred between GMP and NWMPG when pursuits move between the normal road network and the motorway network, so that Command and Control is maintained throughout. The Supervising Officer in the control room has the authority to direct that a pursuit be discontinued if they assess that it is right to do so, having regard to all of the circumstances which are known to them, which may include information not immediately available to the police officer(s) involved in the pursuit.
Although I found that the absence of any control-room Command and Control had not contributed to either death in this case, the following matters gave rise to concern, having regard to the inherent risk of pursuits, which are likely to move between ordinary road and motorway networks in the Greater Manchester area;
(1) The GMP Force Duty Supervisor assumed that the NWMPG Supervisor had taken Command and Control when they had not done so;
(2) The NWMPG Supervisor did not communicate whether they had taken Command and Control clearly;
(3) The GMP Force Duty Supervisor did not consider that they had any authority to perform Command and Control of the pursuit once it had entered the motorway network; and
(4) The Protocol did not operate in practice so that there was no effective Command and Control at any point during the pursuit .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate clearly whether Command and Control has been taken
Wider context from the report “I received evidence in both inquests that there is a Protocol between GMP and NWMPG (which is based at the Cheshire Constabulary) dated June 2015 in accordance with the College of Police Authorised Professional Practice for Police Pursuits, for the Command and Control of pursuits. That Protocol is intended to provide a mechanism for Command and Control to be undertaken and transferred between GMP and NWMPG when pursuits move between the normal road network and the motorway network, so that Command and Control is maintained throughout. The Supervising Officer in the control room has the authority to direct that a pursuit be discontinued if they assess that it is right to do so, having regard to all of the circumstances which are known to them, which may include information not immediately available to the police officer(s) involved in the pursuit.
Although I found that the absence of any control-room Command and Control had not contributed to either death in this case, the following matters gave rise to concern, having regard to the inherent risk of pursuits, which are likely to move between ordinary road and motorway networks in the Greater Manchester area;
(1) The GMP Force Duty Supervisor assumed that the NWMPG Supervisor had taken Command and Control when they had not done so;
(2) The NWMPG Supervisor did not communicate whether they had taken Command and Control clearly ;
(3) The GMP Force Duty Supervisor did not consider that they had any authority to perform Command and Control of the pursuit once it had entered the motorway network; and
(4) The Protocol did not operate in practice so that there was no effective Command and Control at any point during the pursuit.
” 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 Design accreditation, retraining and continuing professional development for personnel involved in pursuit management.
Verbatim wording from the response “• Accreditation, re-training and Continuous Professional Development (CPD) are in design and final details will be confirmed through the working group.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the managing pursuits protocol to clarify command and control responsibilities for pursuits, including cross-border pursuits.
Verbatim wording from the response “As a result of this tragic incident GMP and Cheshire Police (on behalf of the NWMPG) have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all GMP control room staff involved in the management of police pursuits.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the devised one-day initial pursuit course to supervisors and operators managing initial-phase pursuits.
Verbatim wording from the response “GMP have committed to further training for all those who may be involved in the command and control of police pursuits. It was identified that whilst drivers had received significant investment over recent years this had not been the case for officers and staff engaged on the command-and-control element of pursuit management.” Source location Response from Greater Manchester 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 Circulate the revised managing pursuits protocol to all GMP control room staff involved in managing police pursuits.
Verbatim wording from the response “As a result of this tragic incident GMP and Cheshire Police (on behalf of the NWMPG) have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all GMP control room staff involved in the management of police pursuits.” Source location Response from Greater Manchester 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 Complete design and deliver a four-day tactical-phase commanders’ course to Force Duty Officers and Assistant Force Duty Officers.
Verbatim wording from the response “• A 4-day tactical phase commanders’ course is in the final stages of design by the Driver Training Unit and Command Training (Specialist Operations). This will be delivered to the 8 Force Duty Officers (FDO) and 7 Assistant Force Duty Officers (AFDO) within GMP. This will enable a policy change with the authorisation of pursuits moving from the Force Duty Supervisor to the FDO/AFDO role. A training schedule is being drawn up and delivery anticipated within the next 6 months.” Source location Response from Greater Manchester 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 Establish and operate a Pursuit Management Working Group to review and redevelop training for pursuit dispatch operators and commanders.
Verbatim wording from the response “GMP have committed to further training for all those who may be involved in the command and control of police pursuits. It was identified that whilst drivers had received significant investment over recent years this had not been the case for officers and staff engaged on the command-and-control element of pursuit management.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and clarify the managing pursuits protocol to remove ambiguity about command and control.
Verbatim wording from the response “As a result of this tragic incident GMP and Cheshire Police (on behalf of the NWMPG) have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all GMP control room staff involved in the management of police pursuits.” Source location Response from Greater Manchester 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 Complete design and deliver a four-day tactical-phase commanders’ course for GMP force duty and assistant force duty officers.
Verbatim wording from the response “• A 4-day tactical phase commanders’ course is in the final stages of design by the Driver Training Unit and Command Training (Specialist Operations). This will be delivered to the 8 Force Duty Officers (FDO) and 7 Assistant Force Duty Officers (AFDO) within GMP. This will enable a policy change with the authorisation of pursuits moving from the Force Duty Supervisor to the FDO/AFDO role. A training schedule is being drawn up and delivery anticipated within the next 6 months.” Source location Response from Greater Manchester 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 and deliver a one-day initial pursuit course for supervisors and operators managing initial-phase pursuits.
Verbatim wording from the response “• A 1-day initial pursuit course has been devised by the Driver Training Unit. This will be delivered to Supervisors and operators involved in the management of initial phase pursuit and will align with training provided to Police drivers who have completed the Initial Pursuit course (IPP). A training schedule is being drawn up now for delivery anticipated to be completed within the next 6-9 months due to high numbers requiring training.” Source location Response from Greater Manchester 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 Design accreditation, retraining and continuing professional development for pursuit management staff.
Verbatim wording from the response “• Accreditation, re-training and Continuous Professional Development (CPD) are in design and final details will be confirmed through the working group.” Source location Response from Greater Manchester 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 Circulate the revised managing pursuits protocol to GMP control-room staff involved in managing police pursuits.
Verbatim wording from the response “As a result of this tragic incident GMP and Cheshire Police (on behalf of the NWMPG) have revised the managing pursuits protocol and produced a clearer document which removes the previous ambiguity on the issue of Command and Control. This document will be circulated to all GMP control room staff involved in the management of police pursuits.” Source location Response from Greater Manchester 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 Design and deliver training for Team 3 dispatch operators managing specialist resources.
Verbatim wording from the response “• Training for Team 3 dispatch operators – those managing specialist resources – is being designed. Delivery of this is planned to take place within the next 6-9 months.” Source location Response from Greater Manchester 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 The omission to establish formal command and control did not contribute to the deaths, and failures to take command are not common.
Verbatim wording from the response “GMP agree with the coroners findings that this omission did not contribute to the outcome and observe that, having reviewed similar pursuits, that failure to take command and control is not a common issue.” Source location Response from Greater Manchester 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 The absence of formal pursuit command and control did not contribute to the outcome, and such failures are not common.
Verbatim wording from the response “GMP agree with the coroners findings that this omission did not contribute to the outcome and observe that, having reviewed similar pursuits, that failure to take command and control is not a common issue.” Source location Response from Greater Manchester Police
Open published response
13 Apr 2022 Hannah Grace Beardshaw · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to make method of entry kits readily available to trained users View source Delays in escalating incidents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hannah Grace Beardshaw · 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
Hannah Grace Beardshaw was found hanging at her home on 20 April 2021 after contacting a friend, leaving a note of intent, and researching methods of taking her own life. The concerns identified were delays in escalating and responding to the incident, limited availability of method-of-entry kits, and document-management issues within Greater Manchester Police.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to make method of entry kits readily available to trained users
Wider context from the report “The IOPC highlighted a number of learning recommendations on how GMP handled the incident which to date have not been implemented:
• A delay in escalating the incident, resulting in almost a 4 hour delay to respond to the incident.
• A failure to make method of entry kits more readily available to those trained in their use .
• Improvement in document management
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Delays in escalating incidents
Wider context from the report “The IOPC highlighted a number of learning recommendations on how GMP handled the incident which to date have not been implemented:
• A delay in escalating the incident , resulting in almost a 4 hour delay to respond to the incident.
• A failure to make method of entry kits more readily available to those trained in their use.
• Improvement in document management
” 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 Measure attendance times daily and escalate aged high- and medium-risk incidents through district command meetings.
Verbatim wording from the response “Stringent measurement of attendance times are in place with daily data produced for both FCC and district colleagues. Any incidents within the grade 1 and 2 queues that are over 24 hours old are flagged to District Silver Commanders by the FCC Supervisor responsible for that district at the district morning pascetter meetings, via email or Teams message if insufficient supervisors are on duty within the FCC to have a dedicated supervisor per district. These in the main are grade 2 incidents where efforts to speak with the caller/victim have failed due to their availability and there is deemed no threat to life to warrant forced entry under S.17 PACE.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement risk-based incident grading with mandatory supervisory escalation for unallocated high- and medium-risk incidents.
Verbatim wording from the response “GMP revisited it’s Graded Response Policy (GRP) and made changes implementing a new GRP on the 1 February 2022. Incidents are now graded following a risk assessment via the THRIVE (Threat, Harm, Risk, Investigation, Vulnerability, Engagement) framework and assessed on the information received as opposed to incident type or crime category. Incidents graded 1 are high risk incidents that require a response time within 15 minutes, incidents graded 2 are medium risk incidents that require a response time within 1 hour these are referred to as ‘go now’ incidents, incidents graded C are low risk incidents that can be responded to outside of 1 hour and are referred to as ‘go later’. C incidents are often dealt with by appointment at a time suitable to the victim in line with their needs.” Source location Response from Greater Manchester Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train Force Contact Centre staff on THRIVE, the revised grading policy and escalation requirements.
Verbatim wording from the response “All staff within the Force Contact Centre (FCC) have received training on THRIVE and the new GRP incorporating escalation. At shift changeover times if an incident has not been resourced within the target time frame for arrival, staff within the FCC will escalate to district supervision.” Source location Response from Greater Manchester 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 Districts and branches determine how Method of Entry equipment is distributed after officers complete training.
Verbatim wording from the response “Each GMP District or Branch has a Method of Entry (MOE) SPOC (Single Point of Contact) who is responsible for the maintenance, storage and ordering of MOE kit and equipment. Most districts have one central storage area of all MOE kit and some designated vehicles also have MOE equipment stored within them.” Source location Response from Greater Manchester Police
Open published response
7 Dec 2021 ANTHONY JAMES FITZPATRICK · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to use objective and consistent criteria for risk assessment View source Lack of a plan to address the known risk-assessment problem View source Failure to ensure that recorded risk grades have a clear shared meaning 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 FITZPATRICK · 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 Fitzpatrick had a long history of mental health problems and attended local A&E departments on three occasions in the year before his death, with two attendances followed by custody. The report identified inconsistent and inaccurate assessment of risk by healthcare professionals, with unclear risk grades recorded in the electronic custody record and no plan to address the problem despite it being known.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to use objective and consistent criteria for risk assessment
Wider context from the report “(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████ , meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record.
(2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials .
(3) Despite being aware of this problem, there was no plan in place to address it.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a plan to address the known risk-assessment problem
Wider context from the report “(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record.
(2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials.
(3) Despite being aware of this problem, there was no plan in place to address it .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that recorded risk grades have a clear shared meaning
Wider context from the report “(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record .
(2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials.
(3) Despite being aware of this problem, there was no plan in place to address it.
” Open source report
27 May 2021 Zeyna Partington · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Failure to implement the national system for automatic notification of medium ACT marker ANPR hits across all forces View source Lack of GMP Officers’ knowledge and understanding of ACT marker levels and their implications for missing from home investigations View source Inadequate resourcing and allocation of officers to grade 2 calls within an hour View source Delays in placing ACT markers on vehicles during missing from home investigations View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Zeyna Partington · 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
Zeyna Partington was reported missing on 8 August 2019 and was believed to be at risk of suicide. Her vehicle was detected by ANPR in Derbyshire, but GMP did not become aware of this until 10 August; she was then found deceased in a nearby field after taking an overdose of prescribed medication. The substantive concerns included inadequate understanding of ACT marker levels, delays or gaps in national ANPR notification, and the absence of a fully implemented national system across all forces.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the national system for automatic notification of medium ACT marker ANPR hits across all forces
Wider context from the report “3. Despite a new national system being available this has still not been implemented across all forces meaning a force is not automatically notified if a vehicle with a medium ACT marker hits an ANPR camera nationally .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of GMP Officers’ knowledge and understanding of ACT marker levels and their implications for missing from home investigations
Wider context from the report “1. There is a lack of knowledge and understanding by GMP Officers as to the different level of ACT markers and the implications the varying levels may have on investigations particularly missing from home investigations .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate resourcing and allocation of officers to grade 2 calls within an hour
Wider context from the report “2. If the policy is not to place an ACT marker on a vehicle until the missing from home report is completed then this can mean a delay of several hours, particularly as the court heard it is often difficult to resource and allocate officers to grade 2 calls within an hour . In this case if the radio operator had not acted outside of policy then the hits on the 8th August in both Rochdale and Derbyshire would not have been known at all.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Delays in placing ACT markers on vehicles during missing from home investigations
Wider context from the report “2. If the policy is not to place an ACT marker on a vehicle until the missing from home report is completed then this can mean a delay of several hours , particularly as the court heard it is often difficult to resource and allocate officers to grade 2 calls within an hour. In this case if the radio operator had not acted outside of policy then the hits on the 8th August in both Rochdale and Derbyshire would not have been known at all.
” 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 and deliver the technical and organisational changes required to connect GMP to the National ANPR Service.
Verbatim wording from the response “In relation to a longer term solution, the new National ANPR Service has now been deployed to the majority of the 43 UK forces with the exception of GMP and one other. We are working proactively to make improvements that will enable GMP to connect to the National ANPR Service in the near future. These changes include moving from Windows 7 to Windows 10 and undertaking comprehensive IT capability checks. We have a project team dedicated to this and they are in consultation with the Home Office in order to make progress as soon as possible. Determining an exact timescale for connectivity to the NAS involves a number of factors, several of which are outside of our control.” Source location 2021-0181-Response-from-Greater-Manchester-Police_Published
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 and update the GMP Missing From Home policy to specify ACT marker use, timely activation responses, and supervisory checks.
Verbatim wording from the response “In addition to the above, internally we are in the process of reviewing and updating the GMP Missing From Home policy. Following your observations and recommendations and the changes to the national guidance, this will be updated to include more specific information on the use of ACT markers. This will include the expedient application of the correct level of marker in circumstances such as this case has highlighted. It will also include guidance on the use and review of markers and highlight expectations on the need for a timely response to activations.” Source location 2021-0181-Response-from-Greater-Manchester-Police_Published
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 Communicate key changes and learning from relevant policies and guidance to operational officers and staff through a comprehensive communication plan.
Verbatim wording from the response “Although the content of the College of Policing guidance document on the use of markers and the Missing From Home policy are known to specific practitioners, the evidence presented at the Inquest into Zeyna Partington's death indicates there is a need to ensure increased awareness of the content across operational staff; specifically uniform frontline officers and staff from the operational communications branch.” Source location 2021-0181-Response-from-Greater-Manchester-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The exact timescale for connectivity to the National ANPR Service cannot be determined because several influencing factors are outside the force’s control.
Verbatim wording from the response “In relation to a longer term solution, the new National ANPR Service has now been deployed to the majority of the 43 UK forces with the exception of GMP and one other. We are working proactively to make improvements that will enable GMP to connect to the National ANPR Service in the near future. These changes include moving from Windows 7 to Windows 10 and undertaking comprehensive IT capability checks. We have a project team dedicated to this and they are in consultation with the Home Office in order to make progress as soon as possible. Determining an exact timescale for connectivity to the NAS involves a number of factors, several of which are outside of our control.” Source location 2021-0181-Response-from-Greater-Manchester-Police_Published
Open published response
30 Apr 2021 Jade Rayner · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to record a reported sexual allegation as a crime View source Unavailability of alcohol misuse support programmes able to meet complex trauma-related needs View source Failure to offer support set out in the Victims Code View source Failure to investigate a reported sexual allegation View source Lack of a clear multi-agency strategy for supporting complex cases View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jade Rayner · 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
Jade Nicole Rayner was a vulnerable adult with complex mental and physical health needs, including seizures, alcohol use and fluctuating capacity. She was found unresponsive at home on 30 March 2020 and had a fatal level of prescribed antidepressants and alcohol in her system. Concerns included the absence of an effective multi-agency strategy, failures in recording and investigating a reported sexual offence, and alcohol misuse support that could not meet the needs of a complex case involving underlying trauma.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record a reported sexual allegation as a crime
Wider context from the report “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code.
2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol.
3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of alcohol misuse support programmes able to meet complex trauma-related needs
Wider context from the report “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code.
2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol.
3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to offer support set out in the Victims Code
Wider context from the report “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code.
2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol.
3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate a reported sexual allegation
Wider context from the report “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code.
2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol.
3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear multi-agency strategy for supporting complex cases
Wider context from the report “1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in a professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process. The inquest was told that GMP did not record it as a crime. The officer giving evidence to the inquest initially gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. It was then indicated that it should have been recorded as a crime. The inquest was told it was not investigated and was written off following a strategy meeting. Jade Rayner was not as a consequence offered by GMP the support set out within the Victims Code.
2. Her case was complex, and the evidence was that there was not a clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol.
3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce streamlined single inboxes for consistent routing of enquiries and concerns.
Verbatim wording from the response “Initial work completed also includes a dip-sample of how partner e-mails received by the District Safeguarding Team have been managed, and a streamlined process with single 'in-boxes' has been introduced to ensure consistency, and allow all to easily route enquiries or concerns.” Source location 2021-0128-Response-from-Greater-Manchester-Police-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a central Crime Recording and Resolution Unit to support accurate recording of relevant incidents.
Verbatim wording from the response “In relation to National Crime Recording Standards, the timescale of 72 hours to record a crime was removed on 31 April 2015. In order to train officers in this area a variety of training methods have been implemented, and since the HMICFRS Victim Services Assessment in November 2020, GMP have introduced a central Crime Recording and Resolution Unit which will help ensure crimes are recorded for all relevant incidents.” Source location 2021-0128-Response-from-Greater-Manchester-Police-Redacted
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 district vulnerability-email management and implement arrangements to identify and record crime, assess victim risk, mitigate it, and record actions.
Verbatim wording from the response “In relation to Ms Jade Rayner's case, officers did consider recording a crime following the email from social services on the 8 October but it was only after the joint visit, five days later that the offences of Misconduct in Public Office was considered. Additional work has been completed by the Public Protection Governance Unit, who have reviewed the management of district vulnerability e-mail accounts in order to; Identify and address gaps in systems and processes for identifying and recording all reports of crime, and put in place arrangements to make sure that in all investigations the risk to the victims has been appropriately assessed, risk mitigated and actions recorded.” Source location 2021-0128-Response-from-Greater-Manchester-Police-Redacted
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 training methods for officers on National Crime Recording Standards.
Verbatim wording from the response “In relation to National Crime Recording Standards, the timescale of 72 hours to record a crime was removed on 31 April 2015. In order to train officers in this area a variety of training methods have been implemented, and since the HMICFRS Victim Services Assessment in November 2020, GMP have introduced a central Crime Recording and Resolution Unit which will help ensure crimes are recorded for all relevant incidents.” Source location 2021-0128-Response-from-Greater-Manchester-Police-Redacted
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 officers with feedback on crime-recording understanding and knowledge.
Verbatim wording from the response “Sergeant ████████ has been given feedback in relation to his understanding and knowledge of crime recording.” Source location 2021-0128-Response-from-Greater-Manchester-Police-Redacted
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 Alcohol misuse support for complex trauma-related cases was considered best addressed by the Greater Manchester Health and Social Care Partnership.
Verbatim wording from the response “3. The evidence was that the existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver.” Source location 2021-0128-Response-from-Greater-Manchester-Police-Redacted
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 Force Crime Registrar review concluded that no recordable crime had been committed.
Verbatim wording from the response “Following investigation it has now been established that officers from the Criminal Investigation Department at Stockport visited Jade Rayner on 14 October 2019 and considered whether any offences had been committed. The Force Crime Registrar has also reviewed the matter and concluded no recordable crime has been committed.” Source location 2021-0128-Response-from-Greater-Manchester-Police-Redacted
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 Victim Support referral requires consent, and no referral was required because she had capacity to decide whether to engage.
Verbatim wording from the response “Furthermore in relation to Jade's victim support, referral to the Victim Support referral service is based in consent, and given that she had capacity to make her own decisions she would not have been referred in the absence of consent to engage with the service.” Source location 2021-0128-Response-from-Greater-Manchester-Police-Redacted
Open published response
11 Feb 2021 Robert Hardy · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to provide and signpost appropriate victim support to vulnerable victims View source Failure to record an assault with a weapon as a crime in the crime recording system View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert Hardy · 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 Stephen Hardy was found at home on 6 August 2020 suspended from a ligature; the inquest concluded that his death was suicide. The principal concern was that an assault involving a weapon was not recorded as a crime promptly, affecting the provision of and signposting to appropriate victim support despite his recognised vulnerabilities.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide and signpost appropriate victim support to vulnerable victims
Wider context from the report “The evidence before the inquest was that GMP had not recorded the assault with a weapon as a crime within the crime recording system. It was accepted that this should have happened. The concern arises in relation to the impact this then had on the provision of and signposting of him to appropriate victim support given his recognised and known vulnerabilities .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record an assault with a weapon as a crime in the crime recording system
Wider context from the report “The evidence before the inquest was that GMP had not recorded the assault with a weapon as a crime within the crime recording system . It was accepted that this should have happened . The concern arises in relation to the impact this then had on the provision of and signposting of him to appropriate victim support given his recognised and known vulnerabilities.
” 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 Deliver a Force-wide training programme to improve compliance with National Crime Recording Standards.
Verbatim wording from the response “Whilst the CRRU is being established, GMP has taken steps to improve performance in the short term. This has included a significant training programme for all officers and a new role for Incident Progression Teams (IPTs) across the Force which are reviewing and ensuring that Grade 1-3 incidents are NCRS compliant. This work is being quality assured by dip sample via the Crime Standards Board which reports to the Deputy Chief Constable.” Source location 2021-0039-Response-from-Greater-Manchester-Police-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Making a Difference System to enable staff to offer Victim Services by text message and email for victim self-referral.
Verbatim wording from the response “GMP is in the process of implementing the "Making a Difference System," which is a computer system which will give staff the opportunity to make a pre-approved offer of Victim Services via text message and email to victims. This would be a sign-post only and would require the victim to 'self-refer,' into the available services. This system should be implemented by May 2021.” Source location 2021-0039-Response-from-Greater-Manchester-Police-Redacted
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 Establish the central Crime Recording and Resolution Unit to record relevant crimes centrally and complete phased implementation across the Force.
Verbatim wording from the response “The HMICFRS Victim Services Assessment of November 2020 identified organisational under-recording of crime and its findings are driving major improvements into our processes specifically around the crime recording and ensuring that the minimum standards set within the National Crime Recording Standards (NCRS) are met. Pivotal to this improvement is the establishment of a central Crime Recording and Resolution Unit (CRRU), which will help ensure crimes are submitted for all relevant incidents.” Source location 2021-0039-Response-from-Greater-Manchester-Police-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Incident Progression Team review of Grade 1–3 incidents for National Crime Recording Standards compliance, with Crime Standards Board dip-sample quality assurance.
Verbatim wording from the response “Whilst the CRRU is being established, GMP has taken steps to improve performance in the short term. This has included a significant training programme for all officers and a new role for Incident Progression Teams (IPTs) across the Force which are reviewing and ensuring that Grade 1-3 incidents are NCRS compliant. This work is being quality assured by dip sample via the Crime Standards Board which reports to the Deputy Chief Constable.” Source location 2021-0039-Response-from-Greater-Manchester-Police-Redacted
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 with Victim Support the point at which victim-support offers and referrals are made, aiming to move them to the earliest possible opportunity.
Verbatim wording from the response “In relation to victim support, GMP works in partnership with the Victim Support service, commissioned by the GMCA to provide victim support services. This service is designed on a "consent-based," model, which is currently offered and referred, at the point of officer attendance.” Source location 2021-0039-Response-from-Greater-Manchester-Police-Redacted
Open published response
18 Nov 2020 Alfie Gildea · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 22 Limited police recognition and use of Claire's Law in domestic abuse cases View source Unqualified staff making key MARAT decisions View source Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators View source Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators View source Poor information sharing and joint risk recognition across statutory agencies View source Limited police training and capability to identify coercive and controlling behaviour View source Insufficient health visitor capacity for safeguarding and interagency work View source Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible View source Reduced specialist support and oversight for low and medium risk domestic abuse cases View source Failure to share complete relevant information between police and CPS View source Failure of CPS decision makers to follow guidance and document prosecution assessments View source Limited health visitor understanding of coercive and controlling behaviour View source Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs View source Failure to share perpetrator risk information with alleged victims View source Failure to place domestic abuse suspects on protective bail conditions during further investigation View source Failure to provide safe opportunities for domestic abuse disclosure View source Failure to pursue further enquiries supporting victimless domestic abuse prosecutions View source Failure to routinely document police and CPS case discussions View source Failure to use the MARAC framework when appropriate View source Limited police training in domestic abuse risk evaluation and scoring View source Insufficient resourcing of the MARAT frontline service View source Failure to conduct required health visiting conversations face to face View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 20
Action
Conduct district safeguarding-team deep-dive reviews and circulate domestic abuse, child-protection and adults-at-risk triage expectations.
Stated completedThe respondent said that this action was complete when they made their response on 24 December 2020. View source
Action
Revise the Domestic Violence Disclosure Scheme policy so safeguarding teams consider Clare’s Law on every domestic abuse incident and Detective Inspectors authorise disclosure wording.
Stated completedThe respondent said that this action was complete when they made their response on 24 December 2020. View source
Action
Review vulnerability training and design, establish and test a new force-wide vulnerability training offer.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 December 2020. View source
Action
Obtain authority to appoint the recruited Domestic Abuse Coordinator to promote a consistent force-wide MARAC approach.
Stated plannedThe respondent said that this action was planned when they made their response on 24 December 2020. View source
Action
Share guidance with safeguarding officers and staff on correctly applying the serial domestic abuse perpetrator marker.
Stated plannedThe respondent said that this action was planned when they made their response on 24 December 2020. View source
Action
Improve iOPS information-marker functionality and availability for high-risk and serial victims and perpetrators.
Stated plannedThe respondent said that this action was planned when they made their response on 24 December 2020. View source
Action
Recruit dedicated DVPO officers and operate a process for prompt victim contact, support, district follow-up and compliance checks.
Stated completedThe respondent said that this action was complete when they made their response on 24 December 2020. View source
Action
Establish a specific safeguarding-team triage training course incorporating information-sharing guidance.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 December 2020. View source
Action
Introduce an iOPS marker recording Clare’s Law applications and whether a disclosure was made.
Stated plannedThe respondent said that this action was planned when they made their response on 24 December 2020. View source
Action
Attend CPS evidence-led prosecution training and develop comparable training for the wider GMP workforce.
Stated plannedThe respondent said that this action was planned when they made their response on 24 December 2020. View source
Action
Invite GMP domestic abuse investigators to CPS training so aligned evidence-led prosecution training can be delivered across GMP.
Stated plannedThe respondent said that this action was planned when they made their response on 24 December 2020. View source
Action
Revise the domestic abuse policy to define and govern application of the serial domestic abuse perpetrator marker.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 December 2020. View source
Action
Implement the revised force-wide DVPN/DVPO policy and training package, including inspector review, documented refusal rationales and visit timescales.
Stated completedThe respondent said that this action was complete when they made their response on 24 December 2020. View source
Action
Establish a safeguarding course for officers and staff who evaluate risk and provide formal training on identifying risk factors.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 December 2020. View source
Action
Deliver rolling virtual continuing professional development covering domestic abuse, coercive control, stalking, risk assessment, DASH, strangulation and related safeguarding topics.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 December 2020. View source
Action
Explore automation of domestic abuse information markers and improve staff understanding of when and how markers should be applied.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 December 2020. View source
Action
Review bail and released-under-investigation practice and discuss results with the Public Protection Governance Unit to ensure force-wide compliance.
Stated in progressThe respondent said that this action was in progress when they made their response on 24 December 2020. View source
Action
Provide clearer domestic abuse risk-grading guidance and disseminate it through continuous professional development and safeguarding training.
Stated completedThe respondent said that this action was complete when they made their response on 24 December 2020. View source
Action
Develop accompanying training material on the revised Domestic Violence Disclosure Scheme policy and process.
Stated plannedThe respondent said that this action was planned when they made their response on 24 December 2020. View source
Action
Use the revised domestic abuse policy to define responsibilities for considering evidence-led prosecutions.
Stated completedThe respondent said that this action was complete when they made their response on 24 December 2020. View source See 17 more actions
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AI-generated summary
Alfie Gildea · 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
Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Limited police recognition and use of Claire's Law in domestic abuse cases
Wider context from the report “7. Recognition of when and how Claire's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Unqualified staff making key MARAT decisions
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions . Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators
Wider context from the report “2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different . It was unclear why that was the case. However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators
Wider context from the report “4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Poor information sharing and joint risk recognition across statutory agencies
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor . As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator . Opportunities to use the MARAC framework were not taken.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Limited police training and capability to identify coercive and controlling behaviour
Wider context from the report “5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour . Understanding of how coercive and controlling behaviour in a relationship could be identified was limited .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient health visitor capacity for safeguarding and interagency work
Wider context from the report “14. The inquest was told that Health Visitor numbers were reducing due to national funding arrangements . As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other agencies .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible
Wider context from the report “3. It is unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMPs systems . Officers giving evidence did not understand how such information could be accessed or recorded .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Reduced specialist support and oversight for low and medium risk domestic abuse cases
Wider context from the report “9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to share complete relevant information between police and CPS
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed . The file that was submitted omitted key information available to GMP that would have been important to the decision maker . The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure of CPS decision makers to follow guidance and document prosecution assessments
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim . The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Limited health visitor understanding of coercive and controlling behaviour
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself . Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs
Wider context from the report “11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed . There was no evidence of a clear and effective system of notification on the Trafford Division of GMP .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to share perpetrator risk information with alleged victims
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to place domestic abuse suspects on protective bail conditions during further investigation
Wider context from the report “1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required . Instead they were placed under investigation.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safe opportunities for domestic abuse disclosure
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to pursue further enquiries supporting victimless domestic abuse prosecutions
Wider context from the report “8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely document police and CPS case discussions
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to use the MARAC framework when appropriate
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Limited police training in domestic abuse risk evaluation and scoring
Wider context from the report “6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient resourcing of the MARAT frontline service
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced . This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required health visiting conversations face to face
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face . The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” 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 Conduct district safeguarding-team deep-dive reviews and circulate domestic abuse, child-protection and adults-at-risk triage expectations.
Verbatim wording from the response “GMP's Public Protection Governance Unit has conducted a deep-dive review into the standards used in the triage process of six district safeguarding teams, including information sharing between agencies. The purpose of the review was to understand the methodology and information considered as part of the triage decision making process and how this was recorded. This review identified good practice and areas for development moving forward. Triage expectations for domestic abuse, child protection, and adults at risk have been circulated to districts to set out the standards expected during triage. Moving forward, the Public Protection Governance Unit is working with the People and Development Branch to establish a specific triage training course which will include guidance on information sharing.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Domestic Violence Disclosure Scheme policy so safeguarding teams consider Clare’s Law on every domestic abuse incident and Detective Inspectors authorise disclosure wording.
Verbatim wording from the response “The Domestic Violence Disclosure Scheme (DVDS) policy has recently been submitted to GMP’s Policy and Strategy team for rework. The revised policy has made a number of enhancements to ensure that Clare's Law is considered by safeguarding teams on every domestic abuse incident they receive. The revised policy has also re-instated that a Detective Inspector should review and authorise the form of words that is to be disclosed to the victim.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 vulnerability training and design, establish and test a new force-wide vulnerability training offer.
Verbatim wording from the response “DCI ████████ from the Public Protection Governance Unit has been seconded to the People and Development Branch to review all GMP vulnerability training in the first instance. Following initial scoping, she will design, establish, and test a new vulnerability training offer for the force.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 Obtain authority to appoint the recruited Domestic Abuse Coordinator to promote a consistent force-wide MARAC approach.
Verbatim wording from the response “MARACs are set up on each of the districts with a local case management team employed by GMP providing the administration for the meetings. A Domestic Abuse Coordinator has been recruited and is currently awaiting authority to be appointed. The new appointee will take responsibility for ensuring a consistent approach to MARAC is taken across the force.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 guidance with safeguarding officers and staff on correctly applying the serial domestic abuse perpetrator marker.
Verbatim wording from the response “The GMP domestic abuse policy is currently being revised and will shortly be sent out for consultation. It will provide clear definitions on the application and use of the serial domestic abuse perpetrator marker. Guidance will be shared with police officers and police staff based in safeguarding units around the correct application of this information marker on a person’s record.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 Improve iOPS information-marker functionality and availability for high-risk and serial victims and perpetrators.
Verbatim wording from the response “Information markers can be added in iOPS in a very similar manner. At present, there are some enhancements planned for Spring/Summer 2021 which will further improve the information markers available in iOPS, however both high risk and serial victims and perpetrators can now be added by all users. These information markers are presented/visible as per the example below:” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit dedicated DVPO officers and operate a process for prompt victim contact, support, district follow-up and compliance checks.
Verbatim wording from the response “Since the death of Alfie, GMP has recruited two police staff to permanently and solely perform the role of DVPO officers. This has enabled a new process whereby the team now has extra flexibility to contact the victim as soon as the DVPO has been granted and offer additional support. If this contact fails, then the new process outlines the clear responsibilities for districts to make contact with the victim and conduct compliance checks within specified timeframes.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 specific safeguarding-team triage training course incorporating information-sharing guidance.
Verbatim wording from the response “GMP's Public Protection Governance Unit has conducted a deep-dive review into the standards used in the triage process of six district safeguarding teams, including information sharing between agencies. The purpose of the review was to understand the methodology and information considered as part of the triage decision making process and how this was recorded. This review identified good practice and areas for development moving forward. Triage expectations for domestic abuse, child protection, and adults at risk have been circulated to districts to set out the standards expected during triage. Moving forward, the Public Protection Governance Unit is working with the People and Development Branch to establish a specific triage training course which will include guidance on information sharing.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an iOPS marker recording Clare’s Law applications and whether a disclosure was made.
Verbatim wording from the response “In Spring/Summer 2021, there will be a specific DVDS marker available in iOPS which will be applied to a person's record to reflect that they have made an application under Clare's Law. The information marker will denote whether a disclosure was made or not and where further information about the disclosure can be located. This will also make it far more visible to all officers that concerns have been raised by either an individual, a third party, or by GMP.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 Attend CPS evidence-led prosecution training and develop comparable training for the wider GMP workforce.
Verbatim wording from the response “GMP recognise that this area needs further development and are currently in discussions with the CPS who are delivering training to prosecutors on this topic. It is intended that GMP will attend this training with a view to delivering something similar to the wider GMP workforce. By having a joint training event, this will ensure that the CPS and police are aligned in the delivery and expectations of evidence-led prosecutions.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 Invite GMP domestic abuse investigators to CPS training so aligned evidence-led prosecution training can be delivered across GMP.
Verbatim wording from the response “Analysis and Strategy training, focusing on the importance of case-building domestic abuse cases from the very start to ensure that it could proceed without the victim. GMP has confirmed with Deputy Chief Crown Prosecutor ████████ that a number of GMP officers involved in domestic investigations will be invited to attend this training so that similar training can be delivered across GMP.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the domestic abuse policy to define and govern application of the serial domestic abuse perpetrator marker.
Verbatim wording from the response “The GMP domestic abuse policy is currently being revised and will shortly be sent out for consultation. It will provide clear definitions on the application and use of the serial domestic abuse perpetrator marker. Guidance will be shared with police officers and police staff based in safeguarding units around the correct application of this information marker on a person’s record.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the revised force-wide DVPN/DVPO policy and training package, including inspector review, documented refusal rationales and visit timescales.
Verbatim wording from the response “A revised DVPN/DVPO policy has been signed-off and launched alongside an accompanying training package to reflect the changes to the process. The following changes to the DVPN/DVPO process have now been implemented force wide:” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 Establish a safeguarding course for officers and staff who evaluate risk and provide formal training on identifying risk factors.
Verbatim wording from the response “This Unit is also working with the People and Development Branch to support a newly designed course which is aimed at officers and staff in the organisation who work in a safeguarding role where they need to evaluate risk and provide formal training to support those staff in understanding risk factors and identifying them at the earliest opportunity.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver rolling virtual continuing professional development covering domestic abuse, coercive control, stalking, risk assessment, DASH, strangulation and related safeguarding topics.
Verbatim wording from the response “Between 2015 and 2020, 2773 PCs completed the Safeguarding for Constables course at Sedgley Park which incorporated coercive and controlling behaviours within a relationship. Further CPD was due to be delivered in 2020 but, owing to the COVID-19 pandemic, this has not been achieved. Virtual CPD is taking place from early 2021 on a rolling programme and will cover: domestic abuse definition and typology; the ‘murdered by my boyfriend’ film; coercion and control; stalking and harassment; identifying, assessing, and managing risk; DASH reports; non-fatal strangulation; voice of the child; and incident closing codes.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 Explore automation of domestic abuse information markers and improve staff understanding of when and how markers should be applied.
Verbatim wording from the response “The definitions for repeat and serial victims and perpetrators have been revised since Alfie’s death to simplify them. Where automation of markers can occur, this is being explored, however clear direction on the application and use of the serial domestic abuse perpetrator marker will be shared with police officers and staff when the domestic abuse policy is agreed. The Public Protection Governance Unit is currently working with iOPS and Capita to ensure visibility and understanding of when information markers should be applied and how to do this.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 bail and released-under-investigation practice and discuss results with the Public Protection Governance Unit to ensure force-wide compliance.
Verbatim wording from the response “In May 2019, the NPCC issued updated operational guidance regarding the use of bail to all Forces. This operational guidance followed a review undertaken by Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) which identified that the use of bail across the UK had decreased since the new Bail Act changes were implemented. The operational guidance supported the use of bail in domestic abuse cases and other safeguarding investigations. GMP’s Criminal Justice and Custody branch have recently conducted a review of bail and released under investigation (RUI), which includes domestic abuse cases. The results of this review are being discussed with the Public Protection Governance Unit with a view to ensuring robust compliance across the force.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clearer domestic abuse risk-grading guidance and disseminate it through continuous professional development and safeguarding training.
Verbatim wording from the response “At the time of GMP’s involvement with Alfie’s parents, the force policy stipulated that officers should take into account the circumstances of the incident, the vulnerability of the victim, and the history of the perpetrator when making a risk assessment. The new force policy offers more guidance to officers around risk grading. It has specifically outlined a number of circumstances when certain risk gradings, such as standard risk, would not be appropriate. This includes:” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 accompanying training material on the revised Domestic Violence Disclosure Scheme policy and process.
Verbatim wording from the response “It is intended that when the revised policy is agreed, estimated to be in February 2021, there will be accompanying training material to raise awareness of the key changes and of the process itself.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 Use the revised domestic abuse policy to define responsibilities for considering evidence-led prosecutions.
Verbatim wording from the response “It is recognised that GMP's previous domestic abuse policy did not fully explore or explain 'victimless' or evidence-led prosecutions. The revised domestic abuse policy provides clear definitions and responsibilities for officers investigating domestic abuse offences to consider evidence-led prosecutions where appropriate to do so.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
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 The absent serial perpetrator marker did not prevent officers accessing linked domestic abuse incidents or assessing associated risk factors.
Verbatim wording from the response “The presence of an information marker is just that; it provides information to officers around potential risk factors that they may wish to consider when dealing with incidents. The presence of these markers rarely stipulates that a subsequent action should be followed and it is not intended that this should be the case. Information markers are used to guide officers in making appropriate decisions in accordance with the National Decision Model. Whilst the serial domestic abuse perpetrator marker was not applied in the case of Samuel Gildea, the incidents that he had been linked to as a perpetrator of domestic abuse were visible and accessible to all and officers are expected to assess previous history in coming to assessments about risk factors.” Source location 2020-0242-Response-from-Greater-Manchester-Police-Redacted.pdf
Open published response
12 Mar 2020 Jason Pendlebury · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Failure to share relevant prior mental-health contacts and assessments between GMP and NWAS View source Failure to ensure that referrals to mental health services are received and traceable View source Failure to provide Approved Mental Health Practitioners with full information about relevant mental-health contacts View source Failure to communicate relevant mental-health contacts, assessments and referrals to General Practitioners View source See 1 more concern
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
Jason Pendlebury · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason Pendlebury, a known cocaine user, fell from the roof of a block of flats on 29 September 2018 and died in hospital on 2 October 2018 after sustaining serious injuries. The principal concerns related to communication and information-sharing between Greater Manchester Police, North West Ambulance Service, the GP and mental health professionals about his potential mental health needs and risk.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant prior mental-health contacts and assessments between GMP and NWAS
Wider context from the report “I heard evidence that between 13 August and 22 August 2018 telephone calls were made to Greater Manchester Police (GMP) on 8 separate dates by the Deceased, his wife and his business partner. On all but one of those dates those concerns related to the Deceased's mental health. Of the calls that were made by the Deceased, the call handler reached the conclusion that he had mental health issues. On 3 of the occasions, GMP referred the matter to North West Ambulance Service (NWAS) which resulted in telephone assessments by mental health nurses. The purposes of those telephone assessments was to determine whether an ambulance should attend the Deceased. On two occasions a decision was taken that no ambulance was required. On one occasion an ambulance was dispatched although the deceased refused medical assistance and was not taken to Hospital.
It was not clear from the evidence that the mental health nurses carrying out the telephone assessments were aware of the number of calls that had been made to GMP or of the previous telephone assessments. None of the calls made to GMP or the fact that telephone mental health assessments had taken place was communicated to the deceased's GP. This meant that when the Deceased's wife contacted the GP on 6th September 2018 with concerns about his threats of suicide, the GP did not have all the information that he might of had to determine what action to take.
I also heard that a Multi-Agency Adult Care Safeguarding Team meeting was held at Rochdale Police Station on 28th August 2018. The Approved Mental Health Professional (AMHP) who attended the meeting was not provided with the full details of the telephone calls that had been made to GMP regarding the Deceased's mental health and consequently assessed the risk of harm to himself and others as low. Had the AMHP been provided with full information, it would have automatically generated a referral to the Single Point of Access and led to the involvement of the mental health services.
A further contact with GMP was made on 19th September 2018 and I heard that this triggered a referral to the mental health services. However, GMP were unable to confirm what had happened to the referral and the Mental Health Trust confirmed that they had no knowledge of any referral being made. In addition, GMP did not notify the Deceased's GP that a referral to mental health services had been made.
The matters of concern relate to the quality and systems of communication regarding concerns relating to potential mental health needs between GMP and NWAS and onward communication to General Practitioners and Approved Mental Health Practitioners tasked with assessing risk levels.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that referrals to mental health services are received and traceable
Wider context from the report “I heard evidence that between 13 August and 22 August 2018 telephone calls were made to Greater Manchester Police (GMP) on 8 separate dates by the Deceased, his wife and his business partner. On all but one of those dates those concerns related to the Deceased's mental health. Of the calls that were made by the Deceased, the call handler reached the conclusion that he had mental health issues. On 3 of the occasions, GMP referred the matter to North West Ambulance Service (NWAS) which resulted in telephone assessments by mental health nurses. The purposes of those telephone assessments was to determine whether an ambulance should attend the Deceased. On two occasions a decision was taken that no ambulance was required. On one occasion an ambulance was dispatched although the deceased refused medical assistance and was not taken to Hospital.
It was not clear from the evidence that the mental health nurses carrying out the telephone assessments were aware of the number of calls that had been made to GMP or of the previous telephone assessments. None of the calls made to GMP or the fact that telephone mental health assessments had taken place was communicated to the deceased's GP. This meant that when the Deceased's wife contacted the GP on 6th September 2018 with concerns about his threats of suicide, the GP did not have all the information that he might of had to determine what action to take.
I also heard that a Multi-Agency Adult Care Safeguarding Team meeting was held at Rochdale Police Station on 28th August 2018. The Approved Mental Health Professional (AMHP) who attended the meeting was not provided with the full details of the telephone calls that had been made to GMP regarding the Deceased's mental health and consequently assessed the risk of harm to himself and others as low. Had the AMHP been provided with full information, it would have automatically generated a referral to the Single Point of Access and led to the involvement of the mental health services.
A further contact with GMP was made on 19th September 2018 and I heard that this triggered a referral to the mental health services. However, GMP were unable to confirm what had happened to the referral and the Mental Health Trust confirmed that they had no knowledge of any referral being made. In addition, GMP did not notify the Deceased's GP that a referral to mental health services had been made.
The matters of concern relate to the quality and systems of communication regarding concerns relating to potential mental health needs between GMP and NWAS and onward communication to General Practitioners and Approved Mental Health Practitioners tasked with assessing risk levels.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Approved Mental Health Practitioners with full information about relevant mental-health contacts
Wider context from the report “I heard evidence that between 13 August and 22 August 2018 telephone calls were made to Greater Manchester Police (GMP) on 8 separate dates by the Deceased, his wife and his business partner. On all but one of those dates those concerns related to the Deceased's mental health. Of the calls that were made by the Deceased, the call handler reached the conclusion that he had mental health issues. On 3 of the occasions, GMP referred the matter to North West Ambulance Service (NWAS) which resulted in telephone assessments by mental health nurses. The purposes of those telephone assessments was to determine whether an ambulance should attend the Deceased. On two occasions a decision was taken that no ambulance was required. On one occasion an ambulance was dispatched although the deceased refused medical assistance and was not taken to Hospital.
It was not clear from the evidence that the mental health nurses carrying out the telephone assessments were aware of the number of calls that had been made to GMP or of the previous telephone assessments. None of the calls made to GMP or the fact that telephone mental health assessments had taken place was communicated to the deceased's GP. This meant that when the Deceased's wife contacted the GP on 6th September 2018 with concerns about his threats of suicide, the GP did not have all the information that he might of had to determine what action to take.
I also heard that a Multi-Agency Adult Care Safeguarding Team meeting was held at Rochdale Police Station on 28th August 2018. The Approved Mental Health Professional (AMHP) who attended the meeting was not provided with the full details of the telephone calls that had been made to GMP regarding the Deceased's mental health and consequently assessed the risk of harm to himself and others as low. Had the AMHP been provided with full information, it would have automatically generated a referral to the Single Point of Access and led to the involvement of the mental health services.
A further contact with GMP was made on 19th September 2018 and I heard that this triggered a referral to the mental health services. However, GMP were unable to confirm what had happened to the referral and the Mental Health Trust confirmed that they had no knowledge of any referral being made. In addition, GMP did not notify the Deceased's GP that a referral to mental health services had been made.
The matters of concern relate to the quality and systems of communication regarding concerns relating to potential mental health needs between GMP and NWAS and onward communication to General Practitioners and Approved Mental Health Practitioners tasked with assessing risk levels.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant mental-health contacts, assessments and referrals to General Practitioners
Wider context from the report “I heard evidence that between 13 August and 22 August 2018 telephone calls were made to Greater Manchester Police (GMP) on 8 separate dates by the Deceased, his wife and his business partner. On all but one of those dates those concerns related to the Deceased's mental health. Of the calls that were made by the Deceased, the call handler reached the conclusion that he had mental health issues. On 3 of the occasions, GMP referred the matter to North West Ambulance Service (NWAS) which resulted in telephone assessments by mental health nurses. The purposes of those telephone assessments was to determine whether an ambulance should attend the Deceased. On two occasions a decision was taken that no ambulance was required. On one occasion an ambulance was dispatched although the deceased refused medical assistance and was not taken to Hospital.
It was not clear from the evidence that the mental health nurses carrying out the telephone assessments were aware of the number of calls that had been made to GMP or of the previous telephone assessments. None of the calls made to GMP or the fact that telephone mental health assessments had taken place was communicated to the deceased's GP. This meant that when the Deceased's wife contacted the GP on 6th September 2018 with concerns about his threats of suicide, the GP did not have all the information that he might of had to determine what action to take.
I also heard that a Multi-Agency Adult Care Safeguarding Team meeting was held at Rochdale Police Station on 28th August 2018. The Approved Mental Health Professional (AMHP) who attended the meeting was not provided with the full details of the telephone calls that had been made to GMP regarding the Deceased's mental health and consequently assessed the risk of harm to himself and others as low. Had the AMHP been provided with full information, it would have automatically generated a referral to the Single Point of Access and led to the involvement of the mental health services.
A further contact with GMP was made on 19th September 2018 and I heard that this triggered a referral to the mental health services. However, GMP were unable to confirm what had happened to the referral and the Mental Health Trust confirmed that they had no knowledge of any referral being made. In addition, GMP did not notify the Deceased's GP that a referral to mental health services had been made.
The matters of concern relate to the quality and systems of communication regarding concerns relating to potential mental health needs between GMP and NWAS and onward communication to General Practitioners and Approved Mental Health Practitioners tasked with assessing risk levels.
” 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 Consider the effectiveness of current information-sharing arrangements with partners and brief the Greater Manchester Health and Justice Board on the concerns raised.
Verbatim wording from the response “GMP’s Public Service Reform leads, Chief Supt. ████████ and DCI ████████ are to consider the effectiveness of the current arrangements regarding this type of information sharing with partners and the Greater Manchester Health and Justice Board will be briefed on the concerns raised here (additional information on this body is included in the Summary below).” Source location 2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
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 Participate in planning and developing future Clinical Assessment Service phases, including consideration of a GMP referral pathway.
Verbatim wording from the response “Phase 1 of the CAS has now been implemented, with further phases planned to expand this service. One of areas of expansion is to look at a referral pathway for GMP into the CAS. GMP lead, DCI Whittaker-Murray, attends the Greater Manchester Mental Health CAS planning meeting with key stakeholders, which are reviewing and developing future phases.” Source location 2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
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 and implement a common, documented GMP-wide procedure with partners for responding to mental-health-related risk to life presented to blue-light services.
Verbatim wording from the response “In 2019 The Greater Manchester Health and Justice Board oversaw work to develop and implement a common approach to people in mental health crisis. The involved a working group, Health and Justice Task and Finish Group, which included senior representatives form GMP and the North-West Ambulance Service, in addition to the mental health trusts serving Greater Manchester, local authority approved mental health practitioners and Greater Manchester Combined Authority.” Source location 2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
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 Assess the feasibility of electronic Force-to-Force data exchange between GMP and partner agencies including NWAS.
Verbatim wording from the response “One aspect of our ongoing IT Change Programme is the feasibility of an electronic Force to Force data exchange, which could potentially be used to share data electronically with agencies such as NWAS. It is anticipated that these advances in technology would improve the quality and efficiency of information sharing and is subject to ongoing review.” Source location 2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
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 Operate the 24/7 Mental Health Tactical Advice Service and Vulnerability Support Unit to review incidents, access mental-health records, provide advice and share relevant information with GPs and care teams.
Verbatim wording from the response “At the time of Mr Pendlebury’s death a new “in-house” mental health tactical advice service, called the Control Room Triage (CRT), had just been established within our Operational Communications Branch (OCB). On the 22nd August 2018 the CRT team operated between the hours of 8am until midnight. The CRT did not start covering 24/7 until 1st October 2018. The CRT still operates in the same way today, however is now called the Mental Health Tactical Advice Service (MHTAS).” Source location 2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing multi-agency referral arrangements are considered sufficient for sharing information with GPs through social-care and mental-health triage services.
Verbatim wording from the response “GMP does not routinely or automatically send referrals directly to an individual’s GP. Information is shared via standard local multi-agency arrangements, where a referral is sent through to the appropriate Adult, Child or Mental Health Services triage point for that Area.” Source location 2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
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 Social-care and mental-health triage services are responsible for deciding whether information received from police should be passed onward to the relevant GP.
Verbatim wording from the response “GMP does not routinely or automatically send referrals directly to an individual’s GP. Information is shared via standard local multi-agency arrangements, where a referral is sent through to the appropriate Adult, Child or Mental Health Services triage point for that Area.” Source location 2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
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 The relevant incidents were not coded as mental-health or safeguarding concerns, so there was no requirement to refer them to the CRT.
Verbatim wording from the response “FWIN 425 19/09/18 came in as a domestic and was finalised as a domestic. There was nothing on the FWIN to indicate any mental health issues and therefore no requirement to switch the incident through to the CRT.” Source location 2020-0069-Response-from-Greater-Manchester-Police_Redacted-2
Open published response
29 Aug 2019 Michael Hoolickin · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 15 Insufficient capacity to cross-reference offender intelligence across offenders and agencies View source Failure to require ACOs to access offender records View source Lack of formal information-sharing procedures for integrated teams View source Poor or absent records by SPOs and ACOs View source Failure to undertake multi-agency reviews after high-risk offenders under multi-agency management kill someone View source Lack of training on accessing drug test results View source Failure to update OASYS risk assessments View source Insufficient planning and preparation for service amalgamation View source N-Delius failing to provide timely access to current offender information View source Inadequate agenda, minutes, attendance records and meeting records for IOM cohort meetings View source Failure to accurately share information about offenders between police forces View source Lack of induction training and office procedures on local drug-testing practices View source Lack of clarity and specific instructions on ACO warnings View source Lack of clear arrangements for initiating police curfew checks View source Failure to record licence conditions on the Police National Computer View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Implement police-owned curfew checking arrangements with case-specific management plans, delegated tasking, partner updates and resource assurance.
Stated completedThe respondent said that this action was complete when they made their response on 25 October 2019. View source
Action
Produce and distribute a Greater Manchester custody briefing on responsibilities for detainees subject to licence or supervision and accurate information sharing.
Stated completedThe respondent said that this action was complete when they made their response on 25 October 2019. View source
Action
Revise the Greater Manchester IOM Manual of Guidance to cover multi-agency reviews, curfew management, escalation, information sharing, record keeping and key decisions.
Stated in progressThe respondent said that this action was in progress when they made their response on 25 October 2019. View source
Action
Use structured IOM cohort meeting paperwork, including agendas, action logs, named attendees and timescales, to improve recording of decisions and actions.
Stated completedThe respondent said that this action was complete when they made their response on 25 October 2019. View source
Action
Adopt multi-agency reviews for IOM cases involving a further serious offence, with agreed action plans and partnership-level oversight of learning.
Stated plannedThe respondent said that this action was planned when they made their response on 25 October 2019. View source See 2 more actions
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AI-generated summary
Michael Hoolickin · 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
Michael Hoolickin was attacked and stabbed in an unprovoked assault on 14 October 2016 and died at Manchester Royal Infirmary on 17 October 2016. The report identifies organisational and management failures in supervising the perpetrator, including failures concerning drug testing, information sharing and provision of relevant information, which resulted in a missed opportunity to initiate recall to prison. The Inquest found that this probably contributed to Michael Hoolickin’s death, although it was not causative of the attack.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity to cross-reference offender intelligence across offenders and agencies
Wider context from the report “During the course of the Inquest questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders . In addition whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to require ACOs to access offender records
Wider context from the report “There is no expectation for an ACO to access an offenders records on the case management system in order to inform themselves or to consider whether there is any further relevant 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal information-sharing procedures for integrated teams
Wider context from the report “The evidence before the Court was there are no Standard Operating procedures or formal processes in place for the sharing of information when teams are integrated .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Poor or absent records by SPOs and ACOs
Wider context from the report “The Court had serious concerns as to the poor records or complete lack of records particularly by SPOs and the ACOs.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake multi-agency reviews after high-risk offenders under multi-agency management kill someone
Wider context from the report “The failure to undertake a multi-agency review in cases where a high risk offender subject to multi-agency management has gone on to take someone’s life means both organisational and individual failings are not identified and there is a missed opportunity to learn lessons in order to prevent 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of training on accessing drug test results
Wider context from the report “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results . As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to update OASYS risk assessments
Wider context from the report “At no stage after March 2016 was the offenders OASYS risk assessment updated . Moreover the lack of formal supervision meant this was not addressed.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient planning and preparation for service amalgamation
Wider context from the report “The Court has concerns as to the planning and preparation required for the amalgamation of any new service in order to alleviate the evidenced problems which occurred as a direct result of the previous Transforming Rehabilitation programme.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation N-Delius failing to provide timely access to current offender information
Wider context from the report “Numerous witnesses gave evidence as to the difficulties in accessing this system , its design and the time it takes to access the different parts which hold pertinent information about an offender , describing this as prohibitive. For example for Offender managers trying to read through the file to obtain current information there is nowhere which would easily show the most up to date curfew or the most up to date position as to how often drug testing is being conducted .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate agenda, minutes, attendance records and meeting records for IOM cohort meetings
Wider context from the report “The evidence before the Court was that in respect of the multi-agency IOM meetings there was no formal agenda, no formal minutes, no accurate record kept of these meetings by either GMP or the NPS and no way of ascertaining who had attended these meetings .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately share information about offenders between police forces
Wider context from the report “There was a complete breakdown of communication and information sharing between GMP and Lancashire Constabulary which lead to only information about one of the two offenders being passed on . More importantly there was confusion between the forces as to which offender was being discussed .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of induction training and office procedures on local drug-testing practices
Wider context from the report “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results. As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity and specific instructions on ACO warnings
Wider context from the report “The Court found there is a lack of clarity and specific instructions to the NPS on this point.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clear arrangements for initiating police curfew checks
Wider context from the report “The Court was satisfied from the evidence that there is no clear understanding as to the initiation of curfew checks . It was clear to the Court there was confusion as to whether an offender on a curfew will automatically be subject to curfew checks carried out by the Police or whether such checks will only be conducted following a specific request by the NPS .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record licence conditions on the Police National Computer
Wider context from the report “The Court heard that an offenders’ licence conditions are not held on the Police National Computer database . Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence.
” 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 police-owned curfew checking arrangements with case-specific management plans, delegated tasking, partner updates and resource assurance.
Verbatim wording from the response “It has been agreed with local partners that the responsibility for carrying out curfew checks on offenders within the IOM cohort is owned by the police. Moreover that on a case by case basis there should be an agreed curfew management plan with NPS which is set and regularly reviewed in the IOM case review meetings. The plan should include: what the checks are intended to achieve; the anticipated frequency and timing of curfew checks; and the approach should be justified, necessary and proportionate in accordance with ECHR.” Source location 2019-0292-Response-from-Greater-Manchester-Police-Redacted
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 Produce and distribute a Greater Manchester custody briefing on responsibilities for detainees subject to licence or supervision and accurate information sharing.
Verbatim wording from the response “Custody suites are a conduit for sharing information between forces for out of area arrests including those in breach of licence conditions.This type of contact is daily business and there isn’t any specific guidance for custody staff in relation to how to pass information between police forces. This approach to sharing information about the arrest of a person who is subject to licence conditions meets the requirements for initial notification of arrest to the team responsible for managing that offender.
It is appropriate and proportionate to remind all staff working within custody offices of the importance of paying attention to detail when sharing information.” Source location 2019-0292-Response-from-Greater-Manchester-Police-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Greater Manchester IOM Manual of Guidance to cover multi-agency reviews, curfew management, escalation, information sharing, record keeping and key decisions.
Verbatim wording from the response “This shared approach to reviews will be included in updates to the Greater Manchester IOM Manual of Guidance (August 2018).” Source location 2019-0292-Response-from-Greater-Manchester-Police-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use structured IOM cohort meeting paperwork, including agendas, action logs, named attendees and timescales, to improve recording of decisions and actions.
Verbatim wording from the response “Response: The concerns raised about IOM practice in 2016 are accepted. However, it is important to emphasise that since 2016, there have been improvements to record keeping in line with the content of the revised IOM framework circulated in August 2018. The framework is supported by new paperwork and templates, including draft agendas and action logs with names and timescales.
Learning from this case will inform further revision to the IOM guidance to include the process for escalating cases where police officers consider recall is required with the associated rationale. The revised guidance will also ensure that cases with increasing levels of risk are not only escalated but considered for referral into MAPPA within the individual case reviews.” Source location 2019-0292-Response-from-Greater-Manchester-Police-Redacted
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 Adopt multi-agency reviews for IOM cases involving a further serious offence, with agreed action plans and partnership-level oversight of learning.
Verbatim wording from the response “In these circumstances where the offender is subject of multi-agency protection panel arrangements (MAPPA) there is a statutory framework in existence to ensure lessons are identified and learned. This framework requires the agencies involved in the management of the offender to carry out a multi-agency review.” Source location 2019-0292-Response-from-Greater-Manchester-Police-Redacted
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 National Probation Service is responsible for determining whether licence or supervision conditions have been breached.
Verbatim wording from the response “Response: The PNC is a national database and an entry on the CU page of a person record, concerning supervision or licence details, is completed using a set wording. This includes contact details for the national probation service or Spotlight team managing the subject and the dates between which the licence or supervision is effective. It is accepted that the PNC does not hold specific licence conditions. All persons authorised for detention at a police station should be checked on PNC and it is the responsibility of officers in the force where the subject is arrested to make contact with the relevant probation service office to share details of the arrest from which the NPS can assess whether the licence or supervision conditions have been breached.” Source location 2019-0292-Response-from-Greater-Manchester-Police-Redacted
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 Recording all licence conditions would require a significant increase in administrative time, which is not justified by the available information.
Verbatim wording from the response “At this time the PNC does not hold the specific licence conditions because of the volume of offenders on licence, many of whom have multiple conditions, which are subject to variation. After respectful consideration of the evidence gathered in this inquest and the concerns expressed in the Regulation 28 letter the disadvantage is felt that maintaining a timely and accurate record of all licence conditions would require a significant increase in administrative time which would not be justified given the information is accessible from the NPS who will in any case make a determination on breach.” Source location 2019-0292-Response-from-Greater-Manchester-Police-Redacted
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 Police need not record specific licence conditions because they are accessible from the National Probation Service, which determines any breach.
Verbatim wording from the response “At this time the PNC does not hold the specific licence conditions because of the volume of offenders on licence, many of whom have multiple conditions, which are subject to variation. After respectful consideration of the evidence gathered in this inquest and the concerns expressed in the Regulation 28 letter the disadvantage is felt that maintaining a timely and accurate record of all licence conditions would require a significant increase in administrative time which would not be justified given the information is accessible from the NPS who will in any case make a determination on breach.” Source location 2019-0292-Response-from-Greater-Manchester-Police-Redacted
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-sharing failure in this case does not amount to a systemic issue requiring broader systemic action.
Verbatim wording from the response “Response: Whilst it is accepted that the exchange of information in this case between police officers from Lancashire Constabulary and GMP could and should have been more effective it is respectfully submitted that evidence from this single incident does not amount to a systemic issue.” Source location 2019-0292-Response-from-Greater-Manchester-Police-Redacted
Open published response
15 Aug 2019 Dane Lee Pearson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to assess known vulnerability when issuing CAWNs View source Failure to clarify available steps when serving CAWNs View source Failure to notify people under investigation of decisions View source Lack of documentation explaining the rationale for CAWN issuance View source Failure to update OPUS with vulnerability markers View source Issuing CAWNs on limited evidence regarding identification View source Delays in issuing CAWNs and failure to follow issuance timelines View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Require pre-service vulnerability risk assessments, documenting the rationale and potential impact on the suspect in Child Abduction Warning Notice records.
Stated completedThe respondent said that this action was complete when they made their response on 6 June 2019. View source
Action
Establish audits checking compliance with Child Abduction Warning Notice 48-hour service limits and six-month reviews.
Stated plannedThe respondent said that this action was planned when they made their response on 6 June 2019. View source
Action
Disseminate frontline briefings reminding officers to manage release-under-investigation cases, close records, and inform suspects of outcomes.
Stated completedThe respondent said that this action was complete when they made their response on 6 June 2019. View source
Action
Implement an integrated operating system supporting warning-marker creation, updates, reviews, removal, provenance, accountability, mandatory review notifications, and cautionary prompts.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 June 2019. View source
Action
Write and introduce a force Child Abduction Warning Notice policy and procedure defining officer responsibilities.
Stated completedThe respondent said that this action was complete when they made their response on 6 June 2019. View source See 2 more actions
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AI-generated summary
Dane Lee Pearson · 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
Dane Lee Pearson, who had a history of mental health problems and amphetamine use, was found suspended from a ligature at his home on 13 December 2017. The investigation concluded that the death was suicide, with the medical cause recorded as hanging. Concerns included failures in the issuing and documentation of a Child Abduction Warning Notice, failure to assess or account for his vulnerability, inadequate recording of vulnerability markers, and failure to communicate that criminal proceedings had been discontinued.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to assess known vulnerability when issuing CAWNs
Wider context from the report “2. In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account . A risk assessment had not been carried out . In this case, officers attended at his home address and served the CAWN on him .He refused to sign it on the basis; he had no knowledge of it or the circumstances behind it. It was left with him with no clarification about what if any steps he could take in relation to it. The inquest heard evidence that he was deeply worried about it and the impact of it on his life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify available steps when serving CAWNs
Wider context from the report “2. In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account. A risk assessment had not been carried out. In this case, officers attended at his home address and served the CAWN on him .He refused to sign it on the basis; he had no knowledge of it or the circumstances behind it. It was left with him with no clarification about what if any steps he could take in relation to it . The inquest heard evidence that he was deeply worried about it and the impact of it on his life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to notify people under investigation of decisions
Wider context from the report “4. The inquest was told that he was placed under investigation for a suspected attempt burglary and possession of an offensive weapon. A decision was taken by the OIC and his sergeant that it should be NFAD. The decision was not communicated to Mr Pearson . The officer had not followed the process for notification of decisions to those under investigation . As a result, at the time of his death he believed he may be charged with a criminal offence.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation explaining the rationale for CAWN issuance
Wider context from the report “1. In this case, the CAWN had been issued on limited evidence particularly regarding identification. In addition, it had been issued many months after the allegation and after the authorisation. The inquest was told that the process had not been followed relating to timelines. There was no documentation in existence explaining the rationale for the issuing of the CAWN .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to update OPUS with vulnerability markers
Wider context from the report “3. The inquest heard that OPUS the Police system did not appear to have been correctly updated with markers to flag his vulnerability .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Issuing CAWNs on limited evidence regarding identification
Wider context from the report “1. In this case, the CAWN had been issued on limited evidence particularly regarding identification . In addition, it had been issued many months after the allegation and after the authorisation. The inquest was told that the process had not been followed relating to timelines. There was no documentation in existence explaining the rationale for the issuing of the CAWN.
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Delays in issuing CAWNs and failure to follow issuance timelines
Wider context from the report “1. In this case, the CAWN had been issued on limited evidence particularly regarding identification. In addition, it had been issued many months after the allegation and after the authorisation . The inquest was told that the process had not been followed relating to timelines . There was no documentation in existence explaining the rationale for the issuing of the CAWN.
” 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 Require pre-service vulnerability risk assessments, documenting the rationale and potential impact on the suspect in Child Abduction Warning Notice records.
Verbatim wording from the response “2) Carry out a risk assessment prior to the service of a CAWN to ensure that consideration is given to a suspect’s history, particularly relating to any intelligence about vulnerability or threats, and include the outcome of the risk assessment in the CAWN service forms.” Source location 2019-0056-Responses
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 audits checking compliance with Child Abduction Warning Notice 48-hour service limits and six-month reviews.
Verbatim wording from the response “5) Establish an ongoing audit process for checking the 48-hour time limit and six-month reviews are adhered to.” Source location 2019-0056-Responses
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 Disseminate frontline briefings reminding officers to manage release-under-investigation cases, close records, and inform suspects of outcomes.
Verbatim wording from the response “- The central criminal justice team provides detailed information to local districts to assist them in the management and governance of RUIs.
- Governance expectations and best practise has been disseminated to all districts and branches, this has resulted in changes locally e.g. joining up crime management and RUI activity.
- The bail and RUI policy has been revised to provide clarity on the roles and responsibilities of officers and local leaders in the management of RUI.
- Targeted work, both local and centrally, to close outstanding RUI records.
- Briefings have been disseminated to front line officers to remind them of their responsibility for RUI management, the closure of ICIS records and informing the suspect.
- Local bail managers have introduced trackers to manage RUIs in the same way as pre-charge bail is managed.” Source location 2019-0056-Responses
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an integrated operating system supporting warning-marker creation, updates, reviews, removal, provenance, accountability, mandatory review notifications, and cautionary prompts.
Verbatim wording from the response “As a Force, we are currently in the process of implementing a new, integrated operating system which will replace many of our existing systems. ████████ has worked closely alongside the iOPS team to ensure that all requirements for safely managing intelligence are met.
GMP have provided the following as essential functions in relation to markers;” Source location 2019-0056-Responses
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 Write and introduce a force Child Abduction Warning Notice policy and procedure defining officer responsibilities.
Verbatim wording from the response “Greater Manchester Police (GMP) have instructed all staff across the force to ensure that the correct process regarding identification and timeliness is adhered to. The College of Policing national policy has been reviewed alongside GMP’s policy and a new 2019 policy and procedure document written which details the roles and responsibility of each officer involved in the issuing of a CAWN notice. The CAWN notices will be managed within each district in the Intelligence Hub for consistency. This document and the new process within districts will ensure that staff continue to comply with their responsibilities regarding the CAWN process as below,” Source location 2019-0056-Responses
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 Until IT systems change, investigating officers are responsible for closing records and informing suspects when investigations conclude without further action.
Verbatim wording from the response “As it stands, without changes in our IT systems (the systems will not be upgraded due to the pending the iOPS implementation), it is the responsibility of the OIC to close the ICIS record and inform the suspect when a decision to finalise the crime and take no further action has been reached.” Source location 2019-0056-Responses
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 A warning-marker policy cannot yet be completed pending assessment of the new system and anticipated inquiry requirements.
Verbatim wording from the response “████████ of the Force Intelligence Bureau (FIB) is tasked with writing GMP’s first Force policy and guidance document on the use of WM. This will be completed” Source location 2019-0056-Responses
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 GMP’s existing IT systems will not be upgraded before iOPS implementation, preventing automated notification changes meanwhile.
Verbatim wording from the response “As it stands, without changes in our IT systems (the systems will not be upgraded due to the pending the iOPS implementation), it is the responsibility of the OIC to close the ICIS record and inform the suspect when a decision to finalise the crime and take no further action has been reached.” Source location 2019-0056-Responses
Open published response
23 Jul 2019 Adam Harris · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Prolonged prisoner waiting periods in the van dock area View source Inconsistent guidance on safe positioning of confused or intoxicated prisoners View source Failure to search prisoners before transport View source Lack of formal documented triage and risk assessment for prisoners held in the van dock area View source Lack of clear and detailed handover between arresting and transporting officers View source Delays in opening and entering information in custody records View source Inadequate control of interim paper custody records and processes View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adam Harris · 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
Adam Harris died at Tameside General Hospital on 20 April 2018 from alcohol and cocaine toxicity after collapsing at Ashton Police Station following his arrest and detention. Concerns included the absence of documented triage or risk assessment while prisoners waited in the van dock, lack of searches before transport, unclear handover arrangements, delayed creation of the custody record, and inconsistent evidence about his position in the cell while confused and suspected to be intoxicated.
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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Prolonged prisoner waiting periods in the van dock area
Wider context from the report “1. The inquest heard that there was no formal documented triage/risk assessment in place when a prisoner was held in the van dock area pending space becoming available in the custody suite. The inquest heard that whilst the average wait time in the van dock area across GMP was 15 minutes on occasions the waiting period could be in excess of 60 minutes ;
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Inconsistent guidance on safe positioning of confused or intoxicated prisoners
Wider context from the report “5. The inquest was told by one officer that Mr Harris was left in the cell on his back and that position was correct and in accordance with GMP guidance . Another officer indicated he was left in the recovery position/face down and that was correct/appropriate . Given Mr Harris’s level of confusion and suspected intoxication it was unclear how placing him on his back would assist with managing a risk of aspiration .
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to search prisoners before transport
Wider context from the report “2. Adam Harris was not arrested until he was in the rear of the Police van. None of the officers present searched him before he was placed in the van or before he was transported to Ashton Police Station ;
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal documented triage and risk assessment for prisoners held in the van dock area
Wider context from the report “1. The inquest heard that there was no formal documented triage/risk assessment in place when a prisoner was held in the van dock area pending space becoming available in the custody suite. The inquest heard that whilst the average wait time in the van dock area across GMP was 15 minutes on occasions the waiting period could be in excess of 60 minutes;
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and detailed handover between arresting and transporting officers
Wider context from the report “3. Adam Harris was not transported by the Arresting Officer but by Police Officers operating a divisional van. There was no evidence of a clear and detailed handover between the Arresting Officer and the Transporting Officers . One of the Transporting Officers described the role they played as a police taxi 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Delays in opening and entering information in custody records
Wider context from the report “4. The Custody Sergeant did not open a custody record immediately on Adam Harris’s arrival in the custody office . He used a piece of paper to record the details that were given to him. He did not input details into the custody record until after Adam Harris had been placed in a cell . He indicated that the custody Sergeant course encouraged the use of paper and he had developed his practice from the guidance on the course. It was unclear how the paper was stored and how it supported the requirement to follow the process generated through using the custody system;
” 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 Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate control of interim paper custody records and processes
Wider context from the report “4. The Custody Sergeant did not open a custody record immediately on Adam Harris’s arrival in the custody office. He used a piece of paper to record the details that were given to him. He did not input details into the custody record until after Adam Harris had been placed in a cell. He indicated that the custody Sergeant course encouraged the use of paper and he had developed his practice from the guidance on the course. It was unclear how the paper was stored and how it supported the requirement to follow the process generated through using the custody system ;
” 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 Work with Greater Manchester Combined Authority to explore introducing formal pre-detention medical assessments for detainees waiting over 30 minutes in a police vehicle.
Verbatim wording from the response “Greater Manchester Police are currently working with Greater Manchester Combined Authority and are exploring the introduction of a formal pre-detention medical assessment carried out by a Health Care Professional where a detainee remains in a Police vehicle in a van dock for a period in excess of 30 minutes.” Source location 2019-0247-Response-from-Greater-Manchester-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver annual specialist training on current detainee restraint techniques and continually review those methods using operational, professional and case-review feedback.
Verbatim wording from the response “Response:
All operational Police Officers and Staff are trained annually by our own specialists who teach the latest restraint techniques for detainees. The restraint techniques taught are derived from” Source location 2019-0247-Response-from-Greater-Manchester-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 Review and incorporate relevant transportation-procedure components into annual Personal Safety Training for operational police officers and staff.
Verbatim wording from the response “From August 2019 the contents of the revised “Transportation of Detained Persons” procedure features in the initial Student Police Officer foundation training course delivered to all Student Police Officers on appointment. There are also components of the policy currently being reviewed with a view to being incorporated into the Personal Safety Training courses which all operational Police Officers and staff undertake annually. It is anticipated that the revised training will commence in Autumn / Winter 2019.” Source location 2019-0247-Response-from-Greater-Manchester-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver Transportation of Detained Persons procedure content in the foundation course for all newly appointed Student Police Officers.
Verbatim wording from the response “From August 2019 the contents of the revised “Transportation of Detained Persons” procedure features in the initial Student Police Officer foundation training course delivered to all Student Police Officers on appointment. There are also components of the policy currently being reviewed with a view to being incorporated into the Personal Safety Training courses which all operational Police Officers and staff undertake annually. It is anticipated that the revised training will commence in Autumn / Winter 2019.” Source location 2019-0247-Response-from-Greater-Manchester-Police
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and republish the Transportation of Detained Persons procedure, including dynamic risk assessment and detainee-management responsibilities.
Verbatim wording from the response “It is not current procedure to complete a formal documented risk assessment whilst a detained person remains in a police vehicle, in a van dock, awaiting authority to proceed into the custody suite. Procedures that are in place demonstrate risk assessment is an ongoing process from arrest through to custody handover.” Source location 2019-0247-Response-from-Greater-Manchester-Police
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing allocation, dynamic risk-assessment and custody-prioritisation procedures are relied upon instead of introducing formal documented risk assessments in the van dock.
Verbatim wording from the response “Response:
With regard to the waiting time in the van dock - detainee cell space is allocated presently by a centralised GMP “cell allocation team”. They monitor detainee numbers (in situ or those en route), detainee needs, complexities and staffing levels in order to make an informed decision as to which is the most appropriate custody office to send the arrested person for an allocation. The allocation team make direct contact with the custody office to advise them a detainee is en-route; this in itself is a further check to determine that the custody suite has the capacity and means to accept the detainee. Where there is any need to escalate an allocation decision – there is always a Custody Inspector (Custody Bronze) designated to assist. This approach ensures that the waiting time that a detainee has, is as short as possible taking account of all contributing factors.” Source location 2019-0247-Response-from-Greater-Manchester-Police
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PFD Monitor interpretation No approved technique permits leaving a detainee on their back in a police cell, contrary to the concern that this position complied with guidance.
Verbatim wording from the response “Response:
All operational Police Officers and Staff are trained annually by our own specialists who teach the latest restraint techniques for detainees. The restraint techniques taught are derived from” Source location 2019-0247-Response-from-Greater-Manchester-Police
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations