18 Jun 2019 Alfred Sykes · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Failure to adequately consider and act on missing-person sighting information View source Inadequate planning, staffing and coverage of searches for missing persons View source
Responses linked to these concerns
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AI-generated summary
Alfred Sykes · 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
Alfred Sykes became lost while travelling home by bus on 7 February 2018 and was found dead beneath undergrowth at St Georgian's Cricket Club on 11 February 2018. The principal concern was that information about his last sighting and direction of travel was not given adequate consideration, and that the subsequent police search of the sports fields was inadequate. The report states that a larger search on the morning of 8 February might have found him earlier, although he would not have been found alive in the circumstances described.
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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 adequately consider and act on missing-person sighting information
Wider context from the report “1. GMP were informed that Mr Sykes was missing at around 8.00pm on 7th February. He was treated as a high risk missing person from the outset;
2. At approximately 4.00am on 8th February a member of the public called in to report that he had seen and spoken to a gentleman of Alfred Sykes description at about 4pm on 7th February on Egerton Road asking for directions to Longmead Avenue. When the caller could not help him he then asked if there were any football fields nearby. The caller pointed him in the direction of the sports fields at Woodsmoor, at the end of Egerton Road, including St Georgian's Cricket Club. Alfred Sykes was seen by the caller speaking to other people further along Egerton Road, closer to the sports fields;
3. At about 8.00am two police officers, with no allocated tasks at that time, took it upon themselves to conduct a search of the sports fields. The above report had been mentioned at the morning briefing but there was no plan to carry out any search of the fields. It was apparently more than 300m from the spot where the caller spoke to Alfred Sykes. The two officers attended and walked a route around the fields which did not include all of the periphery. They reported a negative result. In my opinion that search was inadequate to report a negative result, as agreed by ████████ in her evidence;
4. On 11th February two members of the public (one of whom knew of Alfred Sykes) and who had heard he was missing also took it upon themselves to search the fields, finding him as above.
My concern is that the report from the member of the public at 4.00am on 8th February of Alfred Sykes’ last sighting was given any or any adequate consideration and action , seemingly because it was more than 300m radius from ████████ However the significance of the sighting and the information was not lost on two police officers who on their own initiative looked around the playing fields. In evidence, ████████ advised that just two police officers for such a large area was insufficient. I agree.
Had there been a greater number of officers deployed on the morning of 8th February to search the fields to which Alfred Sykes had been directed and was last seen walking towards, it is likely he would have been found that morning.
The evidence is that Alfred Sykes would not have been found alive, in combination his frailties and the weather but in different circumstance (particularly the weather) the outcome might have been different for him and for others in the future.
Further, earlier discovery would have;
1. lessened the anguish for the family;
2. saved resources in the continued search over the following 3 days.
” 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 planning, staffing and coverage of searches for missing persons
Wider context from the report “1. GMP were informed that Mr Sykes was missing at around 8.00pm on 7th February. He was treated as a high risk missing person from the outset;
2. At approximately 4.00am on 8th February a member of the public called in to report that he had seen and spoken to a gentleman of Alfred Sykes description at about 4pm on 7th February on Egerton Road asking for directions to Longmead Avenue. When the caller could not help him he then asked if there were any football fields nearby. The caller pointed him in the direction of the sports fields at Woodsmoor, at the end of Egerton Road, including St Georgian's Cricket Club. Alfred Sykes was seen by the caller speaking to other people further along Egerton Road, closer to the sports fields;
3. At about 8.00am two police officers, with no allocated tasks at that time, took it upon themselves to conduct a search of the sports fields. The above report had been mentioned at the morning briefing but there was no plan to carry out any search of the fields . It was apparently more than 300m from the spot where the caller spoke to Alfred Sykes. The two officers attended and walked a route around the fields which did not include all of the periphery . They reported a negative result. In my opinion that search was inadequate to report a negative result , as agreed by ████████ in her evidence;
4. On 11th February two members of the public (one of whom knew of Alfred Sykes) and who had heard he was missing also took it upon themselves to search the fields, finding him as above.
My concern is that the report from the member of the public at 4.00am on 8th February of Alfred Sykes’ last sighting was given any or any adequate consideration and action, seemingly because it was more than 300m radius from ████████ However the significance of the sighting and the information was not lost on two police officers who on their own initiative looked around the playing fields. In evidence, ████████ advised that just two police officers for such a large area was insufficient . I agree.
Had there been a greater number of officers deployed on the morning of 8th February to search the fields to which Alfred Sykes had been directed and was last seen walking towards , it is likely he would have been found that morning.
The evidence is that Alfred Sykes would not have been found alive, in combination his frailties and the weather but in different circumstance (particularly the weather) the outcome might have been different for him and for others in the future.
Further, earlier discovery would have;
1. lessened the anguish for the family;
2. saved resources in the continued search over the following 3 days.
” 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 high-risk missing-person searches daily and notify the Force Search Coordinator promptly of the circumstances.
Verbatim wording from the response “As a result of this report, with immediate effect all high risk missing person searches being conducted by a PoISA from the Specialist Search Unit, will be reviewed by another officer on a daily basis and the PoISC (Force Search Coordinator) appraised of the circumstances at the earliest opportunity.” Source location 2019-0201-Response-from-Greater-Manchester-Police-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add an annual refresher exercise on missing-person searches to PoISA/Search Manager continuous professional development, using recent force or national incidents.
Verbatim wording from the response “As a result of this incident, the annual POISA/Search Manager CPD will now include refresher training by way of an exercise in respect of missing person search, using incidents that have occurred within the force or nationally over the previous twelve months. This will ensure that officers remain operationally competent and any training issues can be appropriately addressed.” Source location 2019-0201-Response-from-Greater-Manchester-Police-Redacted
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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 300-metre search radius and requirement for confirmed sightings were considered appropriate to avoid ad hoc searching while information remained unconfirmed.
Verbatim wording from the response “As guidance to a reasonable, realistic and proportionate size of search area, a 300 meters radius around the PLS is recommended and nationally recognised in order to achieve a high level of confidence. A radius of 300 metres equates to a total search area of 283,239 Square meters (or 69.9 acres). The 300 metre radius will always be a guide and natural boundaries should be used such as main roads, motorways, railway lines, fences etc.” Source location 2019-0201-Response-from-Greater-Manchester-Police-Redacted
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25 Jan 2019 Anne-Marie Nield · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 9 Absence of non-fatal strangulation from the Domestic Abuse Policy View source Failure of police officers to recognise non-fatal strangulation as a domestic homicide risk factor View source Failure to place risk and vulnerability markers on police systems View source Failure to refer appropriate domestic abuse cases to MARAC View source Failure of police officers to understand and apply the Domestic Abuse Policy View source Inadequate and non-dynamic domestic abuse risk assessment View source Failure to offer DVDS to domestic abuse victims View source Failure to implement all Domestic Homicide Review and Independent Management Review recommendations View source Failure to maintain contact with domestic abuse victims after an alleged perpetrator is charged and granted conditional bail View source See 6 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. 7
Action
Develop GMP’s first force policy and guidance on using warning markers.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2019. View source
Action
Provide non-fatal-strangulation awareness training across frontline, student-officer and specialist adult-abuse investigator courses.
Stated completedThe respondent said that this action was complete when they made their response on 25 January 2019. View source
Action
Provide training on DVDS, risk identification, DASH, RARA, risk levels and MARAC processes.
Stated completedThe respondent said that this action was complete when they made their response on 25 January 2019. View source
Action
Compile recent similar incidents, identify common themes and report learning to the strategic domestic-violence lead.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2019. View source
Action
Deliver domestic-abuse terminology training through student-officer, consolidation and Safeguarding for Constables courses.
Stated completedThe respondent said that this action was complete when they made their response on 25 January 2019. View source
Action
Update the Domestic Abuse Policy to address non-fatal strangulation, public protection and iOPS changes.
Stated plannedThe respondent said that this action was planned when they made their response on 25 January 2019. View source
Action
Implement iOPS warning-marker functionality, including marker management, review notifications, provenance recording and audit details.
Stated in progressThe respondent said that this action was in progress when they made their response on 25 January 2019. View source See 4 more actions
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AI-generated summary
Anne-Marie Nield · 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
Anne-Marie Nield was a repeat victim of domestic violence who died from multiple injuries after her partner inflicted a violent and sustained attack at her home on 8 May 2016. The report identifies concerns about inadequate police risk assessment, delays, failures to provide support and information, and insufficient understanding and application of domestic abuse policies. It also notes that not all recommendations addressing these shortcomings had been implemented two and a half years after her 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 Absence of non-fatal strangulation from the Domestic Abuse Policy
Wider context from the report “3. There is no reference to ‘non-fatal strangulation’ within the current Domestic Abuse Policy. Furthermore, almost all of the Police Officers in this case failed to appreciate the significance of non-fatal strangulation as a specific risk factor for domestic homicide.
” 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 police officers to recognise non-fatal strangulation as a domestic homicide risk factor
Wider context from the report “3. There is no reference to ‘non-fatal strangulation’ within the current Domestic Abuse Policy. Furthermore, almost all of the Police Officers in this case failed to appreciate the significance of non-fatal strangulation as a specific risk factor for domestic homicide.
” 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 risk and vulnerability markers on police systems
Wider context from the report “2. Markers are not being placed on police systems (e.g. OPUS) in line with policy and procedure. Markers are all the more important where resources are finite and demands placed upon the Police Service are increasing. Markers help in identifying/conveying risk and 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 Failure to refer appropriate domestic abuse cases to MARAC
Wider context from the report “5. Risk assessment and the exercising of professional judgement in relation to the level of risk were inadequate and ongoing/dynamic risk assessment was not carried out. A referral to MARAC was not made and DVDS not offered to the deceased, again without expectation.
” 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 police officers to understand and apply the Domestic Abuse Policy
Wider context from the report “1. During the course of the evidence, it became apparent that almost all of the Police Officers involved in this case did not understand or apply the Domestic Abuse Policy properly . In particular, they did not understand the meaning of important terminology such as ‘repeat victim’, ‘repeat perpetrator’ and ‘serious and serial perpetrator . An understanding of and the ability to apply this policy are critical to the risk assessment process and the prevention of domestic homicide.
” 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 and non-dynamic domestic abuse risk assessment
Wider context from the report “5. Risk assessment and the exercising of professional judgement in relation to the level of risk were inadequate and ongoing/dynamic risk assessment was not carried out. A referral to MARAC was not made and DVDS not offered to the deceased, again without expectation.
” 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 DVDS to domestic abuse victims
Wider context from the report “5. Risk assessment and the exercising of professional judgement in relation to the level of risk were inadequate and ongoing/dynamic risk assessment was not carried out. A referral to MARAC was not made and DVDS not offered to the deceased , again without expectation.
” 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 implement all Domestic Homicide Review and Independent Management Review recommendations
Wider context from the report “6. Whilst the Court recognises that the findings of the Domestic Homicide Review and Independent Management Review were accepted in their entirety by the Force and that some action has been taken since in order to address the shortcomings identified, I am concerned to note that two and a half years since the death of Ms Nield not all the recommendations of the DHR and IMR have yet been implemented . This is potentially putting other victims of domestic violence at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contact with domestic abuse victims after an alleged perpetrator is charged and granted conditional bail
Wider context from the report “4. There was little, if any, contact made with the deceased after her partner was charged and granted conditional bail by the Court following the allegation made on the 11th March 2016. Policy and Code were not followed.
” 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 Develop GMP’s first force policy and guidance on using warning markers.
Verbatim wording from the response “There is not currently a force policy or guidance document on warning markers. The decision whether to add a warning marker (WM) to an individual’s nominal profile (OPUS profile) depends solely on the professional judgement of officers.” Source location 2019-0477-Response-from-Greater-Manchester-Police-Redacted
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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 non-fatal-strangulation awareness training across frontline, student-officer and specialist adult-abuse investigator courses.
Verbatim wording from the response “At the time of Anne Marie’s death non-fatal strangulation was not terminology widely known by officers and no training had been given on it, as relatively little was then known about the incidence of non-fatal strangulation in DA victims. The term gained greater recognition as a consequence of some work between GMP and ████████ initially looking at non-fatal strangulation in other contexts but soon recognising that there was a potentially significant link to domestic abuse. As a consequence, the one-day safe-guarding course, which has been delivered since May 2018 to frontline officers, now includes reference to non-fatal strangulation as a specific risk factor for domestic homicide.” Source location 2019-0477-Response-from-Greater-Manchester-Police-Redacted
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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 training on DVDS, risk identification, DASH, RARA, risk levels and MARAC processes.
Verbatim wording from the response “As indicated by ████████ in the course of her evidence to the inquest, there were grounds on which a MARAC referral could have been made in Anne-Marie’s case. It is further accepted that use of, and disclosures pursuant to, the DVDS scheme have improved significantly in the intervening period. As part of the IPLDP initial and consolidation training and the Specialist Adult Abuse Investigators Course, training is provided on the DVDS scheme, as well as on risk identification, assessment and management by means of structured teaching on DASH. This includes the explanation of the RARA model and the definitions of Standard, Medium and High Risk. At the conclusion of the IPLDP, student officers also receive a further four hours training around risk identification and assessment and are then qualified to finalise their own cases that they deem to be “Standard Risk”.” Source location 2019-0477-Response-from-Greater-Manchester-Police-Redacted
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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 Compile recent similar incidents, identify common themes and report learning to the strategic domestic-violence lead.
Verbatim wording from the response “It is acknowledged that despite the aforementioned measures having been introduced that the training and learning has not been thoroughly embedded across GMP. To ensure that the recommendations of past reviews are considered and implemented in full, GMP’s Organisational Learning Board will compile recent similar incidents, look for common themes and report back to the Force’s strategic lead for domestic violence.” Source location 2019-0477-Response-from-Greater-Manchester-Police-Redacted
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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 domestic-abuse terminology training through student-officer, consolidation and Safeguarding for Constables courses.
Verbatim wording from the response “The existence of the Domestic Abuse Policy and the content of it are discussed in the student officer training in the initial stages of training and during consolidation training. As was acknowledged by ████████ during the inquest, GMP’s Domestic Abuse Policy does require updating and will include non-fatal strangulation as a heightened risk factor for victims of domestic abuse. The policy will also need to include significant structural changes within GMP in relation to public protection and a new operating system called iOPS. The structural, procedural and IT changes need to be embedded before the new policy can be written to ensure it is meaningful and fit for purpose by enabling police officers and staff to effectively respond to, and reduce incidents of, reports of domestic abuse.” Source location 2019-0477-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 Update the Domestic Abuse Policy to address non-fatal strangulation, public protection and iOPS changes.
Verbatim wording from the response “The existence of the Domestic Abuse Policy and the content of it are discussed in the student officer training in the initial stages of training and during consolidation training. As was acknowledged by ████████ during the inquest, GMP’s Domestic Abuse Policy does require updating and will include non-fatal strangulation as a heightened risk factor for victims of domestic abuse. The policy will also need to include significant structural changes within GMP in relation to public protection and a new operating system called iOPS. The structural, procedural and IT changes need to be embedded before the new policy can be written to ensure it is meaningful and fit for purpose by enabling police officers and staff to effectively respond to, and reduce incidents of, reports of domestic abuse.” Source location 2019-0477-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 Implement iOPS warning-marker functionality, including marker management, review notifications, provenance recording and audit details.
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.” Source location 2019-0477-Response-from-Greater-Manchester-Police-Redacted
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The first warning-marker policy and guidance document awaits assessment of the new system and mandatory public-inquiry reforms.
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 WMs. This will be completed when several key factors can be fully considered. This includes seeing the capability of our new iOPS system and awaiting mandatory reform requirements from the Anthony Granger Public Inquiry (which is likely to include necessary actions required around WMs). Part of this policy will be that officers and staff are actively encouraged to place appropriate WMs on police records to help manage risk.” Source location 2019-0477-Response-from-Greater-Manchester-Police-Redacted
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Serious Crime Division Coordination Unit is responsible for coordinating, recording and monitoring actions arising from post-incident recommendations.
Verbatim wording from the response “The Serious Crime Division Coordination (SCD) Unit are responsible for coordinating all recommendations received by GMP as part of any post-incident review or investigation and plan, record and monitor all action which is taken in response to those recommendations.” Source location 2019-0477-Response-from-Greater-Manchester-Police-Redacted
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Domestic Abuse Policy cannot be rewritten until related structural, procedural and information-technology changes are embedded.
Verbatim wording from the response “The existence of the Domestic Abuse Policy and the content of it are discussed in the student officer training in the initial stages of training and during consolidation training. As was acknowledged by ████████ during the inquest, GMP’s Domestic Abuse Policy does require updating and will include non-fatal strangulation as a heightened risk factor for victims of domestic abuse. The policy will also need to include significant structural changes within GMP in relation to public protection and a new operating system called iOPS. The structural, procedural and IT changes need to be embedded before the new policy can be written to ensure it is meaningful and fit for purpose by enabling police officers and staff to effectively respond to, and reduce incidents of, reports of domestic abuse.” Source location 2019-0477-Response-from-Greater-Manchester-Police-Redacted
Open published response
28 Dec 2018 Mr Gregory Rekowski · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 14 Failure to escalate welfare incidents to the on-call senior manager View source Lack of clarity about police powers and role for Section 136 from-home cases View source Lack of ward staff awareness of telephone restrictions affecting 111 calls View source Unavailability of an out-of-hours mental-health community response service for face-to-face assessment View source Unclear and delayed police-to-ambulance referral process for welfare concerns View source Delays in accepting and passing on welfare concerns because of confidentiality uncertainty View source Conflicting advice about which agency to contact for welfare concerns View source Failure to identify and disclose material call-handling information during investigation View source Absence of a documented Greater Manchester-wide process for welfare concerns involving risk to life View source Delays and failures in handling welfare concerns within acute inpatient psychiatric wards View source Incorrect completion of triage-system questions View source Insufficient investigation of deaths by NWAS View source Failure to provide face-to-face welfare assessment View source Mental-health telephone triage by staff with insufficient mental-health training View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Gregory Rekowski · 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
Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.
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 escalate welfare incidents to the on-call senior manager
Wider context from the report “No-one considered, at any stage the escalation of this incident to the on-call Senior manager when they were having difficulties contacting the emergency services or when GMP had provided the advice to contact NWAS.
” 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 about police powers and role for Section 136 from-home cases
Wider context from the report “There is a lack of acknowledgment of the role of the police when dealing with people who are taken on a Section 136 from their own home. The Court did not explore the numbers of Section 136 patients who are taken to a place of safety from their home address. The Court heard how Mr Rekowski had been taken from his own home on the 17th September. Other agencies are clearly familiar with this process and how GM policiante this was also used as an explanation as to why GMP may have been restricted in what they could do on the 27th and 28th October ie, “...there is nothing we can do if we attend at his home own. We have no powers.” There appears to be a significant difference between the legal position and the practical reality of how police deal with such matters if they are called to a home address. This inconsistency is causing confusion amongst 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 Lack of ward staff awareness of telephone restrictions affecting 111 calls
Wider context from the report “Non of the ward staff were aware of the restrictions on the ward telephones which prohibit 111 calls from being, this meant time was spent trying to make such calls .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an out-of-hours mental-health community response service for face-to-face assessment
Wider context from the report “The Court heard evidence there is no Mental Health Community Response team available to deal with mental health issues out of hours . The only out of hours service is in A&E which would necessitate someone attending there. Evidence was given as to the substantial increase in such issues being reported to GMP. The Court heard how there is now a mental health professional within the GMP control room to assist with the calls received. However the main issues are in attending to conduct face to face assessments . The police are the service who have a power to enter property, unlike other services. Therefore whilst they may not be best placed in respect of the assessment they are often called. Given the issue in respect of resources laid throughout this Inquest the Court would question the lack of this Mental Health provision .
” 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 and delayed police-to-ambulance referral process for welfare concerns
Wider context from the report “In this case GMP did not call NWAS and asked the nurses to contact NWAS . The Court heard evidence from the Deputy Sector manager for NWAS as to how GMP will contact them to attend concerns for welfare. This was not a process PCT staff were familiar with . This also led to a delay in the call being made .
” 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 accepting and passing on welfare concerns because of confidentiality uncertainty
Wider context from the report “The Court heard the calls between NK and NWAS. Advice was provided to NK that a concern for welfare could not be taken by them due to a potential “breach of confidentiality” . This led to a further delay in this concern for welfare call being passed to NWAS.
” 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 Conflicting advice about which agency to contact for welfare concerns
Wider context from the report “Evidence was heard from the Inpatient Services Manager of PCT of their understanding, that the Police are the organisation to call in relation to concerns for welfare (regarding risk to life). The Court heard PCT are still advised the police are the contact . In addition this the advice within the acute trusts.
” 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 identify and disclose material call-handling information during investigation
Wider context from the report “In cases involving the engagement of Article 2 ECHR there is duty on agencies to investigate the circumstances of the death in order to learn lessons. There was little investigation conducted by NWAS in respect of this case. It was only through the evidence of NK the Court heard of the existence of the 111 telephone calls she had attempted to make and the information provided to her. In addition until the evidence of PR the Court had not been advised of the removal of the call from the allocation list and the decision made this could be triaged by urgent care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Absence of a documented Greater Manchester-wide process for welfare concerns involving risk to life
Wider context from the report “It was clear to the Court from all Senior Managers that there was a distinct lack of understanding across all three agencies of each agencies roles/responsibilities, systems of working and current practices in relation to concerns for welfare involving risk to life (not immediate to someone in the process of harming themselves). The evidence to the Court was of a confused picture across Greater Manchester with no clear guidance as to how to deal with such matters. Moreover it was apparent there is no documented GM wide process to allow staff on the ground clear information as to how to deal with such matters.
” 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 and failures in handling welfare concerns within acute inpatient psychiatric wards
Wider context from the report “The Court heard from the nurses who were tasked to raise a concern for welfare of the practical time difficulties in doing this , given they were working on an acute in-patient psychiatric ward. It was unclear why the clinical lead did not deal with this matter as she was the person to whom the information had initially been provided.
” 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 Incorrect completion of triage-system questions
Wider context from the report “The Court heard how the call was graded as a Grade 3 however when taken through the evidence in Court several questions on the triage system had been incorrectly completed .
” 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 investigation of deaths by NWAS
Wider context from the report “In cases involving the engagement of Article 2 ECHR there is duty on agencies to investigate the circumstances of the death in order to learn lessons. There was little investigation conducted by NWAS in respect of this case . It was only through the evidence of NK the Court heard of the existence of the 111 telephone calls she had attempted to make and the information provided to her. In addition until the evidence of PR the Court had not been advised of the removal of the call from the allocation list and the decision made this could be triaged by urgent care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide face-to-face welfare assessment
Wider context from the report “The decision to remove the concern for welfare call from the allocation list to be triaged by Urgent care meant no face to face assessment was conducted . Moreover the telephone triage call was conducted by a RGN who had limited mental health training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Mental-health telephone triage by staff with insufficient mental-health training
Wider context from the report “The decision to remove the concern for welfare call from the allocation list to be triaged by Urgent care meant no face to face assessment was conducted. Moreover the telephone triage call was conducted by a RGN who had limited mental health training .
” 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 Operate a 24/7 control-room triage service staffed by mental health professionals alongside police communications staff.
Verbatim wording from the response “Control Room Triage
In 2017 North West Boroughs Healthcare NHS Foundation Trust were commissioned to deliver a pilot control room triage (CRT) service in partnership with Greater Manchester Mental Health, Pennine Care NHS Foundation Trust and GMP. This followed a successful business case for an initial 18-month pilot during which two mental health professionals would work alongside GMP staff within the Operational Communications Branch (OCB) 24/7, supporting the police and existing frontline services’ response to mental health demand within GMP calls.” Source location 2018-0411-Response-by-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 Consider better disseminating police powers, obligations and limitations to partner agencies through joint working initiatives.
Verbatim wording from the response “It is accepted that there may be a requirement to improve the understanding amongst partner agencies about police powers in responding to concerns for welfare where the person in question is in a private dwelling. However, the police officers who gave evidence as part of the inquest proceedings demonstrated that they had an accurate understanding of their powers – and the limitations thereon – under s.136. Where a concern for welfare is received in relation to an individual who is within a private dwelling, there is an option under s.135 of the same Act to require the attendance of qualified mental health practitioners to undertake a formal mental health assessment, following which it will be possible for officers to convey an individual found to require detention under the Act to a health-based place of safety.” Source location 2018-0411-Response-by-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 Detention under section 136 was lawful because the person was found in the street, not a private dwelling.
Verbatim wording from the response “Response: Had Mr Rekwowski been taken to hospital under s.136 of the Mental Health Act 1983 (MHA) from his home address on 17 September 2017, this would have been unlawful as the exercise of powers under s.136 requires that the person who is the subject of detention is not in their own home (s.136(1A)). When police attended on 17 September, Mr Rekwowski was, in actual fact, found to be in the street and was lawfully detained pursuant to the police’s s.136 powers as he was not in a private dwelling. This is confirmed within police documentation disclosed in the Inquest proceedings:” Source location 2018-0411-Response-by-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 CRT cannot respond to all mental-health incidents because demand exceeds its commissioned capacity and requires triage.
Verbatim wording from the response “However, it must be recognised that the most significant limitation on the service is the availability of CRT resources. The volume of incidents where a relevant person has mental health needs exceeds CRT capacity and this burden requires the VSU to act as a filter focusing CRT staff time to providing the commissioned service.” Source location 2018-0411-Response-by-Greater-Manchester-Police
Open published response
Concerns raised 14 Failure to make a contemporaneous record of reversal of resource-allocation decisions View source Lack of solid resource commitment to prevent recurrence View source Failure to keep minutes of resource-allocation decisions View source Lack of formal training in risk assessment and child mental health View source Failure to allocate FWIN 0405 View source Failure to make a service call to family members for reassurance View source Failure to provide written rationale for FWIN delays View source Failure to communicate resource-allocation decisions to those who need to know View source Lack of set minimum staffing levels View source Failure to adequately recognise the significance of complex mental health issues in risk assessment View source Delays in processing FWIN 0405 View source Failure to ensure on-duty officer numbers match required staffing levels View source Failure to record rationale for decisions not to allocate additional cover or resources View source Intentional disregard of Force policies and protocols by staff View source See 11 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
Establish recurring resource-planning and dynamic-management meetings with minuted discussions, recorded decisions and circulated outcomes.
Stated completedThe respondent said that this action was complete when they made their response on 11 August 2016. View source
Action
Require the Operational Communications Branch to recall informants or relevant parties within 40 minutes to explain allocation delays and reassess vulnerability, threat, harm and risk.
Stated completedThe respondent said that this action was complete when they made their response on 11 August 2016. View source
Action
Develop a business case for posting two mental-health professionals to the Operational Communications Branch during key demand periods.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 August 2016. View source
Action
Review, launch, disseminate and apply the FWIN Escalation Policy with defined responsibilities, risk assessment, escalation, resourcing and delay-recording requirements.
Stated completedThe respondent said that this action was complete when they made their response on 11 August 2016. View source
Action
Increase front-line capacity by relocating Neighbourhood Police Officers to Response teams.
Stated completedThe respondent said that this action was complete when they made their response on 11 August 2016. View source
Action
Implement demand-based divisional deployment arrangements, including revised shift patterns and resource planning through the Local Policing Review.
Stated completedThe respondent said that this action was complete when they made their response on 11 August 2016. View source
Action
Deliver vulnerability, mental-health and suicide-prevention training for Operational Communications Branch staff, including professional-curiosity, safeguarding and child mental-health content.
Stated completedThe respondent said that this action was complete when they made their response on 11 August 2016. View source
Action
Introduce quality-assurance audits of incident management, with staff feedback and development action plans where performance falls below standard.
Stated completedThe respondent said that this action was complete when they made their response on 11 August 2016. View source
Action
Set minimum staffing levels for Operational Communications Branch Command and Control.
Stated completedThe respondent said that this action was complete when they made their response on 11 August 2016. View source See 6 more actions
×
AI-generated summary
Thomas Martin Gallagher · 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
Thomas Martin Gallagher, aged 16, died by hanging after leaving home on 10 July 2015 and being found suspended from a tree in a nearby park the following morning. The report identified concerns about police handling of the missing-person call, including 14 unexplained delays, failure to allocate the incident or contact the family during the initial hour, inadequate staffing, and failures to follow relevant procedures.
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 a contemporaneous record of reversal of resource-allocation decisions
Wider context from the report “5. That when decisions were taken not to allocate additional cover/resources:
i) no rationale was recorded,
ii) no minutes were kept in relation to the decisions taken during the Monday meeting
iii) no contemporaneous record was made by the Chief Inspector regarding his decision to reverse the earlier agreement to allocate additional resources
&,
iv) the Chief inspector did not communicated his decision to those who needed to know.
” 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 solid resource commitment to prevent recurrence
Wider context from the report “6. Despite hearing evidence on the positive steps taken by GMP since Tom’s death, there was no solid evidence of resource commitment to prevent recurrence .
” 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 keep minutes of resource-allocation decisions
Wider context from the report “5. That when decisions were taken not to allocate additional cover/resources:
i) no rationale was recorded,
ii) no minutes were kept in relation to the decisions taken during the Monday meeting
iii) no contemporaneous record was made by the Chief Inspector regarding his decision to reverse the earlier agreement to allocate additional resources
&,
iv) the Chief inspector did not communicated his decision to those who needed to know.
” 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 training in risk assessment and child mental health
Wider context from the report “1. The lack of formal training in relation to risk assessment and child mental health .
” 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 allocate FWIN 0405
Wider context from the report “9. That FWIN 0405 went unallocated (despite some evidence of attempts to resource) resulting in the very important ‘Golden Hour’ being missed.
” 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 make a service call to family members for reassurance
Wider context from the report “10. That no service call was made to Tom’s family to reassure them that they had not been forgotten .
” 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 written rationale for FWIN delays
Wider context from the report “8. That almost all of the delays placed on the FWIN were without written rationale .
” 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 resource-allocation decisions to those who need to know
Wider context from the report “5. That when decisions were taken not to allocate additional cover/resources:
i) no rationale was recorded,
ii) no minutes were kept in relation to the decisions taken during the Monday meeting
iii) no contemporaneous record was made by the Chief Inspector regarding his decision to reverse the earlier agreement to allocate additional resources
&,
iv) the Chief inspector did not communicated his decision to those who needed to know .
” 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 set minimum staffing levels
Wider context from the report “3. That the Force has no set minimum staffing levels , including within divisional response and the OCB.
” 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 adequately recognise the significance of complex mental health issues in risk assessment
Wider context from the report “It was clear from the initial ‘1-12’ and the additional information recorded by the call taker within FWIN 0405 that Tom was not only vulnerable by virtue of his age but also due to the fact that he had complex mental health issues, the significance of which was arguably understated as a result of point 1 above .
It was accepted during the course of the evidence that the ‘1-12’ had been an initial assessment of risk only.
” 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 processing FWIN 0405
Wider context from the report “7. That there were 14 delays placed on FWIN 0405 .
” 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 on-duty officer numbers match required staffing levels
Wider context from the report “4. That when the persistently low staffing levels were brought to the attention of GMPS’ SLT, on more than one occasion, insufficient action was taken so as to ensure that the number of officers on duty matched those identified as being required ‘on paper’ .
” 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 rationale for decisions not to allocate additional cover or resources
Wider context from the report “5. That when decisions were taken not to allocate additional cover/resources:
i) no rationale was recorded ,
ii) no minutes were kept in relation to the decisions taken during the Monday meeting
iii) no contemporaneous record was made by the Chief Inspector regarding his decision to reverse the earlier agreement to allocate additional resources
&,
iv) the Chief inspector did not communicated his decision to those who needed to know.
” 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 Intentional disregard of Force policies and protocols by staff
Wider context from the report “2. Save for the initial handler, that all staff demonstrated intentional disregard of Force policies and protocols - including those with operational/management responsibilities and the Operational Communications Branch (OCB - see above).
” 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 Establish recurring resource-planning and dynamic-management meetings with minuted discussions, recorded decisions and circulated outcomes.
Verbatim wording from the response “Subsequent to the death of Thomas, a fortnightly resource planning meeting has been instigated where discussions take place around staffing levels and long term resourcing. There is also a weekly Divisional Leadership Meeting for Inspectors and above, during which any issues around staffing can be raised to enable planning and to ensure projected busy dates are catered for. Dynamic Resource Management Meetings are also held as required between shift Supervisors and the Divisional Resource Management Unit for short notice items to be highlighted and resolved by Sergeants and Inspectors. These meetings are now minuted, decisions are recorded by the chair and circulated to all those who need to know to ensure there is a transparent and auditable record. It is proposed that the learning from this case, will be cascaded to all Territorial Commanders.” Source location Thomas-Gallagher-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require the Operational Communications Branch to recall informants or relevant parties within 40 minutes to explain allocation delays and reassess vulnerability, threat, harm and risk.
Verbatim wording from the response “further information and work with them to progress matters pending a resource being available. The escalation (June 2016) policy has been amended to:” Source location Thomas-Gallagher-Response
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 business case for posting two mental-health professionals to the Operational Communications Branch during key demand periods.
Verbatim wording from the response “In addition to this, GMP is developing a business case to have two mental health professionals posted to the OCB during key demand times to professionalise the Police response to mental health calls by identifying high risk incidents and speaking directly with callers to seek more relevant information, ensuring a commensurate response is directed, better assisting the person in need.” Source location Thomas-Gallagher-Response
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, launch, disseminate and apply the FWIN Escalation Policy with defined responsibilities, risk assessment, escalation, resourcing and delay-recording requirements.
Verbatim wording from the response “The FWIN Escalation Policy has been reviewed by the OCB Senior Leadership Team (SLT) to include clearly defined roles and responsibilities for all OCB staff. The reviewed policy was prepared in June 2016 with a formal launch across Force in August 2016.” Source location Thomas-Gallagher-Response
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 Increase front-line capacity by relocating Neighbourhood Police Officers to Response teams.
Verbatim wording from the response “In November 2015, the Superintendent at Bury made the move to increase front line numbers by relocating Neighbourhood Police Officers back to Response teams. Whilst recognising this impacted upon the ability of officers to conduct ‘early interventions’ and engage in long term ‘problem solving’, it was felt that this decision was necessary to service the demand for front line officers. Additionally, this prepared officers for the ‘Local Policing Review’. Prior to this, there had been calls on a divisional level for an increase in officer numbers from front line supervision.” Source location Thomas-Gallagher-Response
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 demand-based divisional deployment arrangements, including revised shift patterns and resource planning through the Local Policing Review.
Verbatim wording from the response “The Divisional SLT at Bury have analysed predicted demand which has been mapped against available local resources throughout any 24/7 period to meet that demand. The Division deploys between 10 and 40 officers at any given time based upon seasonal adjustments, predictive crime analysis and planned events.” Source location Thomas-Gallagher-Response
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 vulnerability, mental-health and suicide-prevention training for Operational Communications Branch staff, including professional-curiosity, safeguarding and child mental-health content.
Verbatim wording from the response “The Target Operating Model contains the guiding principles for GMP, expressly highlighting vulnerability as a priority. In line with this principal, and following ratification by the Organisational Learning Board, the Operational Communications Branch (OCB) has implemented a programme of staff training. The emphasis within this training is on developing professional curiosity to recognise, identify and respond to vulnerability and ensure effective steps are taken to safeguard the vulnerable through mitigation of risk.” Source location Thomas-Gallagher-Response
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 quality-assurance audits of incident management, with staff feedback and development action plans where performance falls below standard.
Verbatim wording from the response “A Quality Assurance ‘audit’ process has been introduced to review incident management by individual staff, enabling a feedback mechanism, post assessment, highlighting good and poor performance. OCB Managers have been tasked to ensure that:” Source location Thomas-Gallagher-Response
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 Set minimum staffing levels for Operational Communications Branch Command and Control.
Verbatim wording from the response “The OCB has set minimum staffing levels with regard to Command & Control. Sickness absence can adversely affect those levels and when sickness is reported at short notice, it may prevent additional staffing being made available to cover.” Source location Thomas-Gallagher-Response
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 Short-notice sickness absence may prevent additional staffing from being provided to maintain minimum staffing levels.
Verbatim wording from the response “The OCB has set minimum staffing levels with regard to Command & Control. Sickness absence can adversely affect those levels and when sickness is reported at short notice, it may prevent additional staffing being made available to cover.” Source location Thomas-Gallagher-Response
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 Fixed divisional staffing levels are not considered necessary because predictive demand models and flexible resource management are used instead.
Verbatim wording from the response “It is correct to say that ‘minimum staffing’ levels for Neighbourhood Policing teams have not been set at a Divisional level: When considering overall demand and the complexities of Policing Manchester, setting a fixed level of resources may have perverse outcomes when responding to cross border incidents and in providing mutual aid in times of emergency. Predictive models based upon extensive analysis provide GMP with a basis on which to meet demand in a way that best protects the Public. Applying an arbitrary target could potentially cause harm in limiting resource management flexibility across the entirety of Greater Manchester.” Source location Thomas-Gallagher-Response
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 College of Policing is responsible for addressing the absence of child-specific mental-health content in national guidance.
Verbatim wording from the response “The current National Police Improvement Agency (NPIA) guidance provided by The College of Policing ‘Responding to People with Mental Ill Health or Learning Disabilities’ relates to a training package launched in 2010. This does not separately deal with Children’s Mental Health and is an issue that is to be addressed with the College of Policing - at the time of Thomas’s death this was the guidance GMP officers were working to.” Source location Thomas-Gallagher-Response
Open published response
18 May 2016 Christopher Philip Fields · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to safeguard an injured or intoxicated vulnerable person before police departure View source Failure to protect a witness from an assailant during police information gathering View source Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients View source Delays in ambulance response to coded emergency calls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christopher Philip Fields · 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
Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red response.
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 safeguard an injured or intoxicated vulnerable person before police departure
Wider context from the report “1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived . Sometime later, the assailant re-entered the flat and beat the deceased to his death.
Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner , why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated , why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found ?
Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE)
” 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 protect a witness from an assailant during police information gathering
Wider context from the report “1. The police were called to the address after the first assault had occurred and were still in attendance when the assailant re-entered the premises via the broken window, which he had smashed out of its frame when entering the first time. Despite this rather bizarre set of occurrences, the police then decided to leave the deceased before the ambulance service arrived. Sometime later, the assailant re-entered the flat and beat the deceased to his death.
Various issues arise as a result of the police actions, being why did they leave a vulnerable person in this manner, why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated, why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him in the situation in which he was found?
Are there issues of training for all GMP officers or did the officers fail to adhere to the approved guidance? (POLICE)
” 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 ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients
Wider context from the report “3. The fact that the call taker coded the call properly and yet this case involved a patient who was clearly critically injured and despite that fact still did not generate a Red response , suggests that the algorithms used for coding are not accurate and not fit for purpose . In my view this is an extremely serious flaw and may/will lead to future deaths occurring unless it is remedied . (NWAS, SECRETARY OF STATE and NHS ENGLAND)
” 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 ambulance response to coded emergency calls
Wider context from the report “2. The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes . In the event, the vehicle did not arrive for 2 hours 8 minutes . Why was the response time so dramatically lengthier than prescribed and is this a matter of resources? (NWAS)
” Open source report
15 Apr 2016 Adele Blakeman · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of the GMP computer system to provide officers with timely access to important information View source Failure to escalate calls for divisional Inspector review View source Lack of understanding of the IMU role in missing person enquiries View source Failure to record pertinent information in individuals’ intelligence profiles 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
Adele Blakeman · 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
Adele Blakeman, who had a history of mental health difficulties and self-harming behaviour, died after taking her own life at Gateley Railway Station on 28 September 2015. The substantive concerns included failures in police information recording and access, classification and escalation of the call, timely allocation of resources, and understanding of the role of the Missing Persons Unit.
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 the GMP computer system to provide officers with timely access to important information
Wider context from the report “1. The GMP computer system hinders officers and does not afford them easy access to important information within the time scales they have available to them , in order for them to adequately assess a situation. Concerns around the efficiency of GMPs antiquated computer system have been raised now on a number of occasions and have featured in several inquests
” 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 calls for divisional Inspector review
Wider context from the report “3. There was a failure to escalate this call as per the escalation procedure to a divisional Inspector for a review
” 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 the IMU role in missing person enquiries
Wider context from the report “4. There is a lack of understanding of the role of the IMU in missing person enquiries .
” 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 pertinent information in individuals’ intelligence profiles
Wider context from the report “2. There is a failure by officers to record pertinent information about an individual on the intelligence section of an individuals nominal profile . There were 5 PPI logs available to Officers no crucial pertinent information from these logs had been placed on her intelligence section , officers would have had to access each of these logs individually and read through the entire entries to elicit any information which may have been relevant. For example the fact that 4 of them involved this individual attending at railway stations or level crossings with a view to attempting to commit suicide. There was also on one mention of involving BTP should there be concerns about this individual, this partnership working was lost in the midst of one PPI Log .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and implement the FWIN Escalation Policy using threat, risk and harm assessments and the National Decision Model.
Verbatim wording from the response “In March 2016 Chief Inspector 05718 ████████ from the Operational Communications Branch (OCB) revised the FWIN Escalation Policy the revised version is currently at the end of the consultation phase.” Source location 2016-0145-Response-by-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 Distribute mobile technology to operational staff to provide frontline officers direct access to GMP systems and information.
Verbatim wording from the response “GMP is investing significantly in the replacement of technology through the IS Transformation Programme to replace existing separate command and control, custody, intelligence, work allocation, and property systems with one user experience and a more intelligence information management process that enables partner agency information sharing (iOPS). The programme will also improve integration of components outside of these core systems, replace ageing data warehouse capabilities and moving to a data centre managed externally by a reliable supplier. Also as part of this programme of work, mobile technology is being distributed to operational staff which is already demonstrating through a pilot site a significant forwards step in information access, input, and decision-making.” Source location 2016-0145-Response-by-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 Replace separate command, control, custody, intelligence, work allocation and property systems through the IS Transformation Programme.
Verbatim wording from the response “GMP is investing significantly in the replacement of technology through the IS Transformation Programme to replace existing separate command and control, custody, intelligence, work allocation, and property systems with one user experience and a more intelligence information management process that enables partner agency information sharing (iOPS). The programme will also improve integration of components outside of these core systems, replace ageing data warehouse capabilities and moving to a data centre managed externally by a reliable supplier. Also as part of this programme of work, mobile technology is being distributed to operational staff which is already demonstrating through a pilot site a significant forwards step in information access, input, and decision-making.” Source location 2016-0145-Response-by-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 Highlight the Information Management Unit’s role in triaging missing-from-home incidents through Divisional Orders.
Verbatim wording from the response “In light of this regulation 28, the role of the Information Management Unit has been highlighted throughout the OCB via inclusion on Divisional Orders on 27th May 2016. This highlights their role in the triage of MFH incidents amongst their other duties.” Source location 2016-0145-Response-by-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 Remind Public Protection Investigation Unit supervisors to quality-assure vulnerable-adult PPI logs, submit relevant intelligence and review warnings on finalisation.
Verbatim wording from the response “In respect of PPI logs, it is the responsibility of the officer submitting the PPI to submit any relevant intelligence from within the report.” Source location 2016-0145-Response-by-Greater-Manchester-Police
Open published response
7 Apr 2016 Joyce Carney · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 4 Lack of agreed police-hospital protocols for joint risk assessments and liaison View source Failure of police-hospital liaison and communication during risk assessment of police-supervised hospital patients View source Failure of risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff View source Failure of senior police officers to reassess risk after concerns about an agitated patient threatening to leave hospital View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joyce Carney · 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
Joyce Carney, who had diabetes and dementia, was knocked to the floor in a hospital corridor by another patient running away from Police Officers. She sustained a fractured neck of femur, underwent surgery, developed infections and deteriorated before dying on 11 February 2015. The principal concerns were the lack of communication and joint risk assessment between Police and Hospital staff, and the absence of protocols to protect other patients, visitors, the public and staff when patients are supervised by Police Officers.
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 agreed police-hospital protocols for joint risk assessments and liaison
Wider context from the report “iv. There are no agreed protocols, policies or procedures between the Greater Manchester Police and the Royal Albert Edward Infirmary, Wigan in relation to joint risk assessments for patients detained at the Hospital under arrest or in the presence of or supervised by Police Officers. Furthermore there is no protocol, in relation to liaison and consultation between the Greater Manchester Police and the Hospital to formulate risk assessments in relation to patients detained at the Hospital under arrest or in the presence of or supervised by Police Officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure of police-hospital liaison and communication during risk assessment of police-supervised hospital patients
Wider context from the report “i. When the Patient was moved to Lowton Ward in the Hospital the risk assessment conducted by the Hospital in relation to the location of the Patient in the Ward involved the Bed Manager, the Ward Manager and the Nurses treating the Patient. The risk assessment did not involve, nor include, the Police Officers who were observing a patient. The risk assessment conducted by the Hospital focussed on the safety of the Patient and did not extend to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and members of staff employed in the Hospital.
ii. The risk assessment conducted by Police Officers, in relation to the Patient at the Hospital, focussed on the Patient and the fact that the Patient may seek to leave the Hospital but the assessment did not include any discussions or liaison with Hospital staff. The risk assessment did not include the protection of other patients in the Hospital, visitors to the Hospital, members of the public or staff employed in the Hospital.
iii. There was no liaison or communication between the Police Officers observing the Patient and the Hospital treating the Patient in relation to the layout of the Hospital or with regard to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital.
” 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 risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff
Wider context from the report “i. When the Patient was moved to Lowton Ward in the Hospital the risk assessment conducted by the Hospital in relation to the location of the Patient in the Ward involved the Bed Manager, the Ward Manager and the Nurses treating the Patient. The risk assessment did not involve, nor include, the Police Officers who were observing a patient. The risk assessment conducted by the Hospital focussed on the safety of the Patient and did not extend to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and members of staff employed in the Hospital.
ii. The risk assessment conducted by Police Officers, in relation to the Patient at the Hospital, focussed on the Patient and the fact that the Patient may seek to leave the Hospital but the assessment did not include any discussions or liaison with Hospital staff. The risk assessment did not include the protection of other patients in the Hospital, visitors to the Hospital, members of the public or staff employed in the Hospital.
iii. There was no liaison or communication between the Police Officers observing the Patient and the Hospital treating the Patient in relation to the layout of the Hospital or with regard to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital.
” 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 senior police officers to reassess risk after concerns about an agitated patient threatening to leave hospital
Wider context from the report “Furthermore the Officers at the Hospital raised concerns with their Supervising Officer, namely a Sergeant at the Police Station, in relation to the Patient being agitated and threatening to leave the Hospital during the afternoon of the 21st December 2014 but neither the Sargent nor any other senior Officer attended the Hospital to conduct any further risk assessment or to reassess the situation .
” Open source report
28 Oct 2015 Christopher John Smith · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Failure to immediately establish responsibility for calling an ambulance 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
Christopher John Smith · 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
Christopher John Smith died instantaneously after jumping from Barton Bridge on 15 July 2015. The principal concern was a 12-minute delay in contacting the ambulance service, caused by a communication breakdown about which service was responsible for making the call, although this did not affect the outcome in this case.
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 immediately establish responsibility for calling an ambulance
Wider context from the report “1) It was clear from the evidence that there was a 12 minute delay in the police contacting the ambulance – the police were notified of the incident but did not contact North West Ambulance Service immediately .
2) In the circumstances of this Inquest I was satisfied that this delay had not had any relevance with regards to Christopher Smith’s death, given that the pathologist had concluded that his death was instantaneous. Any delay in the ambulance arriving was therefore not going to save his life.
3) However, it is perfectly possible to foresee circumstances where a delay in calling for an ambulance may have an effect on the outcome , where someone has jumped or fallen from a lesser distance.
4) I was told that the 12 minute delay was due to a breakdown in communication between Greater Manchester Police control room and the Motorway Control – Greater Manchester Police thought that the Motorway Control were contacting the ambulance and vice versa .
5) It seems to me that procedure should be in place whereby it is immediately established who is going to be responsible for calling the ambulance to avoid any delays, and the ambulance is called for at once.
” Open source report
7 Aug 2015 Ronald Arthur Laidlar · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 High likelihood of violent crimes remaining undetected View source Failure to take fingerprints at the crime scene View source Failure to conduct and verify thorough searches of a deceased person's clothing View source Inadequate investigation of crime-scene evidence and circumstances View source Failure to test the source of blood at a crime scene View source Failure to investigate unexplained blood without relying on an unsupported assumption View source Failure to investigate missing personal property and consider its significance in crime-scene assessment View source Failure to identify and assess injuries relevant to possible third-party involvement View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ronald Arthur Laidlar · 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
Ronald Arthur Laidlar was discovered deceased in the driveway of his house, naked from the waist down and with a considerable amount of blood around his head. The report raised concerns about missing personal property, inadequate searches and scene investigation, failure to test blood evidence or take fingerprints, and insufficient consideration of possible third-party involvement.
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 High likelihood of violent crimes remaining undetected
Wider context from the report “8. If the level of investigation is as poor generally as it was in this case, then the possibility of crimes of violence remaining undetected remains high and therefore the chances of future deaths occurring is increased .
” 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 take fingerprints at the crime scene
Wider context from the report “7. No fingerprints were taken at the scene.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct and verify thorough searches of a deceased person's clothing
Wider context from the report “2. The body was allegedly searched by detective officers and crime scene investigators at the scene. The clothing of the deceased was also similarly “thoroughly searched” and in his statement to the inquest signed on the 14th March 2015, the investigating detective sergeant states (inter alia) “the issue of the missing wallet and ring remain unresolved”. In fact the wallet was found by the relatives of the deceased in the pocket of his trousers which had apparently been thoroughly searched by the police . The sergeant’s evidence then changed to “there is a strong chance they were overlooked ”.
” 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 investigation of crime-scene evidence and circumstances
Wider context from the report “3. The sergeant initially gave evidence that the trousers of the deceased were round his ankles. When shown the crime scene photographs proving this not to be the case, he then said “in truth the trousers were at the scene with his socks and shoes”. The general level of investigation of these matters fell well short of that which the public should be able to expect.
” 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 test the source of blood at a crime scene
Wider context from the report “4. At the scene there was a lot of blood about the deceased’s body and elsewhere. In answer to a question put by the coroner, the police officer confirmed that no checks had been made to test whether the blood was all from the deceased or whether there was anyone else’s blood present .
” 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 unexplained blood without relying on an unsupported assumption
Wider context from the report “5. The officer confirmed that they (the police) were told the deceased suffered from frequent nosebleeds and therefore assumed this accounted for the blood . The consultant pathologist confirmed there was no sign of any blood in or around the nose or mouth. There was again a lack of “curiosity” on the part of the officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate missing personal property and consider its significance in crime-scene assessment
Wider context from the report “1. The daughter of the deceased maintains that her father was wearing a wedding ring which he always wears. In the crime scene photographs, this ring is not apparent and there was no evidence to where it might be. There was no investigation as to whether it had been stolen . Local pawn shops were subsequently visited but with no success. The fact that this was missing does not seem to have been a factor in the assessment as to whether this was a crime scene .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and assess injuries relevant to possible third-party involvement
Wider context from the report “6. The sergeant gave evidence that there were no marks to indicate or support third party involvement . The consultant pathologist found “a small round laceration on the right temple area measuring 0.5cm across which appeared full depth through the skin” . This laceration to the scalp and the bleeding from it, was in fact one of the prime causes of death.
” Open source report
7 Jul 2015 Yvonne Davies and Andrew Francis Davies · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure of attending officers to secure the scene and remove an off-duty colleague View source Failure to prevent an off-duty police officer from contaminating a forensic scene View source Failure of an off-duty police officer to withdraw from a forensic scene 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
Yvonne Davies and Andrew Francis Davies · 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
Yvonne Davies was stabbed in the neck by her husband, Andrew Davies, who then hanged himself. The report raised concerns that an off-duty police officer entered and moved around the scene, potentially contaminating it, and was not removed by the first attending officers.
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 attending officers to secure the scene and remove an off-duty colleague
Wider context from the report “3. Neither of the first two attending officers secured the scene and removed their off-duty colleague from the house.
” 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 prevent an off-duty police officer from contaminating a forensic scene
Wider context from the report “1. The person with whom Mrs Davies was alleged to be having an affair, is a serving GM police officer (he admitted the affair in evidence) and despite the fact that he was off-duty, he was first to the scene of these deaths and using powers under the Police and Criminal evidence Act he broke in to the house . He then proceeded to move around the house, using the sleeve of his pullover when opening doors. By so doing he contaminated the scene for DNA etc.
” 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 an off-duty police officer to withdraw from a forensic scene
Wider context from the report “2. Even when the first two on-duty police officers arrived, he did not remove himself from the property but continued moving around and entered the kitchen area where the body of the wife lay.
” Open source report
7 Jul 2015 Michael Lee Thorley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to examine unexplained discrepancies in telephone location View source Failure of Detective Inspector attendance at this type of death scene View source Delays in gaining entry to premises when a caller may have collapsed inside View source Failure to consider and test alternative third-party involvement in the scene investigation View source Failure to identify relevant medication containers during premises searches View source Lack of a clearly thought-out and applied policy for forced entry decisions View source Failure to account for unexplained absence of drug paraphernalia and opened medication at the scene 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 Lee Thorley · 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 Lee Thorley was found at his home after a delay in gaining entry following an emergency ambulance call. The medical cause of death was combined opiate/opioid toxicity, and the pathologist said there was a chance his life might have been saved if naloxone had been administered immediately. The report raised concerns about the delay in entry, the absence of a clear policy for forced entry, shortcomings in searching and investigating the scene, and the failure of a Detective Inspector to attend.
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 examine unexplained discrepancies in telephone location
Wider context from the report “4. The telephone which was used to make the call was found (after the ambulance service re-called it), well away from the body. No explanation for this was forthcoming. This issue was not even considered as needing examination by the attending officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Failure of Detective Inspector attendance at this type of death scene
Wider context from the report “6. The Detective Inspector did not attend the scene on the day as it was deemed not a Special Procedure Death and not one where he needed to attend. The representative of the Professional Standards Branch concurred with the view expressed by the Coroner that a D.I. should turn out to this type of death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Delays in gaining entry to premises when a caller may have collapsed inside
Wider context from the report “1. There was an inordinate and inexcusable delay in gaining entry to the premises where it was known that the caller to the ambulance service had apparently collapsed mid-call.
” 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 and test alternative third-party involvement in the scene investigation
Wider context from the report “5. None of the investigating officers considered that a third party may have made the phone call and then tidied up the flat and left, locking the door from the outside. When the officers gained entry there was no drug paraphernalia nor were there any opened prescribed medication packets. There was a large quantity of prescribed medication, none of which had been opened. There was no explanation as to why or how this situation may have arisen. This despite the fact that it was known that the deceased’s friend had been present the previous night/early morning, and that she could have had a key. It was assumed that the door had been locked from the inside although there was no evidence to support that contention.
” 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 identify relevant medication containers during premises searches
Wider context from the report “3. When the officers searched the premises they failed to find approximately five empty methadone bottles which were in a kitchen cupboard.
” 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 clearly thought-out and applied policy for forced entry decisions
Wider context from the report “2. There was no clearly thought-out and applied policy as to whether it was better to risk breaking down a door unnecessarily or whether to risk the life of someone who may be collapsed inside.
” 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 unexplained absence of drug paraphernalia and opened medication at the scene
Wider context from the report “5. None of the investigating officers considered that a third party may have made the phone call and then tidied up the flat and left, locking the door from the outside. When the officers gained entry there was no drug paraphernalia nor were there any opened prescribed medication packets. There was a large quantity of prescribed medication, none of which had been opened. There was no explanation as to why or how this situation may have arisen. This despite the fact that it was known that the deceased’s friend had been present the previous night/early morning, and that she could have had a key. It was assumed that the door had been locked from the inside although there was no evidence to support that contention.
” 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 Use the case example in method-of-entry training to teach officers to balance legal entry thresholds with indicators requiring urgent entry to save life.
Verbatim wording from the response “The Specialist Operational Training Unit which is responsible for training officers in both decision making and tactics will use this example during their method of entry training modules. They will highlight the need to balance the thresholds required for entry under Section 17 PACE Act with factors that indicate urgent entry is required to save life. In addition an internal message will be issued forcewide to encourage and empower officers reluctant to execute forced entry tactics in cases where there is concern for welfare. The” Source location 2015-0260-Response-by-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 Issue a forcewide message encouraging and empowering officers to use forced entry when welfare concerns justify it.
Verbatim wording from the response “The Specialist Operational Training Unit which is responsible for training officers in both decision making and tactics will use this example during their method of entry training modules. They will highlight the need to balance the thresholds required for entry under Section 17 PACE Act with factors that indicate urgent entry is required to save life. In addition an internal message will be issued forcewide to encourage and empower officers reluctant to execute forced entry tactics in cases where there is concern for welfare. The” Source location 2015-0260-Response-by-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 No policy issues are known to have affected the officers’ decisions in this case.
Verbatim wording from the response “It is apparent that most officers understand their powers of entry and are willing and able to force entry when it is clearly necessary and appropriate. However it seems that there are some occasions when the particular circumstances and the available information appear to cause a degree of hesitation. Our training and prioritisation is clearly emphasising public safety, and I am not aware of any policy issues that might have affected the officers’ decisions in this particular case.” Source location 2015-0260-Response-by-Greater-Manchester-Police
Open published response
12 May 2015 Paul Mc Guigan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 16 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment View source Lack of recording of pre-conviction disclosures View source Lack of understanding of overseas armed close protection work View source Lack of guidance and transfer arrangements for MAPPA-triggering offenders View source Lack of computer categorisation for close protection occupations View source Lack of clear procedure and funding responsibility for independent forensic psychiatric reports View source Lack of training for officers and civilian employees on disclosure procedures View source Failure to understand and operate the Notifiable Occupation Scheme View source Failure to consider disclosure to employers View source Inadequate and infrequent formal supervision of newly qualified offender managers View source Lack of a national system and contact point for obtaining military information View source Failure to record discussions among key professionals View source Failure of agencies to check and share available information before multi-agency meetings View source Incomplete and unclear procedure for the Common Law Police Disclosure Scheme View source Misunderstanding of residence conditions for offender monitoring View source Lack of recording of offenders' bail conditions View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Mc Guigan · 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
Paul Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.
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 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment
Wider context from the report “I also have a concern that an employer on a private security contract at home has regulated by the SIA and a private security employed overseas [unregulated save for voluntary schemes such as International Code of Conduct for Private Security Service Providers 2010 [ICoC] and accredited certification to the standard ANSI/ SSlS PSC. 1-2012] is not entitled or able to obtain an enhanced CRB and would only ever receive a Standard disclosure on a pre employment check.
It concerns me in particular that in respect of employing on individual on an armed contract then consideration should be given to enabling Private Security Companies a route to obtaining an enhanced 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 Lack of recording of pre-conviction disclosures
Wider context from the report “It is clear that within GMP there was no recording anywhere as to when / if any pre convictions disclosures were made . It is important that there is a system of recording in this scenario and also to whom the disclosure is made. At present no-one can provide any information as to the number of detail of pre-conviction disclosures. In addition this means that officers who may be dealing with someone who has been arrested have no way of knowing if such a pre-conviction disclosure has ever been made.
” 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 overseas armed close protection work
Wider context from the report “In addition I have a concern that there is a complete lack of understanding by the Police and Probation / NOMS as to what close protection work overseas involves and in particular when this involves work on armed contracts .
” 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 guidance and transfer arrangements for MAPPA-triggering offenders
Wider context from the report “It concerns me to ensure that there is clear guidance given by NOMS to the private community rehabilitation companies [e.g. in Manchester Purple Futures] as to assessment of risk and for offenders who then do trigger MAPPA concerns that should be being supervised or assessed for eligibility under MAPPA to be transferred to be supervised by the National Probation Service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of computer categorisation for close protection occupations
Wider context from the report “In respect of the GMP computer system and in respect of occupations that are regulated and require licensing by the SIA, there is no categorisation on the computer for “CLOSE PROTECTION” . Indeed the Court heard that there was some confusion and lack of understanding from many people as to what this occupation actually meant. Close protection work is a separate category of employment within the UK that the SIA regulates and the police system should reflect the occupations subject to regulation. It is important that the police and NOMS have a clear understanding as to what close protection work is to inform risk and risk assessment.
” 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 procedure and funding responsibility for independent forensic psychiatric reports
Wider context from the report “It concerns me that there is not a clear practice and procedure operating within the Court or probation system, including funding responsibility, for obtaining an Independent Forensic Psychiatric Report , particularly in circumstances where a defendant is remanded on bail in the community.
” 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 for officers and civilian employees on disclosure procedures
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees . The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” 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 understand and operate the Notifiable Occupation Scheme
Wider context from the report “In my judgment there was a complete misunderstanding by GMP in respect of the operation of the Notifiable Occupation Scheme HOC 6/2006 .
Of immense concern also the complete failure for a period of approximately 18 months to make any post conviction notifications under the Notifiable Occupation Scheme , which was it transpired, formally withdrawn by the Home Secretary Theresa May MP in March 2015.
I heard and received evidence from the SIA that they were not aware that a regulatory gap existed in respect of the Police’s understanding of the scheme and notifications to themselves . The evidence I heard suggests that such a gap exists at GMP and has done so for in excess of 18 months.
” 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 disclosure to employers
Wider context from the report “In respect of the period of time when Post conviction disclosures were made [before this “back office” function ceased 18 months ago] these were only ever disclosures made to the Regulatory body and consideration never appears to have been given within GMP to disclosure to employers . Given the lack of understanding as to whom some regulatory bodies have responsibility for, this is important.
” 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 and infrequent formal supervision of newly qualified offender managers
Wider context from the report “I heard evidence that the Offender Manager was newly qualified and her formal supervision was inadequate and infrequent . This concerns me. It is important that newly qualified offender managers receive appropriate formal supervision .
” 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 national system and contact point for obtaining military information
Wider context from the report “My concern is to ensure that there is a system, protocol and point of contact for every offender manager nationally [including the private rehabilitation companies now operating as offender managers] that is well known as to who to contact to within the Ministry of Defence to obtain military 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 record discussions among key professionals
Wider context from the report “In addition I heard evidence and it concerns me that in advance of the Multi Agency meeting convened due to concerns as to the Offenders risk, key professionals had had discussions, telephone calls and meetings and I was concerned by the failure to record and document these important discussions , to ensure clarity, understanding and consistency. It is important when key professionals have discussions that these are documented and 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 Failure of agencies to check and share available information before multi-agency meetings
Wider context from the report “It is important irrespective of who is the lead agency at a Multi Agency Meeting that each agency invited to attend checks information held on systems and records to which they have access and provides all this information to a multi agency meeting to ensure that a full and informed assessment of risk takes place and the fullest possible informed information sharing.
” 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 Incomplete and unclear procedure for the Common Law Police Disclosure Scheme
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees. The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” 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 Misunderstanding of residence conditions for offender monitoring
Wider context from the report “I also heard evidence that a GMP officer believed that Bail with a condition of residence was different to “bail live and sleep each night”. It is of concern that there is a misunderstanding within GMP as to what a condition of residence means and how this relates to the monitoring of offenders .
” 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 recording of offenders' bail conditions
Wider context from the report “I heard evidence that in respect of GMP systems and processes there was nowhere on the GMP computer system where bail conditions are recorded , although this used to be possible. It is of concern that there is no system of recording on the GMP computer of offenders bail conditions so that this information can be known by officers and appropriately shared.
” 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 Enter and retain employer-notification decisions on offenders’ intelligence files using a common checkable recording standard.
Verbatim wording from the response “I completely accept that there needs to be a common checkable standard for recording notifications. This will, in future, be entered and held on the intelligence file of offenders.” Source location 2015-0185-Response-by-Greater-Manchester-Police-NOMS-SIA
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train officers on the pressing social need test, including classroom and NCALT training and identifying appropriate disclosure recipients.
Verbatim wording from the response “We will be training officers in understanding their responsibilities under the pressing social need test. This will include classroom and NCALT training. This will address the issue of whom the disclosures need to be made i.e. the employers and/or the regulatory body.” Source location 2015-0185-Response-by-Greater-Manchester-Police-NOMS-SIA
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 current PNC process is considered a tried and tested reliable system for identifying bail conditions, despite occasional human error.
Verbatim wording from the response “I am entirely satisfied with the current process in GMP. It is clear that the official reference point for bail conditions is the PNC. Whilst there will always be errors in human systems, we have a tried and tested reliable system.” Source location 2015-0185-Response-by-Greater-Manchester-Police-NOMS-SIA
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing custody processes are considered sufficient to apply bail conditions proportionately and promptly rectify occasional misinterpretations.
Verbatim wording from the response “Similarly I am satisfied that Custody Sergeants are applying bail conditions proportionately and can layer the amount of control to the risk faced. Custody officers are clear in the important distinction between a “condition of residence” and "live and sleep". It is almost inevitable that, on rare occasions, a constable may misinterpret this or other bail conditions. However this would be rectified quickly as the Custody officer would refuse to accept detention on such occasions. This has never been a significant issue in the organisation.” Source location 2015-0185-Response-by-Greater-Manchester-Police-NOMS-SIA
Open published response
16 Apr 2015 Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 28 Failure of the youth diversion project to provide diversion before criminal justice processing View source Failure to record and explain incomplete medical assessments View source Failure to return completed Appropriate Adult forms to Social Services View source Interagency confusion about safeguarding roles and access to information View source Failure to initiate youth offending and mental health monitoring after case transfer View source Failure to pass complete incident information to attending officers View source Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs View source Insufficient availability of accommodation for children under 17 View source Insufficient recording of safeguarding information by Appropriate Adults View source Failure of youth offending teams to transfer and oversee cases after relocation View source Failure to assess police information when selecting an Appropriate Adult View source Lack of legally required accommodation for 17-year-olds refused bail View source Failure to make safeguarding referrals from custody medical information View source Failure to record safeguarding intelligence on nominal profiles View source Failure to conduct police database checks on standard-risk DASH referrals View source Failure to route domestic violence cases involving 17-year-old children to child protection review View source Lack of shared understanding between police and MEDACS about requested medical assessments View source Lack of interagency understanding for sharing safeguarding information between police and CPS View source Failure to provide Appropriate Adults with relevant custody risk information View source Failure to provide differentiated mental health assessments for children in custody View source Failure to document information provided to MEDACS before medical assessments View source Failure to check and update Prisoner Escort Records before release View source Custody handovers dependent on officers’ and staff’s unpaid free time View source Lack of consistent child safeguarding coverage across Manchester local authorities View source Lack of clear officer guidance for raising safeguarding concerns View source Unclear referral routes for non-criminal safeguarding concerns View source Lack of a process for recording safeguarding concerns View source Lack of a non-criminal safeguarding policy View source See 25 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
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 the youth diversion project to provide diversion before criminal justice processing
Wider context from the report “The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway . There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme .
” 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 and explain incomplete medical assessments
Wider context from the report “It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred .
” 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 return completed Appropriate Adult forms to Social Services
Wider context from the report “Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any 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 Interagency confusion about safeguarding roles and access to information
Wider context from the report “Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles , what they are able and not able to do and also where to access important and effective 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 initiate youth offending and mental health monitoring after case transfer
Wider context from the report “This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside . The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur .
” 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 pass complete incident information to attending officers
Wider context from the report “The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife . The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding.
” 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 safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
Wider context from the report “This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children .
” 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 availability of accommodation for children under 17
Wider context from the report “The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available . Attempts are being made to address this issue but at present the figure remains approximately 20% and the Inquest heard evidence that this was, “not good enough”.
Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities . The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe to do so.
” 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 recording of safeguarding information by Appropriate Adults
Wider context from the report “The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form
” 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 youth offending teams to transfer and oversee cases after relocation
Wider context from the report “There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use.
” 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 assess police information when selecting an Appropriate Adult
Wider context from the report “It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker.
” 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 legally required accommodation for 17-year-olds refused bail
Wider context from the report “There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to.
” 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 make safeguarding referrals from custody medical information
Wider context from the report “Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use .
” 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 safeguarding intelligence on nominal profiles
Wider context from the report “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers . It is a core function of the police to submit such intelligence.
” 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 police database checks on standard-risk DASH referrals
Wider context from the report “when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out . The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender .
” 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 route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report “For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age.
” 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 shared understanding between police and MEDACS about requested medical assessments
Wider context from the report “It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS .
” 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 interagency understanding for sharing safeguarding information between police and CPS
Wider context from the report “There was a lack of understanding between GMP and the CPS as to how such important information should be shared between 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 provide Appropriate Adults with relevant custody risk information
Wider context from the report “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS , nor that she had threatened to jump off a bridge on her release.
” 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 differentiated mental health assessments for children in custody
Wider context from the report “The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults .
” 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 document information provided to MEDACS before medical assessments
Wider context from the report “there was no clarity as to whether this included previous risk assessments , whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the 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 check and update Prisoner Escort Records before release
Wider context from the report “The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge.
” 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 Custody handovers dependent on officers’ and staff’s unpaid free time
Wider context from the report “The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff .
” 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 consistent child safeguarding coverage across Manchester local authorities
Wider context from the report “This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children
” 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 officer guidance for raising safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be 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 Unclear referral routes for non-criminal safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be 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 Lack of a process for recording safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns . There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be 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 Lack of a non-criminal safeguarding policy
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal . There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report
15 Oct 2014 Lucasz Lewandowski · Prevention of Future Deaths report Manchester (North)
View report summary
Concerns raised 7 Lack of communication between GMP and MEDACS about the existence of an escalation protocol View source Lack of resources for mental health response View source Failure to adhere to or use escalation and call grading protocols View source Failure and reluctance to correspond with patients’ GPs and other healthcare professionals after consultation View source Clinical decision-making by a non-medically qualified Practice Manager View source Failure of clinicians to retain responsibility for patients’ safety and wellbeing in the community View source Delays in GMP responses 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
Lucasz Lewandowski · 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
Lucasz Lewandowski suffered catastrophic head injuries after jumping from the roof of his employer’s building on 16 July, and died two days later. The principal concerns included delays and communication failures in emergency and mental-health responses, failures in psychiatric information-sharing and continuity of care, and issues concerning clinical decision-making and responsibility for his safety.
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 communication between GMP and MEDACS about the existence of an escalation protocol
Wider context from the report “2. Lack of communication between GMP and MEDACS regarding the existence of their escalation protocol resulting in the delayed attendance of an FME.
” 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 resources for mental health response
Wider context from the report “3. The use of S.136 of the Mental Health Act due to lack of resources – albeit on logical, pragmatic grounds.
” 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 adhere to or use escalation and call grading protocols
Wider context from the report “1. The timeliness of GMP’s response, against a backdrop of lack of adherence to/use of the escalation and call grading protocols .
” 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 and reluctance to correspond with patients’ GPs and other healthcare professionals after consultation
Wider context from the report “4. The psychiatric practice’s failure and reluctance to correspond with a patient’s GPs and/or other healthcare professionals following consultation , jeopardising continuity of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Clinical decision-making by a non-medically qualified Practice Manager
Wider context from the report “5. Clinical decision-making by a non-medically qualified Practice Manager .
” 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 clinicians to retain responsibility for patients’ safety and wellbeing in the community
Wider context from the report “6. The view of the physician - that responsibility for maintaining a patient’s safety and wellbeing within the community rests entirely with the family and/or patient rather than the clinician .
” 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 GMP responses
Wider context from the report “1. The timeliness of GMP’s response , against a backdrop of lack of adherence to/use of the escalation and call grading protocols.
” 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 Extend Command and Control quality assurance to examine and report compliance with the Escalation Policy.
Verbatim wording from the response “The Branch Commander has identified this is a critical area of our business and has extended quality assurance processes within Command and Control to now examine and report upon compliance with the Escalation Policy within the OCB.” Source location 2014-0445-Response-by-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 Escalation Policy and reinforce accurate incident-log recording, resource updates, prioritisation rationale and supervisory patrol planning.
Verbatim wording from the response “The Escalation Policy has been re-circulated with a message from the Branch senior leaders impressing the importance of accurate recording of information on force wide incident logs (FWINs).” Source location 2014-0445-Response-by-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 the MEDACS Escalation Policy to all custody staff by email and through Custody Branch Orders.
Verbatim wording from the response “The Custody Branch acknowledges and agrees that it is a concern that the custody staff were not aware of the MEDACS Escalation Policy, or that in all appropriate instances staff should escalate calls in order to secure medical care provision, in the most efficient manner to those who need it most.” Source location 2014-0445-Response-by-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 the review of the Escalation Policy to improve risk identification, patrol allocation and supervisory escalation when resources are unavailable.
Verbatim wording from the response “The Operational Communications Branch (OCB) has undertaken a review of its Escalation Policy. The intention of this review, which is in its final stages, is to ensure the OCB works effectively with Divisions to enhance its ability to effectively identify areas of risk and then effectively manage the allocation of patrols to address that risk. In cases when it becomes apparent that resources are unavailable for allocation, the Escalation Policy will ensure the incident is brought to the attention of the appropriate Divisional supervisor.” Source location 2014-0445-Response-by-Greater-Manchester-Police
Open published response
30 Sep 2014 Derek Hawkins · Prevention of Future Deaths report Manchester (North)
View report summary
Concerns raised 1 Lack of objective risk-factor rating in the risk assessment tool 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
Derek Hawkins · 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
Derek Hawkins, who had bipolar disorder and was admitted for reassessment and treatment after increased suicidal thoughts, disclosed on 22 November 2013 that he intended to hang himself. He left the ward unescorted on 24 November and was found hanging in a derelict building near the hospital grounds that evening. The concerns included failures in communication, unclear leave arrangements, inadequate risk assessment after his disclosure of suicidal intent, and a risk-assessment tool that relied on subjective practitioner assessments.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Police; that does not assign responsibility.
PFD Monitor interpretation Lack of objective risk-factor rating in the risk assessment tool
Wider context from the report “(1) The Risk Assessment tool currently in use relies on an individual practitioner’s subjective assessment and description of risk factors . The tool does not provide a means of objectively rating risk factors and means that less experienced practitioners may fail to recognise or identify an increase in risk .
” Open source report
9 Jul 2014 Georgina Lauren Taylor · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of inspection of developing soft estate to assess vehicle restraint protection requirements View source Failure to protect or remove trees within 4.5m of the paved carriageway 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
Georgina Lauren Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Georgina Lauren Taylor died following a road traffic collision on the A627(M), in which a vehicle lost control at excessive speed, struck a tree and rolled. The report raised concerns about trees and other roadside features near the carriageway, including whether they were adequately protected or should have been removed, and about the lack of requirements to reassess protection as roadside vegetation developed.
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 inspection of developing soft estate to assess vehicle restraint protection requirements
Wider context from the report “2. The introduction of the interim requirements for road restraint systems in 2002 identified that all trees with a girth exceeding 500mm (or several closely spaced trees) located within a distance of 4.5m from the paved carriageway require protection. The re-issued requirements in 2004 identified that trees above 300mm in girth should be protected by a suitable vehicle restraint system.
3. Current design standard TD19/06 includes a site specific risk process where topographical features, together with adjacent sources of risk are reviewed in order to identify the most appropriate restraint facility and containment levels and that in relation to the presence of trees adjacent to the nearside verge and protection requirements, it is unclear as to when these regimented and it is likely that they are all ‘self-seeded’ with the larger specimens being over 10 years old. Whilst the vehicle restraint systems in place comply with identified requirements at the time of the construction of the route, there are no current requirements to inspect soft estate as it develops in terms of assessing protection requirements . The application of more recent design standards would have required some of the trees at this location to be protected (as well as the lighting columns) or removed within the 4.5m threshold.
” 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 protect or remove trees within 4.5m of the paved carriageway
Wider context from the report “2. The introduction of the interim requirements for road restraint systems in 2002 identified that all trees with a girth exceeding 500mm (or several closely spaced trees) located within a distance of 4.5m from the paved carriageway require protection . The re-issued requirements in 2004 identified that trees above 300mm in girth should be protected by a suitable vehicle restraint system .
3. Current design standard TD19/06 includes a site specific risk process where topographical features, together with adjacent sources of risk are reviewed in order to identify the most appropriate restraint facility and containment levels and that in relation to the presence of trees adjacent to the nearside verge and protection requirements, it is unclear as to when these regimented and it is likely that they are all ‘self-seeded’ with the larger specimens being over 10 years old. Whilst the vehicle restraint systems in place comply with identified requirements at the time of the construction of the route, there are no current requirements to inspect soft estate as it develops in terms of assessing protection requirements. The application of more recent design standards would have required some of the trees at this location to be protected (as well as the lighting columns) or removed within the 4.5m threshold .
” Open source report
27 Jun 2014 ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 3 Lack of staff training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients View source Lack of a coherent and mutually understood Mental Health Trust and Police policy on involvement in illegal activity View source Failure to use incident reporting and risk-register procedures to identify drug supply or consumption View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
ASHLEY CORIN DE WINTER PONSONBY · 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 Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.
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 staff training in recognising and dealing with physical harm and risks from illicit substance use in wards with dual diagnosis patients
Wider context from the report “1. It is a matter of concern that any ward could be set up and operated involving the inherent risks of drug misuse by dual diagnosis patients without the staff having any training in recognising and dealing with the physical harm and risks arising from the use of illicit substances . The evidence from the independent psychiatrist was that this was an essential ingredient. Consequently, in rehabilitation wards or those with dual diagnosis patients where there is a risk of continuing drug misuse , the concern which arose was that without this, there was a risk of a future death arising. This has implications locally for the Trust, regionally and on a national basis.
” 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 coherent and mutually understood Mental Health Trust and Police policy on involvement in illegal activity
Wider context from the report “3. There was a concern that a lack of a coherent and mutually understood policy between the Mental Health Trust and the Police as to when they would become involved in illegal activity meant that neither the patients nor the staff had clarity on the position . Just because patients have mental disorder, does not absolve them of all legal responsibilities and indeed understanding and facing possible criminal consequences may be important in their overall clinical management and for the administration of justice. It was suggested that this was being considered by Greater Manchester Police and the local Police and Crime Commissioner, but no policy had yet been finalised . Once again, this has local, regional and national implications, and that the concern is without such policies being formulated and implemented, there is a continuing risk of future deaths which could be prevented.
” 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 incident reporting and risk-register procedures to identify drug supply or consumption
Wider context from the report “2. There is a concern that the failure to use the Datix and Trust incident reporting policy, as well as the risk register (or other similar procedures available to other Mental Health Trusts), to identify the problem of drug supply and/or consumption , if unremedied may lead to a future death. It is a concern both locally for the Trust, regionally and nationally, that such procedures should be appropriately used so as to prevent a future death.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and implement a comprehensive policy clarifying police collaboration with other agencies on mental health, learning disabilities and criminal offences in mental health establishments.
Verbatim wording from the response “At the time of Mr Ponsonby’s death on 4th July 2012, there was no formal policy in place between Greater Manchester Police and Manchester Mental Health and Social Care NHS Trust regarding the reporting of crime committed by patients on hospital wards. There are 4 mental health trusts covering the area of Greater Manchester. In early 2012 it was recognised by GMP that there were a number of issues around mental health that needed to be addressed by the introduction of a formal policy. GMP recognised that to make this policy effective it needed to be created with the inclusion of inputs from partner agencies. GMP approached the Association of Greater Manchester Authorities’ (AGMA) to obtain a mandate to undergo such partnership collaboration around this policy.” Source location 2014-0286-Response-by-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 Regularly review the mental health and learning disabilities policy to maintain currency with best practice and legislation.
Verbatim wording from the response “This policy will be regularly reviewed to ensure it remains current with regard to best practice and legislation. Indeed there has only recently been an update completed in relation to Mental Health Diversion Panels.” Source location 2014-0286-Response-by-Greater-Manchester-Police
Open published response
6 Jan 2014 Billy Paul Thomas Salton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 13 Failure to complete MEDACS assessment forms and care plans accurately View source Failure to document non-assessment and avoid misleading medical records View source Failure to obtain and review detained persons’ relevant medical information View source Lack of understanding of required custody observation levels and rationale View source Failure to accurately document custody cell checks View source Failure to complete prisoner transfer documentation accurately View source Failure to staff the Prisoner Processing Unit overnight View source Lack of staff knowledge of MEDACS policies and protocols View source Failure to transfer and replicate medical observation information during GEO AMEY custody View source Lack of specific instructions and effective positioning for CCTV cell monitoring View source Ineffective or absent handovers between custody staff View source Failure to accurately record custody visits and checks View source Failure to record custody risk assessments and rationale for unchanged assessments View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Billy Paul Thomas Salton · 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
Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.
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 complete MEDACS assessment forms and care plans accurately
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan . Such a form should be completed accurately including any negative answers to questions asked .
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 document non-assessment and avoid misleading medical records
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded .
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 obtain and review detained persons’ relevant medical information
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition . Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody .
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 required custody observation levels and rationale
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations . It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 document custody cell checks
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented .
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 complete prisoner transfer documentation accurately
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed . The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 staff the Prisoner Processing Unit overnight
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy .
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 staff knowledge of MEDACS policies and protocols
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols , where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy ).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 transfer and replicate medical observation information during GEO AMEY custody
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person . This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY .
” 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 specific instructions and effective positioning for CCTV cell monitoring
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell . The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen .
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 or absent handovers between custody staff
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff . Important information was missed or lost in translation . Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 record custody visits and checks
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record .
4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted.
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 custody risk assessments and rationale for unchanged assessments
Wider context from the report “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy.
2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is.
3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record.
4. Risk assessments carried out whilst in police custody should be recorded when they are done . If there are no changes to a risk assessment then this should be recorded and any rationale noted .
5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters.
6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate.
7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen.
1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy).
2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody.
3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked.
4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded.
1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody.
2. Staff should be reminded that all cell checks should be accurately documented.
3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY.
” 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 Provide staff inputs using case studies to reinforce recording risk-assessment rationales and custody actions accurately.
Verbatim wording from the response “I do agree with this but can see how this can degrade into quite significant events not being accurately recorded. We will, therefore, shortly be giving a series of inputs to staff which will” Source location 2014-0002-Response-by-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 Require recording of unchanged risk assessments and monitor compliance through Custody Inspector dip sampling.
Verbatim wording from the response “You are right to point out that all risk assessments, including those where there is no change in the detainee’s circumstances, should also be recorded. This requirement has been communicated to custody staff and is currently being monitored by Custody Inspectors undertaking dip sampling of custody records.” Source location 2014-0002-Response-by-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 Develop a custody-office work system that improves CCTV monitoring coverage and accountability.
Verbatim wording from the response “The programme of work I described earlier in improving communication and management of the office is looking at every aspect of the roles staff undertake in Custody. The monitoring of CCTV is one of those roles and they will be looking for a system that matches or improves the coverage of CCTV we have and also provide greater accountability.” Source location 2014-0002-Response-by-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 Operate a computerised MEDACS clinical-record system requiring typed 708e forms and direct transcription into the ICIS custody system.
Verbatim wording from the response “GMP has reviewed its arrangements for communication between custody and clinical staff to negate the practice of MEDACS staff working on two separate records of notes and to improve the continuity of care provided to detainees with health needs.” Source location 2014-0002-Response-by-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 Enable MEDACS clinicians to enter care plans directly into the custody system.
Verbatim wording from the response “To improve clarity on levels of observations we have amended the ‘drop down’ menus accessible to the MEDACS clinicians attending custody suites. Plans are in place to enable MEDACS to directly input their care plans onto our custody system which will further improve communication between custody and clinical practitioners.” Source location 2014-0002-Response-by-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 Issue and check improved guidance for sergeants on completing, timing and signing off Prisoner Escort forms.
Verbatim wording from the response “Since your observations we have put out improved guidance on completion of the PER form to sergeants which include what to record, when it is to be done and how it is to be signed off. This has been extensively checked and has led to improvements in standards.” Source location 2014-0002-Response-by-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 Amend MEDACS observation-level dropdown menus to improve clarity.
Verbatim wording from the response “To improve clarity on levels of observations we have amended the ‘drop down’ menus accessible to the MEDACS clinicians attending custody suites. Plans are in place to enable MEDACS to directly input their care plans onto our custody system which will further improve communication between custody and clinical practitioners.” Source location 2014-0002-Response-by-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 Standardise sergeant handovers around accurate Custody Summary Screens and communication of key detainee risk information.
Verbatim wording from the response “We have conducted a review of handovers between sergeants. As a result we have made it clear to sergeants that the handover need not be a comprehensive review of each detainee. Rather, they should have completed the Custody Summary Screen so that all the relevant detail is available on the ICIS system and the handover should contain key risk issues, for example medical conditions, medication required and so forth.” Source location 2014-0002-Response-by-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 Existing CCTV arrangements are considered sufficient; staff will not be specifically instructed to observe the screen for Level 2 observations.
Verbatim wording from the response “At present we remain satisfied with our current arrangements for CCTV usage. We do use CCTV for constant observations in some cases. However, in the case with Mr Salton, the level of observations was at Level 2.” Source location 2014-0002-Response-by-Greater-Manchester-Police
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations