Concerns raised 2 Failure to eject festival attendees found bringing unlawful drugs onto the site View source Failure to disrupt the open trade in unlawful drugs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Benjamin Thomas Dinan BUCKFIELD · 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
Benjamin Thomas Dinan Buckfield died in hospital on 11 August 2024 after collapsing at the Boomtown music festival, where he had purchased and consumed MDMA. The report raises concerns about the open availability and sale of illegal drugs at the festival and about policies allowing some people found with drugs to remain on site, creating a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to eject festival attendees found bringing unlawful drugs onto the site
Wider context from the report “2. I heard evidence that those found bringing unlawful drugs into Boomtown are not ejected from the site unless they are considered to be carrying quantities that are consistent with being a drug dealer, or they have associated dealer paraphernalia . Those who are found in possession of unlawful drugs who are not considered to be dealers have their drugs confiscated and are allowed entry onto site . I am concerned that as a consequence there is no disincentive for festival goers who attempt to take drugs into Boomtown and that the policy gives rise to a situation where those who have had drugs taken from them will want to replace them. I am concerned that these factors give rise to a demand for, and a market in, the sale of illegal drugs at Boomtown. I heard evidence from a senior officer of Hampshire and Isle of Wight Constabulary who was Gold Commander for Boomtown who also expressed a concerned about this policy. I am concerned that this, combined, with the first concern, give rise to risk of future 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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to disrupt the open trade in unlawful drugs
Wider context from the report “1. I heard evidence that illegal drugs were freely available to purchase at the festival . One of Ben’s friends described how dealers would walk through the campsites shouting the names of the drugs they were offering to supply. I was told this took place as regularly as every twenty minutes and that they saw nothing done to try and disrupt this trade . I am concerned that an unchecked, open and free trade in unlawful drugs will create a risk of future deaths.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Safety Advisory Group and event organiser to manage concerns about the festival’s unlawful-drug policy.
Verbatim wording from the response “The Constabulary remain concerned about this policy but it is a matter to be considered by the Safety Advisory Group as the Constabulary does recognise that the Organisers policy is in line with National guidance and the basis for this policy was articulated by the organisers at the inquest. The Constabulary will manage this concern by working with the SAG and event organiser. As a result of measures brought in through the continual improvement cycle, the event improved in 2025 compared with 2024 and further improvements are expected in 2026, in relation to the concerns raised.” Source location Hampshire and IOW Constabulary
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 Event management, including preventing drug supply, is the organisers’ responsibility under the nationally agreed Purple Guide.
Verbatim wording from the response “The Management of an event, including drug supply and its prevention are the responsibility of the organisers in line with the nationally agreed “Purple Guide”. The Police play an active role via the Safety Advisory Group and review its position regularly. The Constabulary will continue to do so and feedback nationally but notes that the 2025 Boomtown event showed evidence of the changes discussed at the inquest, coming to fruition, as there were less incidents.” Source location Hampshire and IOW Constabulary
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 organisers’ policy on unlawful drug possession is a matter for the Safety Advisory Group and event organiser to consider.
Verbatim wording from the response “The Constabulary remain concerned about this policy but it is a matter to be considered by the Safety Advisory Group as the Constabulary does recognise that the Organisers policy is in line with National guidance and the basis for this policy was articulated by the organisers at the inquest. The Constabulary will manage this concern by working with the SAG and event organiser. As a result of measures brought in through the continual improvement cycle, the event improved in 2025 compared with 2024 and further improvements are expected in 2026, in relation to the concerns raised.” Source location Hampshire and IOW Constabulary
Open published response
Concerns raised 3 Failure of procedures to support appropriately prompt response to collision alerts indicating possible risk to life View source Inadequate training for responding to serious car crash detection alerts View source Insufficient police understanding of serious car crash detection technology View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Robert DILLON · 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
George Robert DILLON, aged 19, lost control of his car on a country road on 18 May 2023 and collided with a tree. He suffered catastrophic injuries and died in hospital on 20 May 2023. The report raised concerns about the understanding, training and procedures for responding promptly to automatic emergency calls from devices indicating a possible collision and risk to life.
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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure of procedures to support appropriately prompt response to collision alerts indicating possible risk to life
Wider context from the report “A. At 22.26pm Hampshire Constabulary’s control room received an automated telephone call from the deceased’s i-Phone indicating that the deceased had been in a serious car crash and was not responding to their i-Phone. The operator logged “no direct request made and cannot hear anything distinctive in the background – no sounds of distress/disturbance. An accurate location was provided by the i-Phone.
B. The iPhone was called back, but the call went straight to voicemail.
C. The control room supervisor forwarded the message to the intelligence team to establish who the i-Phone belonged to and whether there was any serious harm or risk to life at that time.
D. By 22.43 the intelligence team had drawn a blank. But for a separate telephone call from a member of the public at 22.45, further steps may have been made to make contact (one of which, an “!cetrak” message which was sent to the i-Phone at 22.59 asking whether there was an emergency and requesting a 999 call if so) or a Police vehicle may have been assigned to attend the GPS co-ordinates provided by the i-Phone or no further action taken.
E. The evidence indicated that false alarms from electronic devices such as telephones and watches are commonplace, and that locations received from such devices was often inaccurate and liable to involve substantial Police time in tracking the device down.
F. The Apple serious car crash detection automatic calls were a recent development at the time of the index accident. Other manufacturers have launched a similar feature. The investigating officer stated during the inquest that “not enough is known (by the police) about this technology within people’s personal phones.”
G. I am concerned that the understanding, training and procedures need review to assist with appropriately prompt response in situations where there is an indication of a collision where a risk to life may exist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Inadequate training for responding to serious car crash detection alerts
Wider context from the report “A. At 22.26pm Hampshire Constabulary’s control room received an automated telephone call from the deceased’s i-Phone indicating that the deceased had been in a serious car crash and was not responding to their i-Phone. The operator logged “no direct request made and cannot hear anything distinctive in the background – no sounds of distress/disturbance. An accurate location was provided by the i-Phone.
B. The iPhone was called back, but the call went straight to voicemail.
C. The control room supervisor forwarded the message to the intelligence team to establish who the i-Phone belonged to and whether there was any serious harm or risk to life at that time.
D. By 22.43 the intelligence team had drawn a blank. But for a separate telephone call from a member of the public at 22.45, further steps may have been made to make contact (one of which, an “!cetrak” message which was sent to the i-Phone at 22.59 asking whether there was an emergency and requesting a 999 call if so) or a Police vehicle may have been assigned to attend the GPS co-ordinates provided by the i-Phone or no further action taken.
E. The evidence indicated that false alarms from electronic devices such as telephones and watches are commonplace, and that locations received from such devices was often inaccurate and liable to involve substantial Police time in tracking the device down.
F. The Apple serious car crash detection automatic calls were a recent development at the time of the index accident. Other manufacturers have launched a similar feature. The investigating officer stated during the inquest that “not enough is known (by the police) about this technology within people’s personal phones.”
G. I am concerned that the understanding, training and procedures need review to assist with appropriately prompt response in situations where there is an indication of a collision where a risk to life may exist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient police understanding of serious car crash detection technology
Wider context from the report “A. At 22.26pm Hampshire Constabulary’s control room received an automated telephone call from the deceased’s i-Phone indicating that the deceased had been in a serious car crash and was not responding to their i-Phone. The operator logged “no direct request made and cannot hear anything distinctive in the background – no sounds of distress/disturbance. An accurate location was provided by the i-Phone.
B. The iPhone was called back, but the call went straight to voicemail.
C. The control room supervisor forwarded the message to the intelligence team to establish who the i-Phone belonged to and whether there was any serious harm or risk to life at that time.
D. By 22.43 the intelligence team had drawn a blank. But for a separate telephone call from a member of the public at 22.45, further steps may have been made to make contact (one of which, an “!cetrak” message which was sent to the i-Phone at 22.59 asking whether there was an emergency and requesting a 999 call if so) or a Police vehicle may have been assigned to attend the GPS co-ordinates provided by the i-Phone or no further action taken.
E. The evidence indicated that false alarms from electronic devices such as telephones and watches are commonplace, and that locations received from such devices was often inaccurate and liable to involve substantial Police time in tracking the device down.
F. The Apple serious car crash detection automatic calls were a recent development at the time of the index accident. Other manufacturers have launched a similar feature. The investigating officer stated during the inquest that “not enough is known (by the police) about this technology within people’s personal phones.”
G. I am concerned that the understanding, training and procedures need review to assist with appropriately prompt response in situations where there is an indication of a collision where a risk to life may exist.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue written guidance across Hampshire and Thames Valley forces directing deployment for unsupported crash-technology notifications.
Verbatim wording from the response “At the time of the incident there was no national guidance available as to how police forces should be responding to crash notifications. Following the Inquest Hampshire and the Isle of Wight Constabulary accepted the need to put clear guidance in place. As a result immediate action was taken by the Head of Contact Management who;” Source location Response from Hampshire Constabulary
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 a video message updating staff and directing the required response to crash notifications.
Verbatim wording from the response “At the time of the incident there was no national guidance available as to how police forces should be responding to crash notifications. Following the Inquest Hampshire and the Isle of Wight Constabulary accepted the need to put clear guidance in place. As a result immediate action was taken by the Head of Contact Management who;” Source location Response from Hampshire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and bring live an operator toolkit covering abandoned and automated notification calls, including required checks and immediate deployment criteria.
Verbatim wording from the response “In addition the Constabulary has now developed a toolkit to be made available to all operators and control room staff which is due to go live in September. Once it does a copy will be released to the coroner. The toolkit provides guidance for both abandoned and automated notification calls across what are now, a range of sources, including Apple Crash detections. The toolkit directs the call taker to confirm the eastings and northings, to record what was heard in playback, to check whether any incidents have been reported nearby and to search the caller’s history and undertake precautionary background checks. In the case of Apple Crash detection and Ford Notifications if there is no response on call back and no further information the operator is directed to create a Grade 1 incident for immediate deployment.” Source location Response from Hampshire Constabulary
Open published response
29 Dec 2023 Meghan Irene CHRISMAS · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Absence of redundancies or safeguards for early detection of missed communications View source Absence of effective arrangements for sharing important clinical information between private and public healthcare providers View source Failure to provide effective supervision of operators handling calls 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
Meghan Irene CHRISMAS · 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
Meghan Irene CHRISMAS attempted suicide by hanging on 18 October 2021 and, after resuscitation, died two days later on 20 October 2021 from a hypoxic brain injury. The report raised concerns about the delayed handling and supervision of communications in the Hampshire Police Force Control Room and the absence of an adequate structure for sharing important clinical information between NHS and private healthcare providers.
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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of redundancies or safeguards for early detection of missed communications
Wider context from the report “b. The handling of the incident involving Mrs. CHRISMAS in Hampshire Constabulary’s Force Control Room which resulted in a hour delay in determining that an important communication (being a request for assistance) had not been received by a neighbouring force. This raises concerns as to the effectiveness in the supervision of operators handling the calls and the presence of redundancies or safeguards to detect such circumstances sooner to avoid repetition .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of effective arrangements for sharing important clinical information between private and public healthcare providers
Wider context from the report “a. Passage of information between NHS and private healthcare providers. At a time where pressures on the NHS exist, particularly for mental health services, it is of concern that measures which could alleviate this pressure (where someone sources private care) do not exist. There is little or no policy, guidance or other effective arrangements to share important clinical information about patients between private and public healthcare sectors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective supervision of operators handling calls
Wider context from the report “b. The handling of the incident involving Mrs. CHRISMAS in Hampshire Constabulary’s Force Control Room which resulted in a hour delay in determining that an important communication (being a request for assistance) had not been received by a neighbouring force. This raises concerns as to the effectiveness in the supervision of operators handling the calls and the presence of redundancies or safeguards to detect such circumstances sooner to avoid repetition.
” Open source report
Concerns raised 4 Absence of effective dissemination, access and awareness of the "Working near Water Procedure" View source Lack of awareness of risks associated with rear handcuffing when detaining a person near water View source Lack of awareness of Cold Water Shock and its immediate risk to life View source Lack of awareness of the recognised "Shout, Reach, Throw, Row, Go" procedure View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Disseminate the revised Working Near Water Procedure, provide access to its linked training, and direct frontline staff to complete the updated package.
Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2023. View source
Action
Implement the revised Working Near Water Procedure and require the associated training through the specified delivery arrangements.
Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2023. View source
Action
Produce a revised Working Near Water Procedure covering Cold Water Shock, rescue methods and handcuffing risks near water.
Stated completedThe respondent said that this action was complete when they made their response on 18 September 2023. View source
Action
Revise and release the E-Learning package to cover Cold Water Shock and the recognised water-rescue procedure.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 September 2023. View source
Action
Revise annual Personal Safety Training refreshers to cover Cold Water Shock, water-rescue methods and handcuffing risks near water.
Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2023. View source
Action
Add guidance to the revised procedure and annual refresher on avoiding handcuffing near water and handcuffing to the front after a dynamic risk assessment.
Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2023. View source
Action
Revise annual Personal Safety Training refreshers to cover cold-water shock, the rescue method and risks of handcuffing near water.
Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2023. View source
Action
Disseminate the revised Working Near Water Procedure, link its e-learning package, and direct frontline officers and staff to complete the updated training.
Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2023. View source
Action
Produce an updated Working Near Water Procedure highlighting cold-water shock risks and describing the “Shout, Reach, Throw, Row, Go” rescue method.
Stated completedThe respondent said that this action was complete when they made their response on 18 September 2023. View source
Action
Complete and make available a revised e-learning package covering cold-water shock and the “Shout, Reach, Throw, Row, Go” rescue method.
Stated in progressThe respondent said that this action was in progress when they made their response on 18 September 2023. View source See 7 more actions
×
AI-generated summary
Marcel Maksymilian WOCHNA · 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
Marcel Maksymilian WOCHNA, aged 15, drowned in the River Itchen on 8 November 2021 after voluntarily entering the water to evade arrest. The inquest found that insufficient immediate action was taken by attending officers to attempt a rescue, and identified inadequate knowledge of the working near water policy. Principal concerns included lack of awareness of Cold Water Shock, rescue procedures, handcuffing risks near water, and the effective dissemination and awareness of the relevant procedure.
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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of effective dissemination, access and awareness of the "Working near Water Procedure"
Wider context from the report “4. Absence of effective dissemination, access and awareness of the Hampshire Constabulary "Working near Water Procedure" and the risks, mitigations and the need for necessary dynamic risk assessments set out therein .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of risks associated with rear handcuffing when detaining a person near water
Wider context from the report “3. Lack of awareness of risks associated with the use of handcuffs, particularly so to the rear, when detaining a person near water ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of Cold Water Shock and its immediate risk to life
Wider context from the report “1. Lack of awareness of Cold Water Shock and the associated immediate risk to life ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the recognised "Shout, Reach, Throw, Row, Go" procedure
Wider context from the report “2. Lack of awareness of the recognised "Shout, Reach, Throw, Row, Go" procedure ;
” 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 Disseminate the revised Working Near Water Procedure, provide access to its linked training, and direct frontline staff to complete the updated package.
Verbatim wording from the response “The Constabulary’s revised ‘Working Near Water Procedure’ will be disseminated to all officers and staff. In support of learning and understanding, this will include a link to the updated E-Learning package associated to this procedure. Frontline operational officers and staff will be directed to complete the updated training package.” Source location Response from Hampshire Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the revised Working Near Water Procedure and require the associated training through the specified delivery arrangements.
Verbatim wording from the response “I believe the implementation of the revised ‘Working Near Water Procedure’, that will mandate the ████████ally and in person, will sufficiently address the concerns set out in the Regulation 28 notice and will equip our officers and staff to maximise the safety of the public when working near water and prevent such tragic circumstances being repeated in the future.” Source location Response from Hampshire Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce a revised Working Near Water Procedure covering Cold Water Shock, rescue methods and handcuffing risks near water.
Verbatim wording from the response “In addition, an updated ‘Working Near Water Procedure’ has been produced which highlights the impact and immediate risks associated with Cold Water Shock. This forms the basis of the revised E-Learning package and key aspects will be revisited with operational officers and staff annually through face to face training delivered as part of the force’s Personal Safety Training.” Source location Response from Hampshire Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and release the E-Learning package to cover Cold Water Shock and the recognised water-rescue procedure.
Verbatim wording from the response “Cold Water Shock is described within the Constabulary’s ‘Working Near Water Procedure’. However it is recognised that this aspect of the procedure is absent from the E-Learning Training package. This is being rectified and the revised E-Learning package will be made available to officers and staff by the end of November 2023.” Source location Response from Hampshire Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise annual Personal Safety Training refreshers to cover Cold Water Shock, water-rescue methods and handcuffing risks near water.
Verbatim wording from the response “In addition, an updated ‘Working Near Water Procedure’ has been produced which highlights the impact and immediate risks associated with Cold Water Shock. This forms the basis of the revised E-Learning package and key aspects will be revisited with operational officers and staff annually through face to face training delivered as part of the force’s Personal Safety Training.” Source location Response from Hampshire Constabulary
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 Add guidance to the revised procedure and annual refresher on avoiding handcuffing near water and handcuffing to the front after a dynamic risk assessment.
Verbatim wording from the response “The force’s revised ‘Working Near Water Procedure’ and the annual Personal Safety Training refresher will set out that:” Source location Response from Hampshire and Isle of Wight Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise annual Personal Safety Training refreshers to cover cold-water shock, the rescue method and risks of handcuffing near water.
Verbatim wording from the response “In addition, an updated ‘Working Near Water Procedure’ has been produced which highlights the impact and immediate risks associated with Cold Water Shock. This forms the basis of the revised E-Learning package and key aspects will be revisited with operational officers and staff annually through face to face training delivered as part of the force’s Personal Safety Training.” Source location Response from Hampshire and Isle of Wight Constabulary
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 revised Working Near Water Procedure, link its e-learning package, and direct frontline officers and staff to complete the updated training.
Verbatim wording from the response “The Constabulary’s revised ‘Working Near Water Procedure’ will be disseminated to all officers and staff. In support of learning and understanding, this will include a link to the adapted E-Learning package associated to this procedure. Frontline operational officers and staff will be directed to complete the updated training package.” Source location Response from Hampshire and Isle of Wight Constabulary
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce an updated Working Near Water Procedure highlighting cold-water shock risks and describing the “Shout, Reach, Throw, Row, Go” rescue method.
Verbatim wording from the response “In addition, an updated ‘Working Near Water Procedure’ has been produced which highlights the impact and immediate risks associated with Cold Water Shock. This forms the basis of the revised E-Learning package and key aspects will be revisited with operational officers and staff annually through face to face training delivered as part of the force’s Personal Safety Training.” Source location Response from Hampshire and Isle of Wight Constabulary
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 and make available a revised e-learning package covering cold-water shock and the “Shout, Reach, Throw, Row, Go” rescue method.
Verbatim wording from the response “Cold Water Shock is described within the Constabulary’s ‘Working Near Water Procedure’. However it is recognised that this aspect of the procedure is absent from the E-Learning Training package. This is being rectified and the revised E-Learning package will be made available to officers and staff by the end of November 2023.” Source location Response from Hampshire and Isle of Wight Constabulary
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 training and dynamic risk assessments are considered sufficient; a blanket ban on handcuffing near water is not required.
Verbatim wording from the response “It is my position that there should be no ‘blanket ban’ on the use of handcuffs near water as it is critical that frontline officers are able to make informed assessments on the most appropriate means to ensure the safety of the public, their colleagues and themselves.” Source location Response from Hampshire and Isle of Wight Constabulary
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maxine Betty Davison and 4 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to condition firearms licensing delegation on adequate training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training .
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training .
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Absence of a mandatory requirement for role-specific firearms licensing training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training . I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular .
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff ;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
Concerns raised 2 Failure of 999 call triage to quickly and effectively identify the appropriate emergency response agency View source Failure to share information between emergency agencies without repeating caller screening 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
William James Moody · 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
William James Moody, aged 85, intentionally entered the River Itchen from the banks of his home on 19 April 2019 and could not be revived after being taken to Southampton General Hospital. The report raises concerns that Hampshire’s 999 call-handling system may cause delays, missed triage opportunities and inadequate information-sharing between emergency services during mental health crises involving suicidal ideation.
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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure of 999 call triage to quickly and effectively identify the appropriate emergency response agency
Wider context from the report “At Mr Moody’s Inquest I heard that his family (who were present throughout events as his daughter and son-in-law on the Estate in which Mr and Mrs Moody had a cottage) initially called 999 and asked for the Police to attend. The 999 call-taker triaged the call as requiring the attendance of Ambulance Service and deemed this to be a matter that the Police would not attend. This resulted in the family having to redial 999 and ask for an alternative service; during which some level of screening questions were repeated. This caused delay in the family reaching an appropriate service to attend.
I heard evidence from the Mental Health Lead for Hampshire Constabulary who explained that as the incident on the 19th April 2019 was occurring in the person’s home and, as such the Police have no power to intervene where a person is in their own home and in mental health crisis and/or threatening to harm themselves. The situation on the 19th of April was distinguished from that which had happened the day before, on the 18th April, as the incident on the 18th had occurred in a public place and so, in that case, the police had a duty to attend.
I heard further evidence that there is a Memorandum of Understanding (“MOU”) between Hampshire Police and the South Central Ambulance Service as to who is the primary response agency for persons making threats of suicidal ideation.
Ultimately, the family were confused as to where help would come from and the call-handler will not transfer the call to a particular route/service unless the caller makes the decision as to which service they need. Despite there being a MOU between the agencies this does not appear to be something that the general public is aware of, and the task of making the general public aware of this is likely to be insurmountable and therefore it remains entirely foreseeable that future delays could occur because callers are unaware of which emergency service is the correct one to request in a situation where a person is suffering a mental health crisis episode and/or expressing suicidal ideation within the boundaries of their home.
I heard further evidence regarding the existence of a different triage system, that operates in at least one area/jurisdiction of the country, but this only applies when a caller dials the 111 service; callers are given an option of accessing “Mental Health” services and this allows calls to be triaged through to an appropriately trained team/call-handler who can ask a set of wider diagnostic questions to understand and establish which agency, on the particular facts, should be the primary response service to that individual.
In the situation of Mr Moody it transpired that it was actually a mixed response that was required; both the Police and Ambulance services.
I am concerned that the current system of dealing with 999 calls in Hampshire gives rise to the potential for opportunities to be missed to triage the emergency call quickly and effectively , and to share information between agencies without the need to repeat the screening approach, and these factors may result in further deaths in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to share information between emergency agencies without repeating caller screening
Wider context from the report “At Mr Moody’s Inquest I heard that his family (who were present throughout events as his daughter and son-in-law on the Estate in which Mr and Mrs Moody had a cottage) initially called 999 and asked for the Police to attend. The 999 call-taker triaged the call as requiring the attendance of Ambulance Service and deemed this to be a matter that the Police would not attend. This resulted in the family having to redial 999 and ask for an alternative service; during which some level of screening questions were repeated. This caused delay in the family reaching an appropriate service to attend.
I heard evidence from the Mental Health Lead for Hampshire Constabulary who explained that as the incident on the 19th April 2019 was occurring in the person’s home and, as such the Police have no power to intervene where a person is in their own home and in mental health crisis and/or threatening to harm themselves. The situation on the 19th of April was distinguished from that which had happened the day before, on the 18th April, as the incident on the 18th had occurred in a public place and so, in that case, the police had a duty to attend.
I heard further evidence that there is a Memorandum of Understanding (“MOU”) between Hampshire Police and the South Central Ambulance Service as to who is the primary response agency for persons making threats of suicidal ideation.
Ultimately, the family were confused as to where help would come from and the call-handler will not transfer the call to a particular route/service unless the caller makes the decision as to which service they need. Despite there being a MOU between the agencies this does not appear to be something that the general public is aware of, and the task of making the general public aware of this is likely to be insurmountable and therefore it remains entirely foreseeable that future delays could occur because callers are unaware of which emergency service is the correct one to request in a situation where a person is suffering a mental health crisis episode and/or expressing suicidal ideation within the boundaries of their home.
I heard further evidence regarding the existence of a different triage system, that operates in at least one area/jurisdiction of the country, but this only applies when a caller dials the 111 service; callers are given an option of accessing “Mental Health” services and this allows calls to be triaged through to an appropriately trained team/call-handler who can ask a set of wider diagnostic questions to understand and establish which agency, on the particular facts, should be the primary response service to that individual.
In the situation of Mr Moody it transpired that it was actually a mixed response that was required; both the Police and Ambulance services.
I am concerned that the current system of dealing with 999 calls in Hampshire gives rise to the potential for opportunities to be missed to triage the emergency call quickly and effectively, and to share information between agencies without the need to repeat the screening approach , and these factors may result in further deaths in the future.
” Open source report
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked View source See 3 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
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Risk of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report
Concerns raised 2 Failure to relay known emergencies or serious situations to police in a timely way View source Unclear procedures for licence security staff calling police assistance in time-critical situations 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
Jason Marshall GREGORY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason Gregory became involved in a disturbance and was physically restrained by door security staff, including by an arm hold around his neck. He suffered ventricular fibrillation and cardiac arrest, with contributory factors including exertion, excitement, cocaine and alcohol intoxication. The concerns were about delays in relaying serious incidents to police and uncertainty among security staff about how to request police assistance in time-critical situations.
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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to relay known emergencies or serious situations to police in a timely way
Wider context from the report “I heard evidence that door security staff called Southampton Citywatch (Whisky 1) just after midnight on 6 May 2017 by radio reporting a serious disturbance and requesting urgent police attendance at the scene, but this was refused and were told that a call should be made to emergency services using the 999 service. I am concerned that if there is an emergency or serious situation in Southampton known to Citywatch staff by reason of their monitoring or reports received, this fact is not being relayed to Hampshire Police in a timely way and so there is a risk that there will be delays in police officers attending and members of the public are at risk of death or serious injury as a consequence.
It is unclear to licence security staff how they should call for assistance from the police when dealing with time critical situations at busy times.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Unclear procedures for licence security staff calling police assistance in time-critical situations
Wider context from the report “I heard evidence that door security staff called Southampton Citywatch (Whisky 1) just after midnight on 6 May 2017 by radio reporting a serious disturbance and requesting urgent police attendance at the scene, but this was refused and were told that a call should be made to emergency services using the 999 service. I am concerned that if there is an emergency or serious situation in Southampton known to Citywatch staff by reason of their monitoring or reports received, this fact is not being relayed to Hampshire Police in a timely way and so there is a risk that there will be delays in police officers attending and members of the public are at risk of death or serious injury as a consequence.
It is unclear to licence security staff how they should call for assistance from the police when dealing with time critical situations at busy times.
” Open source report
Concerns raised 13 Failure to complete SASH forms for risk information emerging outside current court detention View source Failure to ensure clarity about information available during prison reception View source Failure to ensure Detention Officer PER training is completed View source Failure to complete SASH forms for relevant recent self-harm or suicide risk View source Failure to ensure receipt and training for important medical and risk information at prison reception View source Cell safety features permitting door wedging and ligature use View source Radio connection delays affecting emergency information relay View source Failure to ensure secure handover of PER documentation View source Failure to provide PER staff with relevant previous self-harm and suicide risk information View source Failure of court custody staff to contribute relevant risk information to the PER View source Incomplete provision of anti-ligature protection on cell doors View source Failure to record checks of PER completion and quality View source Failure of regular maintenance checks to identify defective anti-barricade doors View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Folley · 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 Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.
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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to complete SASH forms for risk information emerging outside current court detention
Wider context from the report “I was also left with a concern that GEOAmey staff would only complete a SASH form if the current risk was identified during Mr Folley’s detention at Portsmouth magistrates’ court and not if anything came to the attention of the court detention officer to indicate there was a risk of self-harm or suicide within the last month before arrest .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clarity about information available during prison reception
Wider context from the report “During the inquest, it became apparent that despite extensive questioning of police/custody staff, GEOAmey staff, prison officers and healthcare professionals, it would not be possible to establish with any degree of certainty exactly what information was available during the induction process once Mr Folley arrived at prison.
I heard from prison officers and a senior nurse involved in the reception process but there was no clarity regarding exactly what information was available to them namely, the PER itself, the HDLS reports or information that had clearly been faxed to the prison by court staff such as the warrants setting out the grounds for the remand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Detention Officer PER training is completed
Wider context from the report “c) Detention Officer PER training may not have been completed if a DO had many years of experience in the police force which would give what he referred to as “grandfather rights” .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to complete SASH forms for relevant recent self-harm or suicide risk
Wider context from the report “h) The suicide/self harm warning alert (SASH) at page 9 of the PER was meant to be completed if there was a risk of self-harm or suicide since arrest or within the last month . In other words, it was felt the relevant period to be considered was not just the current period of detention but also anything relevant within a month before arrest. In this case the SASH form was never 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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure receipt and training for important medical and risk information at prison reception
Wider context from the report “The nurse confirmed that at the time of Mr Folley’s reception checks he did not see the PER or HLDS reports but told me that he now does. In addition, he could not recall any specific training and the system for receipt of important medical information sounded haphazard as hardcopy documents were simply left on a desk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Cell safety features permitting door wedging and ligature use
Wider context from the report “I heard evidence that prisoners are issued with plastic mirrors that are frequently used as wedges in cell doors . This means officers are vigilant to ensure prisoners only have one mirror each and if there are more in a cell than necessary they will be removed. It was suggested that a thicker mirror could be issued or a mirror/reflective panel could be inserted into the wall. This was an ongoing process of replacement in the prison.
Window design was also being considered and I was informed a trial had begun prison to roll out a new type of window but that this could take up to 2 years to complete .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Radio connection delays affecting emergency information relay
Wider context from the report “There was conflicting evidence during inquest about the effectiveness of when the Code Blue call was made and whether this resulted in any delay in the information being passed to the ambulance service. On balance of probabilities, the problem seemed to come from the fact that the custody manager did give the correct callsign but because there is a two second delay when pressing the radio button this may not have been picked up immediately in the control room . This is of significant concern both in respect of the safety prison officers but also the need to obtain medical help for prisoners and suggests the need to update the radio system
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure secure handover of PER documentation
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry. This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded.
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody 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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to provide PER staff with relevant previous self-harm and suicide risk information
Wider context from the report “b) Mr Folley was assessed as NCTS (no current thoughts of self-harm or suicide) and thus placed on the lowest observation rate of 60 minutes. However, access to previous data held on police (both internal and external) and other agency systems was not available to officers completing the PER and thus they could rely on current observations only . Despite this, it was essential to consider the risk of self-harm or suicide demonstrated and recorded over the previous months (July – September) not simply since detention on this occasion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure of court custody staff to contribute relevant risk information to the PER
Wider context from the report “I am concerned that the impression created was that GEOAmey staff do not actively engage in and contribute to the contents of the PER to highlight any information relevant to risk assessment irrespective of what source it comes from.
In addition, there was apparently no log of ████████ call to the court cells. The electronic PER had been checked and nothing was logged. There is no reason to believe ████████ call was not made and it is of concern that there was no apparent system for logging such a call let alone action in the contents of her request .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Incomplete provision of anti-ligature protection on cell doors
Wider context from the report “I also heard that steps had been taken to fit anti-ligature strips in some but not all cell doors .
All of these suggestions seemed eminently sensible yet the pace of these changes does need to be considered .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to record checks of PER completion and quality
Wider context from the report “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry . This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded .
f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody 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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure of regular maintenance checks to identify defective anti-barricade doors
Wider context from the report “I heard evidence that every effort was made to gain quick access into Mr Folley self once it became apparent that he had barricaded the door. This was significantly hindered by painting the screws on the anti-barricade plate but significantly, by the fact that even when the plate was removed the bar would not open outwards towards this landing due to a brick hanging down in the door frame. Whilst it has to be accepted that Winchester prison is not a modern prison nevertheless this should have been picked up during regular maintenance checks . I was shown some records this tended to imply that either checks had not been carried out on a regular basis or the checks themselves were not adequate . Either way this is of concern.
” 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 which Detention Officers completed an initial custody course.
Verbatim wording from the response “In conjunction with the Learning and Professional Development department, Force Custody will conduct a review to establish those Detention Officers who were undertook an initial custody course. Consideration is being given to ensure that those identified undertake the course at the earliest opportunity.” Source location 2019-0230-Response-by-Hampshire-Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the next custody newsletter to reinforce PER completion, inspection, warning-page, envelope, risk-marker and external-information responsibilities.
Verbatim wording from the response “Force Custody publishes a quarterly newsletter to all custody officers and detention officers. The next publication is due in September 2019 and will reinforce the issues addressed in this Regulation 28 Notice.” Source location 2019-0230-Response-by-Hampshire-Constabulary
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 Mandate PER e-learning for all Custody and Detention Officers and track completion to 100%.
Verbatim wording from the response “Hampshire Constabulary will mandate that all Custody Officers and Detention Officers undertake the force endorsed electronic self-learning package on PERs, irrespective of when they last completed it. The content of the course will be reviewed annually by the Force Custody Senior Management Team (Force Custody) to ensure it remains accurate and fit for purpose thereby ensuring that officers are appropriately trained in” Source location 2019-0230-Response-by-Hampshire-Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review force policies and procedures and add the notice’s issues to relevant documents where necessary.
Verbatim wording from the response “Force Custody is currently conducting a full review of our Force Policies and Procedures. The issues raised in this Regulation 28 Notice will be reviewed and added to relevant policies and procedures if not already included.” Source location 2019-0230-Response-by-Hampshire-Constabulary
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 Recommend that Learning and Professional Development review the initial custody course’s PER lesson plan and content against the notice and professional guidance.
Verbatim wording from the response “PER training is already included in the initial custody course for both Custody Officers and Detention Officers. A recommendation will be made to the Learning and Professional Development department who deliver the course to review the current lesson plan and course content to ensure it meets the requirements of this Regulation 28 Notice and guidance contained within the College of Policing Authorised Professional Practice.” Source location 2019-0230-Response-by-Hampshire-Constabulary
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 Officers must rely on each police force or agency to place relevant information on the national Police National Computer.
Verbatim wording from the response “Through the newsletter we will equally remind staff to consider the potential external sources of information available to them, including information held on other police force and agency systems when managing risks and completing PERs. This will be dependent on individual case by case circumstances as it is impracticable for data to be obtained from each outside agency on every occasion. Officers must rely on each force or agency adhering to its responsibilities to ensure relevant data is included on the national PNC system to which all forces have access.” Source location 2019-0230-Response-by-Hampshire-Constabulary
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 All detention officers had received PER training during the previous two years; only some may not have completed initial custody training.
Verbatim wording from the response “2. Under Section 5, at paragraph 1(c) it outlines that, ‘Detention officer PER training may not have been completed….’ However, all detention officers have received PER training over the last two years. ████████ stated that detention officer initial training may not have been completed if the detention officer had many prior years of experience in policing. The difference here is between initial training and PER training.” Source location 2019-0230-Response-by-Hampshire-Constabulary
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 Obtaining information from every external agency on every occasion is impracticable, so officers cannot routinely obtain all external data.
Verbatim wording from the response “Through the newsletter we will equally remind staff to consider the potential external sources of information available to them, including information held on other police force and agency systems when managing risks and completing PERs. This will be dependent on individual case by case circumstances as it is impracticable for data to be obtained from each outside agency on every occasion. Officers must rely on each force or agency adhering to its responsibilities to ensure relevant data is included on the national PNC system to which all forces have access.” Source location 2019-0230-Response-by-Hampshire-Constabulary
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 Detention officers completing PERs had access to Hampshire Constabulary systems and the Police National Computer, but not other forces’ internal systems.
Verbatim wording from the response “1. Under Section 5, at paragraph 1(b) the report outlines that the officers completing the Prisoner Escort Record (PER) did not have access to the data held on Police (both internal and external) and other agency systems. The officers completing the PER did have access to Hampshire Constabulary internal systems and the Police National Computer but would not have had direct access to other police force internal crime or intelligence recording systems.” Source location 2019-0230-Response-by-Hampshire-Constabulary
Open published response
Concerns raised 2 Failure to equip searchers with tracking devices View source Unavailability of a stand-alone mapping system for police search advisers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
James David Barrett · 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
James David Barrett, who had Alzheimer's dementia, went missing from his home on 7 August 2015 and was found deceased on 13 August 2015. The concerns related to the effectiveness and speed of the missing-person search, including reliance on separate mapping arrangements and the lack of tracking devices for searchers.
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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to equip searchers with tracking devices
Wider context from the report “I was also told that the search for Mr Barrett could have been more effective if searchers had been equipped with tracking devices which would allow search organisers to see precisely where searchers had looked for him . I should be grateful if Hampshire Police could consider obtaining there devices for use in missing persons searches.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a stand-alone mapping system for police search advisers
Wider context from the report “If the mapping of the search for Mr Barrett had been completed on one mapping system, I believe the search for him could have been conducted more quickly and effectively. This could be done in future if the police search advisers had available to them a stand-alone mapping system rather than relying on a volunteer organisation to map out searches . I was told that a bid for such a mapping system by the police search team has been turned down by Hampshire Constabulary and I would ask that this decision be reviewed in the light of the circumstances of Mr Barrett's death.
” 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 Submit a business case proposing purchase of the MAPYEX system and explaining its intended use.
Verbatim wording from the response “You have stated a duty to respond by the 11th April, 2016. I can confirm that a business case has been submitted by Sergeant Turner proposing the purchase of a MAPYEX system at £51,000 along with detail of how the system will be used to reach maximum benefits. On the 2nd March, 2016 I recommended the purchase for ratification to Assistant Chief Constable Scott Chilton.” Source location James-BARRETT-Response
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 Recommend purchase of the MAPYEX system for Assistant Chief Constable ratification.
Verbatim wording from the response “You have stated a duty to respond by the 11th April, 2016. I can confirm that a business case has been submitted by Sergeant Turner proposing the purchase of a MAPYEX system at £51,000 along with detail of how the system will be used to reach maximum benefits. On the 2nd March, 2016 I recommended the purchase for ratification to Assistant Chief Constable Scott Chilton.” Source location James-BARRETT-Response
Open published response
Concerns raised 1 Road layout and surrounding hedgerows affecting driver visibility and road safety View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
William John Watson · 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
William John Watson, aged 93, died in hospital after being seriously injured in a head-on road traffic collision while overtaking a coach on the Middle Road, Isle of Wight, on 22 October 2013. The concern was that the road layout and surrounding hedgerows near the bus stop at Tapnell might have affected drivers’ visibility and road safety, particularly in light of other road traffic incidents on that stretch.
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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Road layout and surrounding hedgerows affecting driver visibility and road safety
Wider context from the report “1. During the course of the evidence, it became clear that there had been other road traffic incidents along this stretch of the Middle Road, and it was a matter of concern that the layout of the road, and surrounding hedgerows, adjacent to the bus stop at Tapnell, on the Newport bound carriageway, might be affecting drivers’ visibility and thereby the safety of the road itself .
” Open source report
Concerns raised 3 Lack of arrangements enabling doctors to report relevant information during firearms licence terms View source Failure to enable General Practitioners to share public-safety information with relevant authorities View source Lack of independent and transparent firearms licensing decisions for current or former police employees 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
William Howard DOWLING and Victoria Elaine ROSE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 2 March 2013, William Howard Dowling shot Victoria Elaine Rose twice in the head before shooting himself in the head. The report raised concerns about information sharing between general practitioners and firearms licensing authorities, the wider public-safety implications of confidentiality, and the independence and transparency of firearms licensing decisions involving current or former police employees.
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 Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements enabling doctors to report relevant information during firearms licence terms
Wider context from the report “(1) During the course of the hearing I heard evidence from ███████ Wiltshire Police Firearms Licensing Manager, who indicated to me that at the present moment in time aside from a letter (copy attached marked A – since July 2011) which is sent to General Practitioners when firearms licence applications are successful or where they are renewed, giving a doctor the opportunity to relay relevant information in relation to their patient within 14 days, there is currently no memorandum of understanding or legislation that allows doctors the ability during the duration of the term of a firearms license, which stands at 5 years, to report matters which may have a bearing on that patient’s suitability to hold a firearms license and possess firearms . Doctors of course are bound at the present moment in time by patient confidentiality. I am concerned that this restriction may impede the firearms authority from making crucial decisions as regards individuals possessing firearms and continuing to hold a firearms licence in circumstances which, at present, may not come before the attention of the Firearms Authority unless the matter has ordinarily come before the police’s attention as a consequence of other aspects of their duties.
In evidence from ███████ she made me aware that Wiltshire Police through the cooperation of NHS Wiltshire Clinical Commissioning Group and two Doctor’s Surgeries were piloting a scheme (directly prompted Victoria’s two sons as a result of his tragedy) effective from September 2013, to allow an increase in the sharing of information in particular having a bearing on the suitability of an individual to hold a firearms licence. She indicated that as a result of this pilot scheme an individual’s firearms were taken away at short notice as a result of the information received from the General Practitioner. This pilot scheme seems to me to be an utterly sensible idea although at present it is a pilot scheme and is not a national concept . This ought to be urgently reviewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to enable General Practitioners to share public-safety information with relevant authorities
Wider context from the report “(2) I am also concerned that any review arising out of this letter should not be singularly restricted as regards sharing information solely related to the suitability of somebody to hold a firearms licence. Information sharing with a view to public safety should be a reason for General Practitioners to make relevant authority(s) aware and I have in mind here the example of a driver whose eyesight is failing and where advice given from a GP to inform the DVLA, however that driver chooses not to do so as it will mean their licence may be revoked. If it is a matter of public safety then I am concerned at present moment in time that confidentiality appears to outweigh the concept of public safety .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hampshire and Isle of Wight Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of independent and transparent firearms licensing decisions for current or former police employees
Wider context from the report “(3) I am also concerned as regards decisions being made relating to firearms licensing in respect of current employees within that licensing organisation’s (ie the Police) employment or even former employees . Licensing and the determination of such matters should be seen to be transparent and independent . In evidence although relating to matters some 16 years previously there were issues raised by family concerning complaints by Mr Dowling’s ex wife at the time they were getting divorced that appeared to have been “brushed under the carpet” by the police in respect of which Bill was a serving officer. In any event those concerns were not dealt with satisfactorily from the complainant’s perspective. I am concerned that to have a firearms licensing authority dealing with applications from existing police employees or even former employees of that police force is open to possible abuse . Bill Dowling was an exceptionally well known and respected former police employee and my concern is that such matters relative to firearms are so serious that consideration ought to be given to introducing an independent layer so as to ensure independence and transparency .
” Open source report
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Addressed to “Hampshire Constabulary”, a former name of Hampshire and Isle of Wight Constabulary.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations