13 Apr 2021 NATASHA JENNIFER IRENE CRABB · Prevention of Future Deaths report Surrey
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Concerns raised 2 Lack of restriction on the quantity of butane gas that can be purchased View source Lack of legal powers to prevent capable people inhaling butane or remove butane from them 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
NATASHA JENNIFER IRENE CRABB · 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
Natasha Jennifer Irene Crabb died at Princess Gardens, Woking, on 29 June 2018 after continuing to inhale butane gas following her self-discharge from hospital. The substantive concerns were that inhaling butane was lawful, there were no legal powers to prevent a person with capacity from inhaling it or to remove it from them, and there was no restriction on the amount of butane that could be purchased.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of restriction on the quantity of butane gas that can be purchased
Wider context from the report “2. There is no restriction on the amount of butane gas that can be purchased making it easy for a person addicted to inhaling butane gas to obtain large amounts of the gas at one time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of legal powers to prevent capable people inhaling butane or remove butane from them
Wider context from the report “1. Inhaling butane is lawful and there are no legal powers to prevent a person with capacity inhaling butane nor to remove butane from them. The effects of inhalation can be fatal.
” Open source report
15 Mar 2021 Joe Peter Robinson · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Failure to share and embed lessons about policing plans across other Force Areas 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
Joe Peter Robinson · 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
Joe Peter Robinson became unwell and collapsed near Ashton Canal in the early hours of 14 June 2020, and attempts to resuscitate him were unsuccessful. The post-mortem examination found that he died from a combination of MDMA and ketamine. The concerns included the absence of first-aid or paramedic facilities at a large unlicensed gathering, and uncertainty about whether lessons concerning policing plans had been shared and embedded across other force areas.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to share and embed lessons about policing plans across other Force Areas
Wider context from the report “The evidence before the inquest was that Greater Manchester Police became aware of the event but felt unable to prevent it from continuing. The inquest was told that at the time GMP did not have a clear plan to deal with such a situation. However, since this event at Daisy Nook and a similar one that same night also in South Manchester they have developed a robust plan and there have not been similar large scale illegal gatherings.
What was not clear from the inquest was whether the lessons learnt of the need for policing plans to prevent such events occurring and reduce the risk of future deaths occurring had been shared and embedded in other Force Areas.
” Open source report
18 Nov 2020 Alfie Gildea · Prevention of Future Deaths report Manchester South
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Concerns raised 22 Limited police recognition and use of Claire's Law in domestic abuse cases View source Unqualified staff making key MARAT decisions View source Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators View source Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators View source Poor information sharing and joint risk recognition across statutory agencies View source Limited police training and capability to identify coercive and controlling behaviour View source Insufficient health visitor capacity for safeguarding and interagency work View source Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible View source Reduced specialist support and oversight for low and medium risk domestic abuse cases View source Failure to share complete relevant information between police and CPS View source Failure of CPS decision makers to follow guidance and document prosecution assessments View source Limited health visitor understanding of coercive and controlling behaviour View source Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs View source Failure to share perpetrator risk information with alleged victims View source Failure to place domestic abuse suspects on protective bail conditions during further investigation View source Failure to provide safe opportunities for domestic abuse disclosure View source Failure to pursue further enquiries supporting victimless domestic abuse prosecutions View source Failure to routinely document police and CPS case discussions View source Failure to use the MARAC framework when appropriate View source Limited police training in domestic abuse risk evaluation and scoring View source Insufficient resourcing of the MARAT frontline service View source Failure to conduct required health visiting conversations face to face View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alfie Gildea · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Limited police recognition and use of Claire's Law in domestic abuse cases
Wider context from the report “7. Recognition of when and how Claire's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Unqualified staff making key MARAT decisions
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions . Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators
Wider context from the report “2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different . It was unclear why that was the case. However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators
Wider context from the report “4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs policy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Poor information sharing and joint risk recognition across statutory agencies
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor . As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator . Opportunities to use the MARAC framework were not taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Limited police training and capability to identify coercive and controlling behaviour
Wider context from the report “5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour . Understanding of how coercive and controlling behaviour in a relationship could be identified was limited .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient health visitor capacity for safeguarding and interagency work
Wider context from the report “14. The inquest was told that Health Visitor numbers were reducing due to national funding arrangements . As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible
Wider context from the report “3. It is unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMPs systems . Officers giving evidence did not understand how such information could be accessed or recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Reduced specialist support and oversight for low and medium risk domestic abuse cases
Wider context from the report “9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to share complete relevant information between police and CPS
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed . The file that was submitted omitted key information available to GMP that would have been important to the decision maker . The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of CPS decision makers to follow guidance and document prosecution assessments
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim . The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Limited health visitor understanding of coercive and controlling behaviour
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself . Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs
Wider context from the report “11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed . There was no evidence of a clear and effective system of notification on the Trafford Division of GMP .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to share perpetrator risk information with alleged victims
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to place domestic abuse suspects on protective bail conditions during further investigation
Wider context from the report “1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required . Instead they were placed under investigation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safe opportunities for domestic abuse disclosure
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to pursue further enquiries supporting victimless domestic abuse prosecutions
Wider context from the report “8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely document police and CPS case discussions
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to use the MARAC framework when appropriate
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Limited police training in domestic abuse risk evaluation and scoring
Wider context from the report “6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient resourcing of the MARAT frontline service
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced . This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required health visiting conversations face to face
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face . The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Place Domestic Violence Disclosure Scheme guidance on a statutory footing through the Domestic Abuse Bill.
Verbatim wording from the response “The Domestic Violence Disclosure Scheme (DVDS), also known as Clare’s Law, is an important tool designed to keep people safe and we are working with the police to review the guidance used by forces. Under Clause 70 of the Domestic Abuse Bill, we are seeking to place the guidance that underpins DVDS onto a statutory footing to drive greater use and consistent application of the scheme by placing an express duty on the police to have regard to the guidance. Alongside legislation, we are reviewing the content of the guidance to ensure they are applied consistently across the country and are as effective as possible in helping to protect victims. This review will consider the timelines involved in the process and the use of risk assessments and safety planning.” Source location 2020-0242-Response-from-Home-Office-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue considering how to work with police forces to improve understanding and enforcement of the coercive and controlling behaviour offence.
Verbatim wording from the response “The coercive and controlling behaviour offence is increasingly being used by police, but we continue to consider how best to work with forces to ensure they understand it and enforce the laws with maximum effect.” Source location 2020-0242-Response-from-Home-Office-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Domestic Violence Disclosure Scheme guidance with police, including process timelines, risk assessments and safety planning.
Verbatim wording from the response “The Domestic Violence Disclosure Scheme (DVDS), also known as Clare’s Law, is an important tool designed to keep people safe and we are working with the police to review the guidance used by forces. Under Clause 70 of the Domestic Abuse Bill, we are seeking to place the guidance that underpins DVDS onto a statutory footing to drive greater use and consistent application of the scheme by placing an express duty on the police to have regard to the guidance. Alongside legislation, we are reviewing the content of the guidance to ensure they are applied consistently across the country and are as effective as possible in helping to protect victims. This review will consider the timelines involved in the process and the use of risk assessments and safety planning.” Source location 2020-0242-Response-from-Home-Office-Redacted.pdf
Open published response
12 Nov 2020 Chelsie Violet Greatorex · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Delays in contacting complainants seeking support View source Inadequate support for complainants seeking assistance View source Failure to conduct child sexual assault investigations through a specialist officer or team View source Delays in investigation and progression of sexual assault cases View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Chelsie Violet Greatorex · 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
Chelsie Violet Greatorex took an overdose of prescribed medication on 10 March 2020 and died later that day despite emergency treatment. The report describes concerns about her anxiety as a complainant in a sexual assault case, delays in the investigation, the lack of specialist handling despite her being a child when the alleged assault occurred, and limited support after she contacted police.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Delays in contacting complainants seeking support
Wider context from the report “d. When Ms Greatorex sought support from the MPS, no contact was made for four days , even then, the extent of the support was an email with the contact details of a borough psychological support service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inadequate support for complainants seeking assistance
Wider context from the report “d. When Ms Greatorex sought support from the MPS, no contact was made for four days, even then, the extent of the support was an email with the contact details of a borough psychological support service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct child sexual assault investigations through a specialist officer or team
Wider context from the report “b. Despite the fact that Ms Greatorex was a child when the events of the allegation took place, the investigation was not conducted by a specialist officer or team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Delays in investigation and progression of sexual assault cases
Wider context from the report “c. Delays in the investigation were identified ,
• despite naming the suspect and their place of study, no interview took place for over 3 months .
• a decision to prosecute was not arrived at until late December 2020 .
• A court hearing was not listed until January 2020 .
” 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 Publish a national strategy addressing all forms of child sexual abuse.
Verbatim wording from the response “Recognising that Ms. Greatorex was 17 years old when she was sexually assaulted, you may also wish to be aware that the government will shortly be publishing a first of its kind national strategy on tackling all forms of child sexual abuse. A key element of this strategy will be working across government to improve the way the criminal justice system responds to child sexual abuse and to ensure victims and survivors receive the support they deserve. We will continue to prioritise child sexual abuse as a national threat in the Strategic Policing Requirement, to empower police forces to maximise their specialist skills and expertise to tackle these crimes.” Source location 2021-0018-Response-from-Home-Office-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest additional annual funding through 2022 to recruit more Independent Sexual Violence Advisers.
Verbatim wording from the response “Furthermore, the government is committed to ensuring access to high quality support for victims and survivors of rape and sexual assault, wherever they live in the country and regardless of when the abuse occurred. In 2020/21, the Ministry of Justice has awarded £12m to 91 rape support centres across England and Wales to provide independent, specialist support to victims of sexual violence, including victims of child sexual abuse, an increase of £4m from 2019/20. The government has also announced that an additional £4m per year until 2022 will be invested in recruiting more Independent Sexual Violence Advisers (ISVAs) who play a vital role in informing and supporting victims at every stage of the criminal justice process.” Source location 2021-0018-Response-from-Home-Office-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue prioritising child sexual abuse as a national threat in the Strategic Policing Requirement.
Verbatim wording from the response “Recognising that Ms. Greatorex was 17 years old when she was sexually assaulted, you may also wish to be aware that the government will shortly be publishing a first of its kind national strategy on tackling all forms of child sexual abuse. A key element of this strategy will be working across government to improve the way the criminal justice system responds to child sexual abuse and to ensure victims and survivors receive the support they deserve. We will continue to prioritise child sexual abuse as a national threat in the Strategic Policing Requirement, to empower police forces to maximise their specialist skills and expertise to tackle these crimes.” Source location 2021-0018-Response-from-Home-Office-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out a cross-system review of the criminal justice response to rape and report a package of improvement actions.
Verbatim wording from the response “That is why, along with the Ministry of Justice and the Attorney General’s Office, the Home Office is currently carrying out a review of the criminal justice response to rape. The scope of the review covers the length of the criminal justice process, from police report and investigation through to final outcome in court, so that we can take a comprehensive view of any issues that need to be addressed within the system and take action accordingly.” Source location 2021-0018-Response-from-Home-Office-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consult on a Victims’ Law to guarantee victims’ rights and hold agencies accountable for delivering them.
Verbatim wording from the response “The Regulation 28 Report raises specific concerns about the level of communication and information that Ms. Greatorex received from the police during the investigation and the support that was offered to her. The government wants to ensure that the rights of victims are recognised at every stage of the criminal justice system. For this reason, we recently published a new, restructured Victims’ Code which sets out 12 key overarching rights regarding the support that victims should receive from the police, courts and other criminal justice agencies. We will also be consulting on a new Victims’ Law that will guarantee that victims receive their rights under the Code and agencies are held to account for delivering them.” Source location 2021-0018-Response-from-Home-Office-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund rape support centres across England and Wales to provide independent specialist support to victims of sexual violence.
Verbatim wording from the response “Furthermore, the government is committed to ensuring access to high quality support for victims and survivors of rape and sexual assault, wherever they live in the country and regardless of when the abuse occurred. In 2020/21, the Ministry of Justice has awarded £12m to 91 rape support centres across England and Wales to provide independent, specialist support to victims of sexual violence, including victims of child sexual abuse, an increase of £4m from 2019/20. The government has also announced that an additional £4m per year until 2022 will be invested in recruiting more Independent Sexual Violence Advisers (ISVAs) who play a vital role in informing and supporting victims at every stage of the criminal justice process.” Source location 2021-0018-Response-from-Home-Office-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a restructured Victims’ Code establishing overarching rights to support during the criminal justice process.
Verbatim wording from the response “The Regulation 28 Report raises specific concerns about the level of communication and information that Ms. Greatorex received from the police during the investigation and the support that was offered to her. The government wants to ensure that the rights of victims are recognised at every stage of the criminal justice system. For this reason, we recently published a new, restructured Victims’ Code which sets out 12 key overarching rights regarding the support that victims should receive from the police, courts and other criminal justice agencies. We will also be consulting on a new Victims’ Law that will guarantee that victims receive their rights under the Code and agencies are held to account for delivering them.” Source location 2021-0018-Response-from-Home-Office-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Metropolitan Police Service will respond separately on specific investigation matters because it is operationally independent.
Verbatim wording from the response “In your letter you ask that I ensure the matters you have raised are considered by the Metropolitan Police Service. I should stress that the Metropolitan Police Service is operationally independent and, as such, will respond separately on the specifics of the investigation in question. I am therefore responding to the Coroner’s concerns only in so far as they relate to national policy.” Source location 2021-0018-Response-from-Home-Office-Redacted
Open published response
12 Nov 2020 Imane Bouasbia · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to communicate expressed suicidal intent in the handover View source Failure to complete a self-harm or suicide risk assessment View source Failure to provide an adequately expedited and direct response to suicidal thoughts communicated by text 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
Imane Bouasbia · 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
Imane Bouasbia was sexually assaulted on 1 January 2020 and subsequently expressed suicidal thoughts to police. On 3 January 2020, she stepped in front of a moving Central Line tube train at Newbury Park Station and was killed instantly. The principal concerns were failures to communicate her suicidal thoughts, complete a self-harm or suicide risk assessment, and respond adequately to her text message indicating suicidal thoughts.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate expressed suicidal intent in the handover
Wider context from the report “a. The failure of Officer 1 to effectively communicate to Officer 2 either verbally or in the CRIS handover, that Ms Bouasbia had expressed the view that she wished to end her own life following the attack she sustained on 1st Jan 2020.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a self-harm or suicide risk assessment
Wider context from the report “b. The failure of Officer 2 to complete a risk assessment of Ms Bouasbia regarding thoughts of self-harm or suicide .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an adequately expedited and direct response to suicidal thoughts communicated by text
Wider context from the report “c. The police reaction to Ms Bouasbia’s text message at of 3rd January 2020 indicating suicidal thoughts was limited to a non-expedited instruction on a CAD action . The only response to Ms Bouasbia was a further text message rather than a telephone call .
” Open source report
25 Sep 2020 Vaidotas Gerbutavicius · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Inadequacy of legislation for dealing with offences involving DNP supplied for human consumption View source DNP toxicity affecting young and vulnerable individuals View source Lack of internet protections prohibiting the sale of DNP View source Failure to prevent internet availability of DNP as diet pills View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Vaidotas Gerbutavicius · 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
Vaidotas Gerbutavicius, aged 21, ingested slimming pills containing 2,4-dinitrophenol after drinking alcohol and died in hospital on 10 March 2018. The report raised concerns that DNP remained readily available online, that existing legislation was inadequate, and that protections preventing its internet sale were absent.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of legislation for dealing with offences involving DNP supplied for human consumption
Wider context from the report “2. In the UK, the lead organisation tasked with the disruption of the supply of 2, 4 – dinitrophenol, for human consumption is the Food Standards Agency. The Inquest received information from the Deputy Head of the National Food Crime Unit (part of the Food Standards Agency). He confirmed that “the views of the FSA Chief Executive and FSA Chair individually, is the current legislation is wholly inadequate and in no way can appropriate means by which to deal with offences that can result in the deaths of those who consume it (DNP) and these individuals are often young and vulnerable people”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation DNP toxicity affecting young and vulnerable individuals
Wider context from the report “1. Evidence was heard during the course of the Inquest that from 2007, to date, there have been at least 32 deaths from DNP toxicity . Many of those affected are young and vulnerable individuals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of internet protections prohibiting the sale of DNP
Wider context from the report “4. Prohibitions are in place on search engine algorithms used to prevent delivery of search results for TNT. 2, 4 – dinitrophenol is also used as an explosive, but there are no such internet protections in place to prohibit its sale .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent internet availability of DNP as diet pills
Wider context from the report “3. Evidence was given at the inquest that DNP is still readily available over the internet, as diet pills.
” Open source report
3 Mar 2020 Katrina Margaret Mary O’Hara · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Failure to provide replacement phones when victims’ phones are seized during an investigation View source Failure to recognise the perpetrator’s suicide risk as a significant domestic abuse risk factor for the victim View source Failure to ensure that non-emergency 999 calls from victims are taken or followed up without requiring the victim to call back View source Failure to ensure police officers are trained to use Niche for linking events and notifying investigation leads View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Katrina Margaret Mary O’Hara · 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
Katrina Margaret Mary O’Hara was stabbed by her ex-partner outside her place of work on 7 January 2016 and was pronounced deceased at the scene. The report raises concerns about police handling of non-emergency domestic abuse calls, recognition of a perpetrator’s suicide risk, provision of replacement phones when victims’ phones are seized, and the use and training of the Niche police software system.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide replacement phones when victims’ phones are seized during an investigation
Wider context from the report “iii. It is not unusual that the mobile phones of victims are seized by police as part of investigation into domestic abuse related allegations. Until the death of Miss O’Hara, Dorset Police did not provide replacement phones, leaving victims potentially without a means to communicate with others, including in an emergency . As stated above, Dorset Police now have a store of mobile phones available to supply to victims where their phones have been seized as evidence. I am concerned that this may not be in place across the police forces of England and Wales and that victims in some areas are being left without the means of contacting others, including the emergency services, when their phones have been seized by police during an investigation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the perpetrator’s suicide risk as a significant domestic abuse risk factor for the victim
Wider context from the report “ii. Dorset Police have changed their Domestic Abuse Investigation Policy and Procedure to include the suicide risk of the perpetrator of domestic abuse as a significant risk factor for the victim of domestic abuse . This is a recent change and reflects the growing understanding that the perpetrator who has “nothing left to lose” poses a significant risk to his or her victim. I am concerned that this change in policy in Dorset may not be reflected nationwide .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that non-emergency 999 calls from victims are taken or followed up without requiring the victim to call back
Wider context from the report “i. I am concerned that Police Forces across England and Wales may still be employing a policy similar to that previously employed by Dorset Police, with regard to non-emergency calls made to 999 . Dorset Police have recognised the courage it takes a victim of domestic violence to make a call to the police so have now ensured that, depending on the risk level and whether police attendance will be required, the call will either be taken by the 999 call handler, or, where it is deemed that no police attendance at any time is likely required, the caller will be called back at a later convenient time. It is no longer left to the victim to make a subsequent call to the police in relation to the same complaint. The concern is that if similar policies are not in place across the police forces in England and Wales, victims of offences, who may have had to take a huge risk to themselves or others to make the call to the police, are being asked to call back on a different number if their call is not categorised as an emergency .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police officers are trained to use Niche for linking events and notifying investigation leads
Wider context from the report “iv. “Niche” is a software program used by, I understand, 23 police forces across England and Wales. I do not know if more forces are due to adopt Niche in the future. I am concerned that appropriate training needs to be provided to police officers to ensure they have a good understanding of Niche and how to “link” events to an occurrence and to ensure that the appropriate individuals, for example the officer leading an investigation, are notified of any developments in a case .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot and evaluate approaches for identifying and tackling high-risk offenders, including adding suicide indicators to potential risk indicators.
Verbatim wording from the response “In respect of potential risk indicators in perpetrators, the Home Office is working with a number of police forces and the College of Policing to pilot and evaluate approaches to identifying and tackling high risk offenders. This work includes adding suicide indicators to the list of potential risk indicators. In parallel work is ongoing to review findings from domestic homicide reviews and academic research with a view to more accurately identifying key characteristics and risk factors for domestic homicides.” Source location 2020-0051-Response-from-Crime-Policing-and-Fire-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review domestic homicide review findings and academic research to improve identification of characteristics and risk factors for domestic homicides.
Verbatim wording from the response “In respect of potential risk indicators in perpetrators, the Home Office is working with a number of police forces and the College of Policing to pilot and evaluate approaches to identifying and tackling high risk offenders. This work includes adding suicide indicators to the list of potential risk indicators. In parallel work is ongoing to review findings from domestic homicide reviews and academic research with a view to more accurately identifying key characteristics and risk factors for domestic homicides.” Source location 2020-0051-Response-from-Crime-Policing-and-Fire-Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police forces are responsible for operational matters concerning call handling, evidence seizure and training on Niche systems.
Verbatim wording from the response “The matters you raise in relation to call handling, seizure of evidence and police training on Niche systems are primarily operational matters for the police. However, the Home Office liaises closely with policing leads and the College of Policing on domestic abuse issues and understands that domestic abuse cases are accorded a high priority by forces. Experience during the recent pandemic lockdown period has seen police forces employing innovative tactics to ensure that victims of domestic abuse can contact them in a wider range of ways – including for example on line as well as by telephone – as well as targeting high risk perpetrators. Police forces will be maintaining and building on such innovation as lockdown eases and good practice will be shared through the College of Policing.” Source location 2020-0051-Response-from-Crime-Policing-and-Fire-Service
Open published response
Concerns raised 3 Insufficient independent data on the effects and lethality of Taser use View source Failure of police training to specify safe limits for the number and duration of Taser activations View source Lack of understanding of incremental risk from multiple Taser activations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marc Antony Cole · 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 23 May 2017, Marc Antony Cole ingested a substantial amount of cocaine, behaved in a paranoid and psychotic manner, self-harmed and was Tasered three times by police before suffering a cardiac arrest and dying in hospital. The report raised concerns about limited independent data on the lethality and incremental risks of multiple or sustained Taser activations, and whether police advice and training were therefore deficient or incomplete.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient independent data on the effects and lethality of Taser use
Wider context from the report “It was said by a number of witnesses that the Taser is not a device without risk but that there is limited data as to its effects upon individuals (both generally but more particularly in those classified as vulnerable).
In evidence it was clear that there is no understanding about the potential for incremental risk with multiple Taser activations and no training provided as to the maximum number of activations nor of their duration which is appropriate or safe.
The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’).
It was clear from the evidence of ████████ (an intensivist consultant) that a Taser does carry a risk – despite, he said, the claims of the manufacturers - but the extent of that risk is far from clear.
Two forensic pathologists gave evidence and confirmed their joint opinion that the Taser caused (together with other things) Mr Cole’s death in that it played a more than minimal, trivial or negligible part.
Although I found as a fact that the training given to the police officers was appropriate I did so ONLY upon the basis that it was given based upon the limited knowledge presently available.
I am concerned, based upon the evidence that was led before the jury, that there is insufficient independent data as to the lethality of Taser use and that, therefore the advice and training provided to police officers may be deficient or incomplete.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of police training to specify safe limits for the number and duration of Taser activations
Wider context from the report “It was said by a number of witnesses that the Taser is not a device without risk but that there is limited data as to its effects upon individuals (both generally but more particularly in those classified as vulnerable).
In evidence it was clear that there is no understanding about the potential for incremental risk with multiple Taser activations and no training provided as to the maximum number of activations nor of their duration which is appropriate or safe.
The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’).
It was clear from the evidence of ████████ (an intensivist consultant) that a Taser does carry a risk – despite, he said, the claims of the manufacturers - but the extent of that risk is far from clear.
Two forensic pathologists gave evidence and confirmed their joint opinion that the Taser caused (together with other things) Mr Cole’s death in that it played a more than minimal, trivial or negligible part.
Although I found as a fact that the training given to the police officers was appropriate I did so ONLY upon the basis that it was given based upon the limited knowledge presently available.
I am concerned, based upon the evidence that was led before the jury, that there is insufficient independent data as to the lethality of Taser use and that, therefore the advice and training provided to police officers may be deficient or incomplete.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of incremental risk from multiple Taser activations
Wider context from the report “It was said by a number of witnesses that the Taser is not a device without risk but that there is limited data as to its effects upon individuals (both generally but more particularly in those classified as vulnerable).
In evidence it was clear that there is no understanding about the potential for incremental risk with multiple Taser activations and no training provided as to the maximum number of activations nor of their duration which is appropriate or safe.
The evidence was that the training given to police officers in this aspect is as set down by the College of Policing and that it is silent as to the potential incremental risk of multiple and or sustained activations (the so called ‘detention under power’).
It was clear from the evidence of ████████ (an intensivist consultant) that a Taser does carry a risk – despite, he said, the claims of the manufacturers - but the extent of that risk is far from clear.
Two forensic pathologists gave evidence and confirmed their joint opinion that the Taser caused (together with other things) Mr Cole’s death in that it played a more than minimal, trivial or negligible part.
Although I found as a fact that the training given to the police officers was appropriate I did so ONLY upon the basis that it was given based upon the limited knowledge presently available.
I am concerned, based upon the evidence that was led before the jury, that there is insufficient independent data as to the lethality of Taser use and that, therefore the advice and training provided to police officers may be deficient or incomplete.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce transparency measures requiring recording and annual publication of police use-of-force data.
Verbatim wording from the response “In 2017, we introduced new transparency measures, which mean that all officers have to record the location and outcome of all police use of force, along with the ethnicity and age of those involved. Use of force incidents, are recorded by all 43 Home Office police forces in England and Wales and reported to the Home Office annually. This data is published annually, the most recent publication was 19 December 2019⁷.” Source location 2020-0087-Response-from-the-Home-Office
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 Taser medical evaluations, guidance, training and ongoing scrutiny are considered adequate to ensure police use of force is as safe as possible.
Verbatim wording from the response “I am grateful to you for highlighting your concerns about the use of Taser. As you would expect, we take seriously your concerns concerning the circumstances of Mr. Cole’s death. We have carefully reviewed the processes and safeguards in place for the police use of Taser, including the independent evaluations of the medical implications of Tasers carried out by SACMILL, the guidance available, the high standards of training, and the ongoing scrutiny of the Taser use. I am satisfied that they are adequate and help ensure that any use of force by the police is proportionate, necessary and as safe as possible.” Source location 2020-0087-Response-from-the-Home-Office
Open published response
29 Jan 2020 Thiago Araujo · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Lack of support or education for families and carers managing emotionally unstable personality disorder View source Failure to make arrangements to address risks when closing crisis team referrals View source Lack of a process for families to escalate concerns to prevent delivery of hazardous packages View source Failure to inform families about the facility for reopening crisis team support View source Delays of 14 days in securing mental health act assessments View source Failure to act on an inpatient admission plan following identification of acute suicide risk 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
Thiago Araujo · 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
Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of support or education for families and carers managing emotionally unstable personality disorder
Wider context from the report “3. Family and carers of patients diagnosed with emotionally unstable personality disorder do not receive support or education upon management of this diagnosis from Camden and Islington NHS Trust, unless the patient has been received for treatment by the personality disorder service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to make arrangements to address risks when closing crisis team referrals
Wider context from the report “1. On 24 January 2020 Mr Araujo had discharged himself from psychiatric inpatient care he was to be supervised by the Camden and Islington NHS trust crisis team. Mr Araujo failed to engage with the crisis team and following a meeting on 30 January 2020 the crisis team closed Mr Araujo’s referral . In the course of this closure no arrangements were made to address the risks presented by Mr Araujo .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for families to escalate concerns to prevent delivery of hazardous packages
Wider context from the report “6. In the days leading to Mr Araujo’s death his family became aware that he had made an online purchase of ████████ which was to be delivered to his father’s home address. Despite raising these issues with Camden and Islington NHS trust, the Metropolitan police and employees of the post office there appeared to be no process available to the family to escalate their concerns to prevent delivery of this package .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to inform families about the facility for reopening crisis team support
Wider context from the report “2. Following Mr Araujo’s death it has become clear that the closure of his case by the crisis team was not permanent, and had Mr Araujo or his family approached the crisis team to reopen his case, steps could have been taken to reinstate crisis team support . Mr Araujo’s family were unaware of this facility .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Delays of 14 days in securing mental health act assessments
Wider context from the report “5. In evidence the community recovery team indicated that a factor in their inaction was the knowledge that arranging a section 135 mental health act 1983 warrant assessment would take two weeks . Such an assessment requires actions by an approved mental health practitioner from the local authority, two section 12 mental health act approved doctors, the assistance of the Metropolitan police and the local magistrates court to secure a warrant. A delay of 14 days in securing a mental health act assessment is in my opinion unacceptable .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to act on an inpatient admission plan following identification of acute suicide risk
Wider context from the report “4. By 4 February 2020 the Camden and Islington community recovery team identified an acute risk of suicide in Mr Araujo, faced with his non-compliance with community treatment they considered an admission into inpatient care . No actions were taken to affect this plan .
” Open source report
1 Nov 2019 Xavier Thomas and 10 others · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 7 Counter-terrorism investigation concerns View source Emergency response concerns for terrorist attacks View source Concerns about rental vehicles used in terrorist attacks View source Communications concerns View source Protective security concerns View source Concerns about locating casualties View source Medical equipment and training concerns View source See 4 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
Xavier Thomas and 10 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 3 June 2017, three attackers carried out vehicle and knife attacks at London Bridge and Borough Market, killing eight victims: Xavier Thomas, Christine Archibald, Sara Zelenak, James McMullan, Sébastien Bélanger, Alexandre Pigeard, Kirsty Boden and Ignacio Echeverría Miralles de Imperial. The report identifies substantive concerns relating to protective security, counter-terrorism investigations, emergency response, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Counter-terrorism investigation concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations , emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Emergency response concerns for terrorist attacks
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks , communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Concerns about rental vehicles used in terrorist attacks
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Communications concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications , locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Protective security concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security , counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Concerns about locating casualties
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties , medical equipment and training, and rental vehicles used in terrorist attacks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Medical equipment and training concerns
Wider context from the report “The substantive matters of concern are set out throughout the remainder of the Report, including MC1 to MC18, addressed to the relevant public authorities and industry body, concerning protective security, counter-terrorism investigations, emergency response to terrorist attacks, communications, locating casualties, medical equipment and training , and rental vehicles used in terrorist attacks.
” Open source report
24 Oct 2019 Douglas Paul Oak · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 9 Lack of general awareness of Acute Behavioural Disturbance View source Insufficient frequency and variety of ABD training View source Unsuitability of existing ABD training package for control-room staff View source Failure of Emergency Services to use mutually understood control-room terminology View source Insufficient ABD training for Police and Ambulance Service front-line and control-room staff View source Confusion over Police procedures for requesting Ambulance support View source Absence of Clinical Governance Boards in Police Forces View source Lack of cross-working within the emergency services View source Absence of joint national guidance on Police and Ambulance Service management of ABD View source See 6 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
Douglas Paul Oak · 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 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of general awareness of Acute Behavioural Disturbance
Wider context from the report “i. There is a lack of awareness generally regarding ABD and I would request consideration is given to the inclusion of the signs, symptoms and management of ABD within the First Aid Manual so that all those trained in first aid are able to deal with a patient presenting with ABD.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient frequency and variety of ABD training
Wider context from the report “iv. I also have concerns in relation to the frequency of the delivery of the training referred to in (iii) and I therefore request consideration be given to that training being delivered regularly, at least on an annual basis and with a variety of training techniques, including simulation and role play scenarios.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Unsuitability of existing ABD training package for control-room staff
Wider context from the report “vii. In relation to the training package that has been provided by the College of Policing regarding ABD, although ████████ has recommended this could be rolled out to control room staff, the package is tailored for front-line staff . I would therefore request consideration is given to a specific training package on ABD being designed and rolled out to those working in the control room environment by the College of Policing together with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Services to use mutually understood control-room terminology
Wider context from the report “v. Given that the Police and Ambulance Services work very closely in treating and managing a patient with ABD, and other patients who present with life threatening conditions, it is important that they understand each other. It was clear from this Inquest that there is different terminology used by the different services, the meaning of which is not understood by the other Emergency Services . An example of this was the use of the phrase “on the hurry up”. Although the confusion regarding this terminology was not found to be causative or contributory to Doug’s death, it could be in respect of a future death. I therefore request that consideration is given to the joint national training packages for all Emergency Services, namely the Police Service, Ambulance Service and the Fire Service on the workings within each control room and around the language used in the control rooms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient ABD training for Police and Ambulance Service front-line and control-room staff
Wider context from the report “iii. I believe it is likely there are persons working within Ambulance Service Trusts and Police Forces, whether it be on the front line or in the control room who are not aware of ABD and the serious risk to life it presents . I therefore request that consideration is given to ensuring all those working on the front line, or in control rooms in Ambulance Service Trusts and Police Forces in England and Wales are trained in ABD.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Confusion over Police procedures for requesting Ambulance support
Wider context from the report “ix. It was clear from the evidence that there appears to be confusion of when Dorset Police Officers should call 999 directly and when they should request assistance through the Police control room . I would request that there is consideration of the redrafting of the current “Police Requesting Ambulance Support” policy within Dorset Police and specifically when Police Officers should dial 999. In addition, I would request consideration of training be provided by Dorset Police to all Police Officers regarding the use of dialling 999 when contacting other Emergency Services. In doing this I would ask that consideration is given to liaising with the other local emergency services regarding their expectations, especially SWAST.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Absence of Clinical Governance Boards in Police Forces
Wider context from the report “viii. Evidence was given that Dorset Police have established a Clinical Governance Board which helps to create an awareness of, and improvement in, medical care provided by those working in the Police Service. This is not something adopted by all Police Forces in England and Wales and I therefore request that consideration is given to setting up a Clinical Governance Board in every Police Force in England and Wales.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-working within the emergency services
Wider context from the report “vi. Extending this point further, evidence was given that there would be benefit in cross working within the emergency services , so for example an Ambulance Clinician working within the Police control room to provide advice. I would therefore request that consideration is given on a national level to cross working within the emergency services.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Absence of joint national guidance on Police and Ambulance Service management of ABD
Wider context from the report “ii. There is no joint national guidance on the management of ABD by those who work for the Police and Ambulance Services, both on the front-line and in the control rooms. They are the people most likely to encounter those suffering with ABD and in most cases work together in the management of these patients. Accordingly, I request consideration is given to providing joint national guidance on the management of ABD patients by the Police and Ambulance Services to include:
• the provision of chemical sedation in pre-hospital care
• the training of all paramedics in administering chemical sedation
• the categorisation of Emergency Service calls relating to ABD
• the transfer of an ABD patient to hospital
” Open source report
28 Aug 2019 Amir Siman-Tov · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 14 Failure to communicate and establish vomiting during return to the healthcare unit View source Failure to provide detailed written clinical information and directions on discharge View source Failure to use the code blue procedure to summon an immediate emergency ambulance View source Failure to administer naloxone in suspected opiate overdose View source Lack of authority to require healthcare staff participation in the ACDT process View source Failure of the Consultant Forensic Psychiatrist to read ACDT documents View source Failure to apply renal impairment information in codeine overdose assessment View source Failure of healthcare staff to understand and participate in the ACDT process View source Failure to position an unresponsive patient on the floor for effective resuscitation View source Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC View source Unclear healthcare staff roles in the ACDT process View source Failure to provide explicit clinical direction and handover to night staff View source Inconsistent checks that detainees swallow issued medication View source Failure to wake, assess and take vital signs of a sleeping patient at risk View source See 11 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
Amir Siman-Tov · 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
Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and establish vomiting during return to the healthcare unit
Wider context from the report “9. During the journey back to the Colnbrook IRC Mr Siman-Tov vomited several times. He vomited on his return to the healthcare unit. The nurse on duty was not told by the escorting custody staff and did not ask about any vomiting in the returning minus. In oral evidence the nurse said that had he known of the vomiting then he would have returned Mr Siman-Tov to the hospital for further assessment. He did not know because he did not ask and was not told .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detailed written clinical information and directions on discharge
Wider context from the report “8. On discharge Mr Siman-Tov in the early evening of the 16ᵗʰ February 2016 was returned to Colnbrook IRC with no accompanying clinical information at all and no advice or directions to the clinical staff at the Colnbrook IRC from the hospital . The only information provided was that one of the hospital doctors had spoken to one of the Colnbrook IRC on the telephone and that Mr Siman-Tov was “good to go”. Failure to provide detailed written information puts patients at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to use the code blue procedure to summon an immediate emergency ambulance
Wider context from the report “12. At approximately 3.10 on the 17ᵗʰ February 2016 Mr Siman-Tov was found to be unresponsive by custody officers. Medical assistance was called for but the required “code blue” for summoning an immediate emergency ambulance was not used .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to administer naloxone in suspected opiate overdose
Wider context from the report “14. An emergency bag was brought containing adrenaline autoinjector and also naloxone which Dr Harris said was a temporary antidote to opiates . A nurse gave an injection of adrenaline into the thigh “because he thought it might help”. Naloxone was not given , even though ████████ had required emergency admission the day prior because of an opiate overdose. This puts detainees at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of authority to require healthcare staff participation in the ACDT process
Wider context from the report “4. The Centre Manager gave evidence that he recognised the importance of the ACDT process in keeping detainee’s safe and he actively encouraged as wide participation in the process as possible. He stated that he was only able to direct the custody staff and it was not in his power to direct that healthcare staff participated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of the Consultant Forensic Psychiatrist to read ACDT documents
Wider context from the report “3. The Consultant Forensic Psychiatrist did not read the ACDT documents . This puts detainees at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to apply renal impairment information in codeine overdose assessment
Wider context from the report “6. Mr Siman-Tov was taken to the Hillingdon Hospital in the late morning following his overdose on the 16ᵗʰ February 2016. At the Hillingdon Hospital an assessment, examination and blood tests were taken. The blood tests indicated renal impairment. An information system TOXBASE is used in emergency departments to provide assistance to clinicians. Toxbase indicates that in renal impairment greater care must be taken in cases of codeine overdose. This was missed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of healthcare staff to understand and participate in the ACDT process
Wider context from the report “1. A GP who had seen Mr Siman-Tov during his stay at Colnbrook IRC told the jury that he never seen and was not aware of the content of ACDT documents and regarded the documents as a custody officer process. He told the Court that it was not customary for healthcare staff to attend or participate in the ACDT process . This puts detainees at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to position an unresponsive patient on the floor for effective resuscitation
Wider context from the report “13. Nursing and other staff arrived. A custody officer asked the nurse if Mr Siman-Tov should be moved to the floor for resuscitation. The nurse replied no. Dr Harris, an expert in Emergency Medicine said that he should have been moved to the floor for effective resuscitation . This puts detainees at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital clinicians to account for available medical monitoring and supervision when returning patients to Colnbrook IRC
Wider context from the report “7. The hospital clinicians gave evidence which suggested that they were not fully aware of the level of medical monitoring and supervision available at Colnbrook IRC . Mr Siman-Tov had taken an overdose whilst supervised within that facility and a decision was made to return him to that environment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Unclear healthcare staff roles in the ACDT process
Wider context from the report “2. The nurses who gave evidence similarly were uncertain of their role with respect to the ACDT process and had variable accounts of their involvement in the ACDT process . This puts detainees at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide explicit clinical direction and handover to night staff
Wider context from the report “10. Mr Siman-Tov’s care was then handed over to night staff. No explicit direction or handover was given . The explanation for this was that the observations should be second signature and did not need elaboration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inconsistent checks that detainees swallow issued medication
Wider context from the report “5. Mr Siman-Tov expressed that he might save his medication and take as an overdose. There was conflicting evidence as to the rigour of the checks to ensure detainees had swallowed issued medicine at the time of dispensing and the nurses who gave evidence described different practices of observation . Mr Siman-Tov was able to collect sufficient codeine ultimately to be able to end his life. This lack of consistency of checks puts detainee’s at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to wake, assess and take vital signs of a sleeping patient at risk
Wider context from the report “11. The night nurse on duty at around 2100 noted that Mr Siman-Tov was sleeping and snoring. He made no attempt to wake him, check him or take his vital signs . This put Mr Siman-Tov at risk .
” Open source report
27 Aug 2019 Kay Michelle Martin · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 1 Lack of protective measures for victims of domestic abuse View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kay Michelle Martin · 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
Kay Michelle Martin, referred to as Kay Richardson, died on 21 September 2018 following a brutal and sustained attack by her husband, who then took his own life. The report raised concern that she had no protection in place between 8 August and 18 September 2018 while her husband was under police investigation without bail conditions or other restrictions, including restrictions concerning the family home keys.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of protective measures for victims of domestic abuse
Wider context from the report “I was concerned to hear that from 8th August 2018 to 18th September 2018 Kay Richardson had no protection in place . ████████ was only under investigation by the Police and was not subject to any conditions of police bail or other restrictions such as confiscation (or encouragement) to surrender his family home keys , all of which may have acted as a deterrent.
I was wondering whether you would review these procedures and resources available to protect victims of domestic abuse to prevent future deaths arising.
” 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 Coordinate implementation of actions addressing pre-charge bail use and victim protection.
Verbatim wording from the response “To date, the Home Office has coordinated the implementation of a number of actions on this issue. For example, the National Police Chiefs’ Council (NPCC) has published operational guidance that provides clear advice on domestic abuse and high harm cases, specifying that if a suspect has been arrested in connection with an offence involving vulnerable people or domestic abuse, there should be documented decision-making as to why pre-charge bail has not been used and serious consideration given to the imposition of bail with conditions in order to safeguard the victim. The guidance also advises that a detective inspector should be consulted before a domestic abuse or high harm offence suspect is released under investigation.” Source location 2019-0262-Response-by-Home-Office
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 Work with criminal justice partners to strengthen pre-charge bail frameworks and oversight for high-harm cases.
Verbatim wording from the response “I am acutely aware of issues regarding the use of pre-charge bail, particularly in relation to vulnerable victims and witnesses. As such I am working closely with criminal justice partners on what further mitigations can be put in place. A significant amount of further work is already in train on this matter, including to ensure the robustness of current frameworks and greater oversight of the use of pre-charge bail in high harm cases.” Source location 2019-0262-Response-by-Home-Office
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 Give serious consideration to HMICFRS inspection findings when determining wider pre-charge bail changes.
Verbatim wording from the response “In addition, HMICFRS are inspecting all forces on their use of pre-charge bail. The reports will be key in building our evidence base for what wider changes may be necessary and as such the Government will give serious consideration to its findings.” Source location 2019-0262-Response-by-Home-Office
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 police are responsible for acting on IOPC findings concerning the return of the perpetrator’s home keys.
Verbatim wording from the response “You also raised concerns about the decision of the police to return to the perpetrator his home keys. As I gather you are aware, the Independent Office for Police Conduct investigated this matter in order to understand why such a decision would have been taken and to help prevent such events occurring in the future, and I expect the police to act on the findings.” Source location 2019-0262-Response-by-Home-Office
Open published response
15 Aug 2019 Dane Lee Pearson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to assess known vulnerability when issuing CAWNs View source Failure to clarify available steps when serving CAWNs View source Failure to notify people under investigation of decisions View source Lack of documentation explaining the rationale for CAWN issuance View source Failure to update OPUS with vulnerability markers View source Issuing CAWNs on limited evidence regarding identification View source Delays in issuing CAWNs and failure to follow issuance timelines View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Dane Lee Pearson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dane Lee Pearson, who had a history of mental health problems and amphetamine use, was found suspended from a ligature at his home on 13 December 2017. The investigation concluded that the death was suicide, with the medical cause recorded as hanging. Concerns included failures in the issuing and documentation of a Child Abduction Warning Notice, failure to assess or account for his vulnerability, inadequate recording of vulnerability markers, and failure to communicate that criminal proceedings had been discontinued.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to assess known vulnerability when issuing CAWNs
Wider context from the report “2. In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account . A risk assessment had not been carried out . In this case, officers attended at his home address and served the CAWN on him .He refused to sign it on the basis; he had no knowledge of it or the circumstances behind it. It was left with him with no clarification about what if any steps he could take in relation to it. The inquest heard evidence that he was deeply worried about it and the impact of it on his life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify available steps when serving CAWNs
Wider context from the report “2. In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account. A risk assessment had not been carried out. In this case, officers attended at his home address and served the CAWN on him .He refused to sign it on the basis; he had no knowledge of it or the circumstances behind it. It was left with him with no clarification about what if any steps he could take in relation to it . The inquest heard evidence that he was deeply worried about it and the impact of it on his life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to notify people under investigation of decisions
Wider context from the report “4. The inquest was told that he was placed under investigation for a suspected attempt burglary and possession of an offensive weapon. A decision was taken by the OIC and his sergeant that it should be NFAD. The decision was not communicated to Mr Pearson . The officer had not followed the process for notification of decisions to those under investigation . As a result, at the time of his death he believed he may be charged with a criminal offence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation explaining the rationale for CAWN issuance
Wider context from the report “1. In this case, the CAWN had been issued on limited evidence particularly regarding identification. In addition, it had been issued many months after the allegation and after the authorisation. The inquest was told that the process had not been followed relating to timelines. There was no documentation in existence explaining the rationale for the issuing of the CAWN .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to update OPUS with vulnerability markers
Wider context from the report “3. The inquest heard that OPUS the Police system did not appear to have been correctly updated with markers to flag his vulnerability .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Issuing CAWNs on limited evidence regarding identification
Wider context from the report “1. In this case, the CAWN had been issued on limited evidence particularly regarding identification . In addition, it had been issued many months after the allegation and after the authorisation. The inquest was told that the process had not been followed relating to timelines. There was no documentation in existence explaining the rationale for the issuing of the CAWN.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Delays in issuing CAWNs and failure to follow issuance timelines
Wider context from the report “1. In this case, the CAWN had been issued on limited evidence particularly regarding identification. In addition, it had been issued many months after the allegation and after the authorisation . The inquest was told that the process had not been followed relating to timelines . There was no documentation in existence explaining the rationale for the issuing of the CAWN.
” Open source report
12 Aug 2019 Karen Jane Burns · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Insufficient resources to deal with the volume of calls, particularly at night View source Failure to grade calls correctly 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
Karen Jane Burns · 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
Karen Jane Burns was found hanging from a basketball net at a park in Birmingham at 06.15 on 23 March 2019, after her ex-partner had reported that she had threatened to kill herself. The inquest concluded that her death was suicide. A serious concern was raised about West Midlands Police resources, particularly at night, and the incorrect grading and non-response of the call reporting the threat.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources to deal with the volume of calls, particularly at night
Wider context from the report “1. I heard evidence at the inquest that this call was graded incorrectly. It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response). The evidence confirmed that nearly all the P2 and P3 calls went unanswered that night . This raises a serious concern about the amount of resources available to West Midlands Police. Urgent attention is needed to address the resources available, particularly at night, as current resources are unable to deal with the large volume of cases the Force is expected to deal with .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to grade calls correctly
Wider context from the report “1. I heard evidence at the inquest that this call was graded incorrectly . It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response). The evidence confirmed that nearly all the P2 and P3 calls went unanswered that night. This raises a serious concern about the amount of resources available to West Midlands Police. Urgent attention is needed to address the resources available, particularly at night, as current resources are unable to deal with the large volume of cases the Force is expected to deal with.
” Open source report
Concerns raised 4 Absence of a system providing firearms licensing departments with current medical fitness information View source Lack of skills and training for Firearms Enquiry Officers assessing applicants’ medical fitness View source Lack of mandatory comprehensive training for new Firearms Enquiry Officers View source Insufficient gathering of applicants’ relevant medical information before firearms certification decisions View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christine Ann Lee and Lucy Daisy Lee · 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
Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The jury found that failures in Surrey Police’s firearms licensing decisions contributed more than minimally to the deaths. The report also raised concerns about insufficient mandatory training for firearms licensing officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Absence of a system providing firearms licensing departments with current medical fitness information
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application .
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm . These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of skills and training for Firearms Enquiry Officers assessing applicants’ medical fitness
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably . I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation .
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory comprehensive training for new Firearms Enquiry Officers
Wider context from the report “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”) . I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete.
Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so.
I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role, in the form of the South Yorkshire Training Course or equivalent , will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient gathering of applicants’ relevant medical information before firearms certification decisions
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant , and the lack of clarity as to what medical conditions may be relevant and must be disclosed , together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness .
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report
Concerns raised 5 Absence of mandatory comprehensive training for Firearms Enquiry Officers View source Lack of relevant training and competence among Firearms Enquiry Officers assessing medical fitness View source Absence of ongoing notification of relevant medical changes during firearms certificate validity View source Insufficient medical-condition disclosure and evidence gathering before firearms licensing decisions View source Absence of a required current GP medical report before firearms certificate applications View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christine Ann Lee and Lucy Daisy Lee · 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
Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The report identified failures by Surrey Police firearms licensing staff to sufficiently investigate and consider relevant information, apply the correct standard of proof, and ensure appropriate senior oversight before returning the perpetrator’s shotgun certificate and shotguns. It also raised concerns about insufficient mandatory training for firearms enquiry officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Absence of mandatory comprehensive training for Firearms Enquiry Officers
Wider context from the report “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”) . I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete.
Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so .
I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role , in the form of the South Yorkshire Training Course or equivalent, will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of relevant training and competence among Firearms Enquiry Officers assessing medical fitness
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably . I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation .
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Absence of ongoing notification of relevant medical changes during firearms certificate validity
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes .”
I understand that this recommendation has not been implemented . This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient medical-condition disclosure and evidence gathering before firearms licensing decisions
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant , and the lack of clarity as to what medical conditions may be relevant and must be disclosed , together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness .
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Absence of a required current GP medical report before firearms certificate applications
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP , obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate , and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented . This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report
19 Jun 2019 Sophie Louise Lyons · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of an effective, adequately funded and targeted multi-agency approach to car cruising View source Failure to coordinate a pan-Greater Manchester approach to car cruising View source Car cruising involving highly dangerous manoeuvres on public roads View source Ineffective enforcement measures against car cruising View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sophie Louise Lyons · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sophie Louise Lyons was struck by a car during a dangerous manoeuvre at an illegal car cruising event in Trafford Park on 31 May 2018. She died in Salford Royal Hospital on 1 June 2018 from a catastrophic traumatic brain injury. The report identified ineffective measures, poor communication, limited resources and an inadequate multi-agency response to the known risks of car cruising.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective, adequately funded and targeted multi-agency approach to car cruising
Wider context from the report “The inquest heard that car cruising had been an issue in Trafford Park for a number of years. The problem (and inherent risk to public safety) was one that both the Local Authority (Trafford MBC) and GMP were aware of. Attempts to tackle it had been ineffective. Car cruising involved highly dangerous manoeuvres being carried out on public roads whilst members of the public were using the roads in significant numbers. The inquest saw video footage that showed the events leading up to the death of Sophie. It was clear that an incident involving disastrous loss of control could have happened at any time that night whilst car cruising was taking place. In addition, the inquest heard that whilst on this occasion Sophie was the sole fatality it could easily have been the case that multiple lives were lost in the incident.
One measure taken involved an application for a Public Spaces Protection Order. This had been a joint initiative but the implementation of enforcement meant that it was not effect.
The inquest heard that to tackle car cruising successfully, an effective multi-agency adequately funded and targeted approach was required . In addition the inquest heard that in an area such as Greater Manchester with multiple Local Authorities and dense population, a pan Greater Manchester approach would be required to prevent not just further incidents in Trafford Park but across Greater Manchester and nationally. The risk being that looking at the problem of car cruising in isolation could result in it being moved on rather than being dealt with effectively.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate a pan-Greater Manchester approach to car cruising
Wider context from the report “The inquest heard that car cruising had been an issue in Trafford Park for a number of years. The problem (and inherent risk to public safety) was one that both the Local Authority (Trafford MBC) and GMP were aware of. Attempts to tackle it had been ineffective. Car cruising involved highly dangerous manoeuvres being carried out on public roads whilst members of the public were using the roads in significant numbers. The inquest saw video footage that showed the events leading up to the death of Sophie. It was clear that an incident involving disastrous loss of control could have happened at any time that night whilst car cruising was taking place. In addition, the inquest heard that whilst on this occasion Sophie was the sole fatality it could easily have been the case that multiple lives were lost in the incident.
One measure taken involved an application for a Public Spaces Protection Order. This had been a joint initiative but the implementation of enforcement meant that it was not effect.
The inquest heard that to tackle car cruising successfully, an effective multi-agency adequately funded and targeted approach was required. In addition the inquest heard that in an area such as Greater Manchester with multiple Local Authorities and dense population, a pan Greater Manchester approach would be required to prevent not just further incidents in Trafford Park but across Greater Manchester and nationally . The risk being that looking at the problem of car cruising in isolation could result in it being moved on rather than being dealt with effectively .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Car cruising involving highly dangerous manoeuvres on public roads
Wider context from the report “The inquest heard that car cruising had been an issue in Trafford Park for a number of years . The problem (and inherent risk to public safety) was one that both the Local Authority (Trafford MBC) and GMP were aware of. Attempts to tackle it had been ineffective. Car cruising involved highly dangerous manoeuvres being carried out on public roads whilst members of the public were using the roads in significant numbers . The inquest saw video footage that showed the events leading up to the death of Sophie. It was clear that an incident involving disastrous loss of control could have happened at any time that night whilst car cruising was taking place. In addition, the inquest heard that whilst on this occasion Sophie was the sole fatality it could easily have been the case that multiple lives were lost in the incident.
One measure taken involved an application for a Public Spaces Protection Order. This had been a joint initiative but the implementation of enforcement meant that it was not effect.
The inquest heard that to tackle car cruising successfully, an effective multi-agency adequately funded and targeted approach was required. In addition the inquest heard that in an area such as Greater Manchester with multiple Local Authorities and dense population, a pan Greater Manchester approach would be required to prevent not just further incidents in Trafford Park but across Greater Manchester and nationally. The risk being that looking at the problem of car cruising in isolation could result in it being moved on rather than being dealt with effectively.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Ineffective enforcement measures against car cruising
Wider context from the report “The inquest heard that car cruising had been an issue in Trafford Park for a number of years. The problem (and inherent risk to public safety) was one that both the Local Authority (Trafford MBC) and GMP were aware of. Attempts to tackle it had been ineffective . Car cruising involved highly dangerous manoeuvres being carried out on public roads whilst members of the public were using the roads in significant numbers. The inquest saw video footage that showed the events leading up to the death of Sophie. It was clear that an incident involving disastrous loss of control could have happened at any time that night whilst car cruising was taking place. In addition, the inquest heard that whilst on this occasion Sophie was the sole fatality it could easily have been the case that multiple lives were lost in the incident.
One measure taken involved an application for a Public Spaces Protection Order. This had been a joint initiative but the implementation of enforcement meant that it was not effect .
The inquest heard that to tackle car cruising successfully, an effective multi-agency adequately funded and targeted approach was required. In addition the inquest heard that in an area such as Greater Manchester with multiple Local Authorities and dense population, a pan Greater Manchester approach would be required to prevent not just further incidents in Trafford Park but across Greater Manchester and nationally. The risk being that looking at the problem of car cruising in isolation could result in it being moved on rather than being dealt with effectively.
” 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 Continue working with police to ensure access to necessary support for responding to illegal car-cruising activity.
Verbatim wording from the response “More broadly, the Home Office will continue to work closely with the police to ensure that they have access to necessary support to deal with car cruising so our response to illegal activity at these events improves and we help to prevent future deaths arising in similar circumstances to Ms Lyons.” Source location 2019-0206-Response-from-the-Home-Office
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 Attend the next Roads Policing Intelligence Forum to support improved cooperation between police forces on car cruising.
Verbatim wording from the response “In terms of a national approach, the police have recognised the need to work closer together on car cruising to prevent success in one area simply moving the problem to another. A national practitioners group has therefore been set up, bringing together car cruising leads from across the country to share best practice and discuss methods for tackling illegal activity at these events. The first national forum was hosted by Essex Police last year with Greater Manchester Police hosting a meeting this year. Reflecting the importance of this issue, the National Police Chiefs’ Council have also agreed to discuss car cruising at the next Roads Policing Intelligence Forum in October. This will provide the opportunity to facilitate better working between police forces to tackle car cruising and my officials have agreed to attend.” Source location 2019-0206-Response-from-the-Home-Office
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Greater Manchester Combined Authority is responsible for responding to the local matters of concern raised in the report.
Verbatim wording from the response “You also raised a number of local matters of concern in your report which, I understand, will be covered in the Greater Manchester Combined Authority’s response.” Source location 2019-0206-Response-from-the-Home-Office
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police determine how and when to use enforcement options for car cruising as an operational matter under local policing plans.
Verbatim wording from the response “PSPOs are one of a range of options and tactics which can be used to tackle car cruising. There are a number of public order and road traffic offences that individuals can be charged with and those driving recklessly or inappropriately can have their vehicles seized. As well as anti-social behaviour legislation, some forces have obtained court injunctions covering whole areas which carry a power of arrest for a breach. Although these injunctions have not stopped illegal activity at car cruising events, they have provided a valuable tool to reduce them with regular enforcement operations taking place using local Neighbourhood Officers, Operational Support Teams and drone support. How and when to use these enforcement options is an operational matter for the police to determine in line with local policing plans.” Source location 2019-0206-Response-from-the-Home-Office
Open published response
19 Jun 2019 Aram Ali Mustafa · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to provide sufficient details about safeguarding concerns and health care matters View source Failure to log safeguarding matters with the safeguarding hub regardless of a person's location in the system View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Aram Ali Mustafa · 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
Aram Ali Mustafa, an asylum seeker living in initial accommodation, was found hanging by a scarf in his room on 4 February 2019 and was declared deceased at 23.10. The report identified concerns that earlier suicide and safeguarding information was not sufficiently detailed or logged across the organisations involved.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient details about safeguarding concerns and health care matters
Wider context from the report “1. When he had first illegally entered the UK Mr Mustafa was deported to Italy on 29/10/18. Just before he was deported he confirmed he would kill himself if he was deported. He was provided with 1:1 constant watch and was successfully deported. When he re-entered the UK on 30/01/19 he was seen by a member of the immigration compliance and enforcement team who completed paperwork for the national asylum accommodation unit who in turn completed a service commission form requesting initial accommodation. The service commission form recorded that he had urgent medical needs and was a safeguarding concern however no detail was provided. Neither G4S nor Urban housing services requested any further details. A system needs to be put in place to ensure organisations provide sufficient details for providers to understand the nature of safeguarding concerns and health care matters. If there are GDPR concerns these could easily be addressed by a consent form at the time the person is first seen.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to log safeguarding matters with the safeguarding hub regardless of a person's location in the system
Wider context from the report “2. The events on 29/10/18 when he made a threat to kill himself were not logged with the safeguarding hub as he was about to be deported. There needs to be a system to ensure all safeguarding matters are logged regardless of where the person is in the system
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require fuller vulnerability details, record them on CID and referral forms, and check CID more thoroughly before onward referral.
Verbatim wording from the response “The Home Office have confirmed that the first responders are being challenged for further detail when referring a case into NAAU (National Asylum Allocation Unit) in relation to any indication of vulnerabilities. This information is being recorded on the CID database and on the SCF 4386 referral form prior to being forwarded to the Routing Team. CID is being checked more thoroughly by the Intake Team to reduce the risk of missing information that wasn’t forthcoming from the referring officers.” Source location 2019-0508-Response-from-Government-Legal-Department-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot and introduce a vulnerability-scoring purpose matrix to guide escalation and Safeguarding Hub referrals, subject to senior-management sign-off.
Verbatim wording from the response “Additionally, a NAAU purpose matrix will be piloted, with a point base scoring system which will guide staff in terms of vulnerabilities that require escalation to the Hub. This is awaiting to be signed off by Senior Management. The Matrix which is due to be introduced will help to decide on the level of vulnerability and hence if a Safeguarding Referral is required.” Source location 2019-0508-Response-from-Government-Legal-Department-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Check that referring officers identify and record relevant safeguarding and vulnerability concerns on referral forms.
Verbatim wording from the response “Specific safeguarding and vulnerable concerns are included in the referral form – a list of possible concerns are listed and the referring officer is asked whether they have any relevance to the customer. Checks are put in place to ensure this happens.” Source location 2019-0508-Response-from-Government-Legal-Department-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a shared safeguarding spreadsheet for teams to record actions, updates, onward referrals and Safeguarding Hub referrals.
Verbatim wording from the response “In addition, a spreadsheet has been introduced that records all the safeguarding action and will be jointly in use by all the Teams in accordance with the order of process, i.e. Intake will make the initial input as per referral and followed by RIAV (Routing Initial Accommodation Validation) and Routing updating their subsequent action – this will include onward referrals to the Service Providers, and the Safeguarding Hub.” Source location 2019-0508-Response-from-Government-Legal-Department-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Safeguarding Hub is funded only for asylum-claimant service users and cannot act on referrals made after removal.
Verbatim wording from the response “Referrals can come into the Safeguarding Hub from any source however they deal with service users who have an asylum claim; they are only funded for this. G4S and others would have had access to the Hub provided they are regarding asylum applicants. The Hub could not have done anything if a referral was made post removal. However, if a referral had been made prior to removal and included details of suicide risk, the Hub would have accepted the referral.” Source location 2019-0508-Response-from-Government-Legal-Department-Redacted
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 Information shared with external contractors is limited by GDPR to data shown to be required, relevant, secure and in the applicant’s best interests.
Verbatim wording from the response “We set out below the factors provided by the Home Office to take into account while sharing information with external contractors in line with GDPR.” Source location 2019-0508-Response-from-Government-Legal-Department-Redacted
Open published response
2 Apr 2019 Tarek Mahmood CHOWDHURY · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Inadequate operation of SystmOne when new detainees arrive at IRCs View source Failure to share prisoner information between HMPPS, DEPMU and IRC staff View source Inadequate training of nurses on SystmOne and related access issues View source Failure of the process authorising IRC nurses to access former prisoners’ records View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tarek Mahmood CHOWDHURY · 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
Tarek Mahmood CHOWDHURY was beaten to death by another detainee while detained at Heathrow Immigration Removal Centre on 1 December 2016. The report identified concerns about information sharing between prisons, the Home Office and immigration removal centres, including the availability of intelligence and other records. It also identified concerns about access to and operation of SystmOne healthcare records during the initial screening of detainees transferred from prison.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Inadequate operation of SystmOne when new detainees arrive at IRCs
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs . There are concerns both about the technology itself of SystmOne ; about the process of authorising a nurse in an IRC to see records of a former prisoner; and about whether trainers are able adequately to train nurses in respect of these issues. These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to share prisoner information between HMPPS, DEPMU and IRC staff
Wider context from the report “(1) That there is a failure to share information about prisoners who are to become detainees, between HMPPS and the Home Office’s DEPMU, and between HMPPS and staff in IRCs . The rolling out of Mercury intelligence to DEPMU/IRCs will not solve this problem if other information (in particular NOMIS and OASYS) is still not available to DEPMU/IRCs . This concern is addressed both to the Ministry of Justice (HMPPS) and to the Home Office (DEPMU/IRCs).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of nurses on SystmOne and related access issues
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs. There are concerns both about the technology itself of SystmOne; about the process of authorising a nurse in an IRC to see records of a former prisoner; and about whether trainers are able adequately to train nurses in respect of these issues . These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of the process authorising IRC nurses to access former prisoners’ records
Wider context from the report “(2) That SystmOne is not operating adequately when new detainees arrive at IRCs. There are concerns both about the technology itself of SystmOne; about the process of authorising a nurse in an IRC to see records of a former prisoner ; and about whether trainers are able adequately to train nurses in respect of these issues. These concerns are addressed to NHS England, which is understood to commission and supply SystmOne; and to TPP, which is the technology company which is understood to have developed SystmOne.
” Open source report
27 Mar 2019 Ms Donna Williamson · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to assign responsibility for repairing and securing doors in privately rented accommodation View source Failure to inform victims promptly when suspects are released on bail View source Insufficient clarity and knowledge of professional and legal duties to disclose confidential information about victims at risk View source Failure to contact available support services for disabled private tenants View source Failure of the MARAC process to provide coordinated protection and support for chaotic non-engaging individuals View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ms Donna Williamson · 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
Donna Williamson, a 44-year-old woman with mental health, alcohol dependence, mobility and domestic abuse vulnerabilities, died from stab wounds to the chest after being assaulted with a knife by her ex-partner. The principal concerns included the failure to secure her insecure door, failure to inform her that the suspect had been released on bail, and weaknesses in the MARAC process for protecting chaotic and non-engaging individuals.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to assign responsibility for repairing and securing doors in privately rented accommodation
Wider context from the report “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not . Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted. Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable tenants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to inform victims promptly when suspects are released on bail
Wider context from the report “2. There was a failure to inform the victim that the suspect had been released on bail. Whilst the Metropolitan Police Service have taken steps to address this risk, wider awareness amongst other police forces of the importance of this being completed in a timely manner may be of value.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient clarity and knowledge of professional and legal duties to disclose confidential information about victims at risk
Wider context from the report “4. Key information about the risk to the victim was secured by the police from the suspect’s GP, who has commendably established new procedures for handling domestic abuse, but the GP was unable to articulate what were the criteria when a GP has a duty to disclose confidential information to the police in relation to a victim at risk. There is a risk that GPs in general may not have sufficient knowledge or awareness of their professional and legal duties of disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to contact available support services for disabled private tenants
Wider context from the report “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not. Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted . Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable tenants.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of the MARAC process to provide coordinated protection and support for chaotic non-engaging individuals
Wider context from the report “3. The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. Lengthy evidence was heard from the independent chair of the Domestic Homicide Review, who had conducted 23 such reviews. She said that the MARAC system can be good depending on the priority given by each organization. In this case agencies should have worked together to address risks in the context of her life environment and network. Instead her needs were compartmentalised. Her evidence was clear that no MARAC can deliver the needs of chaotic non engaging individuals . She reported that there were arguments for MARAC and other bodies to be put on a statutory footing. Clearly there is an urgent need for national review how the system can afford protection and support for these particularly vulnerable complex individuals or whether changes need to be made to it.
” Open source report
13 Feb 2019 Branko Zdravkovic · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Failure to make statutory Rule 35 reports for detainees with suicidal tendencies View source Lack of a formal procedure for informing the Home Office when detainees are placed on ACDT View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Branko Zdravkovic · 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
Branko Zdravkovic, who was detained at the Immigration Removal Centre, The Verne, was found suspended by a ligature in a toilet cubicle and died on 9 April 2017. The inquest concluded that his death was suicide, with the medical cause recorded as ligature suspension. Concerns were raised that staff were instructed to use ACDT procedures instead of making Rule 35 reports, and that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to make statutory Rule 35 reports for detainees with suicidal tendencies
Wider context from the report “The Inquest heard evidence from a Doctor and Psychiatrist and Healthcare staff working at the IRC that they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies . There was also evidence from several witnesses that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT. In the case of a suicidal detainee, the ACDT procedure is necessary and desirable, but it cannot replace the statutory duty to make a report under Rule 35 . Rule 35 imposes a requirement to speedily review whether someone should be released because of concerns recorded by the medical practitioner. Without that information being provided the state cannot carry out its obligations under Article 2 ECHR.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal procedure for informing the Home Office when detainees are placed on ACDT
Wider context from the report “The Inquest heard evidence from a Doctor and Psychiatrist and Healthcare staff working at the IRC that they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies. There was also evidence from several witnesses that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT . In the case of a suicidal detainee, the ACDT procedure is necessary and desirable, but it cannot replace the statutory duty to make a report under Rule 35. Rule 35 imposes a requirement to speedily review whether someone should be released because of concerns recorded by the medical practitioner. Without that information being provided the state cannot carry out its obligations under Article 2 ECHR.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise and introduce new Removal Centre Rules, including updated Rule 35 reporting arrangements.
Verbatim wording from the response “The findings of the initial review have been used to inform our separate work to finalise new Removal Centre Rules to replace the current Detention Centre Rules. We are aiming to introduce the new Rules, which will include updates to the reporting system in Rule 35, by July 2019.” Source location 2019-0047-Response-by-Home-Office
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 Remind IRC staff of ACDT information-sharing guidance and responsibilities through communications to all IRC parties.
Verbatim wording from the response “There are clear processes in place to ensure that Home Office officials and case workers are notified when ACDT monitoring is initiated for an individual in detention. The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information on detainees being managed under ACDT procedures to their attention and to confirm that this requirement is understood and action is being taken.” Source location 2019-0047-Response-by-Home-Office
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 Conduct an internal review of Rule 35(2) reporting effectiveness and use its findings to inform wider policy work.
Verbatim wording from the response “The Home Office keeps the effectiveness of its procedures under review. As part of this continuous improvement the Home Office conducted an internal review to analyse the use” Source location 2019-0047-Response-by-Home-Office
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 provisions to identify and flag detainees subject to ACDT monitoring or Rule 35 reporting.
Verbatim wording from the response “The Home Office is making provisions to better identify and flag individuals in IRCs and foreign national offenders in prisons who are subject to ACDT/ACCT¹ monitoring, and those about whom a Rule 35 report has been submitted. This will ensure an early review of suitability for detention and the assessment of adult at risk factors, and will improve information sharing.” Source location 2019-0047-Response-by-Home-Office
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 pilot learning to improve suicide and self-harm prevention guidance and procedures and clarify ACDT information-sharing responsibilities.
Verbatim wording from the response “The Home Office will use the learning from the pilot to improve suicide and self-harm prevention guidance and procedures and to clarify the information sharing responsibilities in relation to those detainees assessed as being at risk of self harm and/or suicide.” Source location 2019-0047-Response-by-Home-Office
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 Seek healthcare-provider assurances on correct Rule 35 processes and consult the assurance forum about broader implementation.
Verbatim wording from the response “NHS England commission health services in prisons and other places of detention including IRCs. This is undertaken through six NHS England Health and Justice Teams. Healthcare in IRCs in Scotland is commissioned by the supplier running those centres. The Home Office’s Director of Detention and Escorting Services will write to NHS England (as the commissioning body for IRC healthcare services in England) and to the healthcare providers at Dungavel IRC by the end of April 2019 to seek assurances that all parties are following the correct process. The Home Office IRC Assurance Group forum will be consulted to consider how this can be more broadly implemented.” Source location 2019-0047-Response-by-Home-Office
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 Home Office training does not direct doctors to substitute ACDT monitoring for Rule 35(2) reporting; the apparent issue was local misunderstanding.
Verbatim wording from the response “Home Office training which touches on Rule 35 reporting in the context of the Adults at Risk policy does not advocate the substitution of Rule 35(2) reporting for the ACDT identification and monitoring procedures. It would appear that there may have been some local misunderstanding on this point at the Verne IRC during the period under examination. There is however no ambiguity that the statutory provision in Rule 35 of the Detention Centre Rules 2001 requires IRC doctors to report certain matters to the manager of the centre and to officials acting on behalf of the Secretary of State. The Detention Centre Rules are unambiguous that only an IRC doctor (‘medical practitioner’) may make a Rule 35 report. The decision to do so in any particular case is solely a matter for the clinical judgment of the IRC doctor.” Source location 2019-0047-Response-by-Home-Office
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 processes ensure Home Office officials and case workers are notified when ACDT monitoring begins for a detained individual.
Verbatim wording from the response “There are clear processes in place to ensure that Home Office officials and case workers are notified when ACDT monitoring is initiated for an individual in detention. The Home Office will take steps to ensure that all staff working in IRCs are reminded of the guidance in place, and of their information sharing responsibilities. This will ensure that information on detainees at risk of suicide and self-harm who are being managed under ACDT procedures is shared promptly and appropriately with all relevant parties. The Director of Detention and Escorting Services will write to all parties in IRCs by the end of April 2019 to bring the requirements for sharing information on detainees being managed under ACDT procedures to their attention and to confirm that this requirement is understood and action is being taken.” Source location 2019-0047-Response-by-Home-Office
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Only an IRC doctor may submit a Rule 35(2) report, and the decision rests solely with that doctor's clinical judgment.
Verbatim wording from the response “Home Office training which touches on Rule 35 reporting in the context of the Adults at Risk policy does not advocate the substitution of Rule 35(2) reporting for the ACDT identification and monitoring procedures. It would appear that there may have been some local misunderstanding on this point at the Verne IRC during the period under examination. There is however no ambiguity that the statutory provision in Rule 35 of the Detention Centre Rules 2001 requires IRC doctors to report certain matters to the manager of the centre and to officials acting on behalf of the Secretary of State. The Detention Centre Rules are unambiguous that only an IRC doctor (‘medical practitioner’) may make a Rule 35 report. The decision to do so in any particular case is solely a matter for the clinical judgment of the IRC doctor.” Source location 2019-0047-Response-by-Home-Office
Open published response
19 Dec 2018 Michal Piotr Netyks · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 8 Deletion of immigration-detention records to prevent accurate death-in-detention statistics View source Failure to verify Treaty-rights evidence with employers or HMRC during deportation appeals View source Failure to review first-floor mezzanine railing and fall-protection design View source Failure to provide deportation documentation in a form understandable to subjects with limited written English View source Lack of deportation-process training for prison custody officers serving deportation documentation View source Incomplete disclosure of casework notes to the inquest View source Lack of access to duty-lawyer immigration advice for deportable foreign national prisoners outside immigration detention centres View source Unavailability of a senior Home Office manager for procedural liaison during inquests View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Michal Piotr Netyks · 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
Michal Piotr Netyks, a Polish national serving a custodial sentence at HMP Altcourse, died after jumping head first from first-floor railings on 7 December 2017, the day he was due to be released but was instead detained under immigration powers. The report identifies concerns about the timing and explanation of the immigration detention paperwork, access to legal advice and support, the prison railings, and aspects of the Home Office’s handling of the case.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Deletion of immigration-detention records to prevent accurate death-in-detention statistics
Wider context from the report “E. On the sixth day of evidence, the Home Office disclosed partially redacted casework (CID) notes but only from 31st October 2017 to 5th November 2018. The entry on 5th November is of the greatest concern given the duty of candour and integrity expected from Government and its Civil servants. The Home Office was made an interested person to protect its rights but also to assist the court. The following entry needs investigation and an explanation as its effect is to manipulate statistics – it appears to be almost a denial of the facts...
“Hi, Name:
Michal Netyks
DOB:
10 Aug 1982
Nationality:
POL
Gender:
M
System:
CID
Notes
Created:05 Nov 2018Created by:M2CAT0Unit:CCD Ops GeType:CASE
Due to the sensitive nature of this case, senior management have taken the decision to make an exception with this case and delete the record indicating Mr Netyks was IS detained from 07.12.17 . This is to prevent MI inadvertently recording this case as a death in immigration detention as Mr Netyks was still serving his custodial sentence at the time of his death. To ensure there are no gaps between the actual time of release from the HMP, current processes are in place to consider and serve detention paperwork in advance of the CRD and to then update the Restriction screen indicating the foreign national offender will be IS detained on the same date of CRD. These actions minimises the risk of release without consideration. Monica Cato Data Analysis & Management Information Team (DAMIT) Criminal Casework Secretariat Tel: ████████
Created:28 Aug 2018Created by:S11TAYLORUnit:Litig Ops Type:CASE
Death in Custody case update: Inquest to be listed”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to verify Treaty-rights evidence with employers or HMRC during deportation appeals
Wider context from the report “D. In this inquest the Home Office were given the status of interested persons from an early stage. The Court has been greatly assisted by counsel and instructing solicitors acting for the department along with two witnesses. It was evident and unhelpful that the Home Office did not have a senior manager present throughout the proceedings to assist the court on procedures, if only by way of liaison. The inquest is not an immigration appeal tribunal and yet on evidence received it is more likely than not that Mr Netyks was exercising Treaty rights through employment and family life in North Wales. It appeared unfair that an incarcerated subject of the deportation process was required to provide evidence of the exercise of Treaty rights when the Home Office Caseworker could easily have made a check with the employer or HMRC for corroboration of his appeal against the stage one process . This is particularly concerning given English was a second language and all documentation was only provided in English. The facility to appear to speak and understand English is not the same as being able to comprehend the written word. This apparent unfairness could be addressed by the issue in B above, or by immigration officers explaining such documentation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to review first-floor mezzanine railing and fall-protection design
Wider context from the report “C. Evidence was received from the Ministry of Justice that the safety considerations from the first floor mezzanine level complied with HMPPS standards. The witness indicated in the witness box that he had never seen the design of the railings at HMP Altcourse before and would be reviewing the first floor Mezzanine safety for this design of Prison . The Court seeks confirmation of this review covering both railings and netting as options. (The Court heard that netting would be problematic given the easy access both from above and below – leading to disruption for the prison).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide deportation documentation in a form understandable to subjects with limited written English
Wider context from the report “D. In this inquest the Home Office were given the status of interested persons from an early stage. The Court has been greatly assisted by counsel and instructing solicitors acting for the department along with two witnesses. It was evident and unhelpful that the Home Office did not have a senior manager present throughout the proceedings to assist the court on procedures, if only by way of liaison. The inquest is not an immigration appeal tribunal and yet on evidence received it is more likely than not that Mr Netyks was exercising Treaty rights through employment and family life in North Wales. It appeared unfair that an incarcerated subject of the deportation process was required to provide evidence of the exercise of Treaty rights when the Home Office Caseworker could easily have made a check with the employer or HMRC for corroboration of his appeal against the stage one process. This is particularly concerning given English was a second language and all documentation was only provided in English . The facility to appear to speak and understand English is not the same as being able to comprehend the written word . This apparent unfairness could be addressed by the issue in B above, or by immigration officers explaining such documentation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of deportation-process training for prison custody officers serving deportation documentation
Wider context from the report “A. Under PSI 52/2011 Annex K Prison Custody Officers (PCO) are to only act as a postman without giving advice when serving papers related to deportation. The Court heard that PCO do not give legal advice but often have to explain the effect of such documentation such as the authority to further detain IS91 (which in this case had to be delivered before a IS91R was received by the prison). Documentation is served without an immigration Officer present and those charged with this role would be more effective if they were provided with a training package, making them aware of the deportation process . The Court is of the view that only the Home Office can deliver this training.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Incomplete disclosure of casework notes to the inquest
Wider context from the report “E. On the sixth day of evidence, the Home Office disclosed partially redacted casework (CID) notes but only from 31st October 2017 to 5th November 2018 . The entry on 5th November is of the greatest concern given the duty of candour and integrity expected from Government and its Civil servants. The Home Office was made an interested person to protect its rights but also to assist the court. The following entry needs investigation and an explanation as its effect is to manipulate statistics – it appears to be almost a denial of the facts...
“Hi, Name:
Michal Netyks
DOB:
10 Aug 1982
Nationality:
POL
Gender:
M
System:
CID
Notes
Created:05 Nov 2018Created by:M2CAT0Unit:CCD Ops GeType:CASE
Due to the sensitive nature of this case, senior management have taken the decision to make an exception with this case and delete the record indicating Mr Netyks was IS detained from 07.12.17. This is to prevent MI inadvertently recording this case as a death in immigration detention as Mr Netyks was still serving his custodial sentence at the time of his death. To ensure there are no gaps between the actual time of release from the HMP, current processes are in place to consider and serve detention paperwork in advance of the CRD and to then update the Restriction screen indicating the foreign national offender will be IS detained on the same date of CRD. These actions minimises the risk of release without consideration. Monica Cato Data Analysis & Management Information Team (DAMIT) Criminal Casework Secretariat Tel: ████████
Created:28 Aug 2018Created by:S11TAYLORUnit:Litig Ops Type:CASE
Death in Custody case update: Inquest to be listed”
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of access to duty-lawyer immigration advice for deportable foreign national prisoners outside immigration detention centres
Wider context from the report “B. Foreign National Prisoners liable for deportation who are not in an Immigration Detention Centre currently have no access to a duty lawyer scheme . It is important that such subjects are not treated as favourably than those in an Immigration detention centre. This could be addressed by providing free legal advice on immigration matters from duty lawyers at a minimum via the prison estate pin phone 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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a senior Home Office manager for procedural liaison during inquests
Wider context from the report “D. In this inquest the Home Office were given the status of interested persons from an early stage. The Court has been greatly assisted by counsel and instructing solicitors acting for the department along with two witnesses. It was evident and unhelpful that the Home Office did not have a senior manager present throughout the proceedings to assist the court on procedures, if only by way of liaison . The inquest is not an immigration appeal tribunal and yet on evidence received it is more likely than not that Mr Netyks was exercising Treaty rights through employment and family life in North Wales. It appeared unfair that an incarcerated subject of the deportation process was required to provide evidence of the exercise of Treaty rights when the Home Office Caseworker could easily have made a check with the employer or HMRC for corroboration of his appeal against the stage one process. This is particularly concerning given English was a second language and all documentation was only provided in English. The facility to appear to speak and understand English is not the same as being able to comprehend the written word. This apparent unfairness could be addressed by the issue in B above, or by immigration officers explaining such documentation.
” Open source report
19 Dec 2018 Kurt Cochran and 5 others · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 18 Lack of consistent and up-to-date national protective security advice View source Failure of supervisory systems to audit ADAM System use View source Failure to record reasons for closing a Subject of Interest View source Lack of clear required intervals for officers to access the ADAM System View source Inadequate training for lone-actor and multi-actor marauding attacks View source Failure to provide revised Post Instructions directly to relevant officers View source Insufficient time for officers to access the ADAM System and review Post Instructions View source Failure to brief officers on the rationale for changes to Post Instructions View source Failure of Post Instructions to be clear and readily interpretable View source Inadequate coordinated training of AFOs, unarmed officers and security officers View source Lack of consistent pre-rental vehicle checks and enquiries View source Lack of regular supervisory audits of policing at the Palace of Westminster View source Lack of armed police protection at a vulnerable public entrance to the Parliamentary Estate View source Lack of periodic audit of Tactical Firearms Reviews View source Failure of Post Instructions to be consistent with tactical plans, orders and practices View source Lack of guidance on removing unconscious persons or bodies from navigable water View source Failure of officers to register for and access the ADAM System View source Insufficient facilities for officers to access the ADAM System View source See 15 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kurt Cochran and 5 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 22 March 2017, Khalid Masood drove a vehicle across Westminster Bridge, fatally injuring Kurt Cochran, Leslie Rhodes, Aysha Frade and Andreea Cristea, before fatally stabbing PC Keith Palmer at the Palace of Westminster. The report raised concerns about the protection of public entrances, officers’ access to and understanding of Post Instructions, use of the ADAM System, supervision and training, and wider protective security measures.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and up-to-date national protective security advice
Wider context from the report “MC14: I suggest that the Secretary of State for the Home Department asks the authorities responsible for preparing and delivering advice on protective security to consider whether any further work can usefully be done on this subject, particularly in preparing and delivering consistent and up-to-date national advice . I also suggest that TfL considers whether there is any further work it can do to improve protective security on major roadways and bridges in the capital, in response to national advice and known threats.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of supervisory systems to audit ADAM System use
Wider context from the report “MC6: It was a matter of concern that officers were unaware of their Post Instructions and that supervisory systems had not identified limited usage of the ADAM System . I therefore suggest that the MPS considers auditing use of the ADAM System periodically , by checks to confirm use at sufficiently regular intervals over the period.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to record reasons for closing a Subject of Interest
Wider context from the report “MC16: I suggest that the Security Service considers whether it would be practicable and beneficial to introduce a procedure whereby any decision to close a person as a Subject of Interest is recorded with brief reasons .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of clear required intervals for officers to access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given . Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system . Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inadequate training for lone-actor and multi-actor marauding attacks
Wider context from the report “MC9: I suggest that the MPS reviews the adequacy of training of officers stationed in the Parliamentary Estate to ensure it includes lone actor and multi-actor marauding attacks .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide revised Post Instructions directly to relevant officers
Wider context from the report “MC1: I suggest that the MPS gives consideration to providing revised Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices (as well as their being accessible through ADAM) and to providing them in a way that requires the recipient to respond indicating safe receipt. I was concerned that, when Post Instructions were updated, they were apparently not emailed or provided in hard copy to relevant officers directly . The system relied upon officers’ use of the ADAM System, which was sporadic . I am aware from the submissions of the MPS that, since the attack, an update is sent to all relevant officers advising them of a revision of Post Instructions and telling them to view the new version on ADAM. The MPS has provided a copy of an example email, which was sent on 11 October 2018. However, it may be valuable for the MPS to go further than this by supplying revised instructions directly to the officers and in requiring an acknowledgement of safe receipt is sent back by the officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for officers to access the ADAM System and review Post Instructions
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals). I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to brief officers on the rationale for changes to Post Instructions
Wider context from the report “MC10: I suggest that the MPS considers the possibility of the firearms assessor / adviser briefing officers as to the rationale for any changes to their Post Instructions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of Post Instructions to be clear and readily interpretable
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions , and some officers when presented with them found it difficult to interpret parts . It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate. It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices, security can be undermined.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inadequate coordinated training of AFOs, unarmed officers and security officers
Wider context from the report “MC8: I suggest that the MPS, with the Parliamentary Authorities, reviews the adequacy of training to ensure that it involves AFOs, unarmed officers and security officers and their co-ordination .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent pre-rental vehicle checks and enquiries
Wider context from the report “MC18: I recommend that the Department for Transport and the British Vehicle Rental & Leasing Association consider introducing a Code of Practice (or at least guidance) on checks to be carried out and/or enquiries made before vehicles are rented .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of regular supervisory audits of policing at the Palace of Westminster
Wider context from the report “MC7: I suggest that the MPS considers instituting regular supervisory audits of policing at the Palace of Westminster (and perhaps other parts of the Parliamentary Estate), preferably by officers outside the PaDP Command.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of armed police protection at a vulnerable public entrance to the Parliamentary Estate
Wider context from the report “MC5: It was a matter of concern that, at the time of the attack, one of the most vulnerable and public entrances to the Parliamentary Estate was not protected by armed police . In my view, the MPS should consider (a) imposing a standing order that there should be armed officers stationed at all open public entry points to the Palace of Westminster (and possibly to some other buildings on the Parliamentary Estate) and (b) introducing a provision that this standing order may only be varied with the written approval of an officer of very senior rank.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of periodic audit of Tactical Firearms Reviews
Wider context from the report “MC11: I suggest that the MPS considers a periodic audit of Tactical Firearms Reviews .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of Post Instructions to be consistent with tactical plans, orders and practices
Wider context from the report “MC4: I suggest that the MPS considers a periodic audit of all extant Post Instructions for the Parliamentary Estate to ensure their consistency and fitness for purpose. This might be part of the supervisory audit discussed at MC7 below, or separate from it. On the evidence I heard, Post Instructions are prepared after careful work by relevant experts within the MPS (firearms tactical assessors, in the case of AFO Post Instructions). Nevertheless, there were deficiencies in the expression of some Post Instructions, and some officers when presented with them found it difficult to interpret parts. It is important that each Post Instruction should be clear and internally consistent, and should be consistent with the broader tactical plan for the Estate . It was clear from the evidence of Commander Usher that Post Instructions should be followed precisely. They should not be subject to personal interpretation, since that would introduce inconsistent practice and would undermine the tactical rationale behind the instructions. Where the content of Post Instructions is ambiguous or not consistent with other orders or practices , security can be undermined.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on removing unconscious persons or bodies from navigable water
Wider context from the report “MC17: I suggest that the Maritime and Coastguard Agency considers whether it or some other body could provide guidance on the removal of unconscious persons or bodies from the water close to those operating on navigable rivers and canals .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of officers to register for and access the ADAM System
Wider context from the report “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given. Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system. Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient facilities for officers to access the ADAM System
Wider context from the report “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals) . I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the voluntary Rental Vehicle Security Scheme requiring participating hire companies to follow a ten-point security Code of Practice.
Verbatim wording from the response “On 6th December 2018 the Department for Transport (DfT) launched the Rental Vehicle Security Scheme (RVSS). Vehicle Hire Companies joining this voluntary scheme agree to follow a 10 Point Code of Practice, including:” Source location 2018-0304-Response-by-Home-Office
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 Continue delivering and regularly revising national protective-security advice, guidance and communications for crowded places and the public.
Verbatim wording from the response “A vital part of this work is considering how we ensure the safety and security of the public at crowded places. The Government continues to undertake a range of communications with those responsible for crowded places and the public to:” Source location 2018-0304-Response-by-Home-Office
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Rental Vehicle Security Scheme’s impact and take-up, including whether code requirements should become mandatory.
Verbatim wording from the response “Companies join the scheme by submitting a completed application form and declaration that they will produce a security plan outlining how they will meet the requirements of the Code of Practice. Plans may be subject to assurance checks by DfT. There has been an encouraging level of take-up of the scheme since its launch, including by market leaders.” Source location 2018-0304-Response-by-Home-Office
Open published response
16 Oct 2018 Jacqueline Oakes · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Lack of a mechanism to alert other agencies when high-risk offenders are released after completing their full sentence 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
Jacqueline Oakes · 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
Jacqueline Oakes was a vulnerable woman who suffered repeated assaults by a man she met in supported living accommodation. Her body was found in her flat on 14 January 2014, and the man was later convicted of her murder; the medical cause of death was multiple injuries. The principal concern was that no agencies were alerted when a high-risk offender was released after completing his sentence, limiting their ability to manage the risks he posed.
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 Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to alert other agencies when high-risk offenders are released after completing their full sentence
Wider context from the report “When an offender is released having completed their full sentence who is known to be a high risk to others there is no mechanism for any other agencies to be alerted to that person’s release . Had an alert been provided to other agencies that came into contact with Jacqueline and ████████ it would have meant they were better able to manage the risks he posed. Consideration should be given to whether such alerts can be provided.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations