25 Jun 2018 John Edward Hill · Prevention of Future Deaths report Dorset
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Concerns raised 1 Failure to routinely seek information from family members or cohabitants when assessing firearm applications View source
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AI-generated summary
John Edward Hill · 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
John Edward Hill was found collapsed and unresponsive at home on 26 May 2017, holding a rifle and with a bullet wound to his forehead. The report raised concerns that firearms licensing enquiries did not routinely include family members or others living with the applicant, who might hold important information relevant to the application and prevention of future deaths.
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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 Failure to routinely seek information from family members or cohabitants when assessing firearm applications
Wider context from the report “v. Evidence was further given that in the Dorset Police policy entitled “Firearms and Explosive Licensing Risk Management Procedure’ dated the 8th May 2015 there is no reference to such contact with family members, friends or associates and that family members or those living at the same address of the applicant, will not be contacted as standard practice. They may, as above, be contacted where there is evidence of domestic abuse.
vi. Evidence was given that it would be beneficial for the Firearms Unit at Dorset Police to write to those living with the applicant to invite them to raise any concerns they wish to in relation to the application. Although this may not be responded to, at least it gives those close to the applicant an opportunity to raise their concerns. There may be for example domestic violence ongoing at the address that has not been brought to the Police Force’s attention due to lack of reporting. This would be key to the firearm application.
2. I have concerns with regard to the following:
i. When the Police consider a firearm application, there may be valuable information that those close to the applicant may have, in circumstances where there is no domestic abuse or violence. Those living with the applicant may have vital information, which could impact upon the grant of a firearms certificate. This information may therefore be key to preventing a future death.
ii. In view of this I would request that consideration is given to reviewing the national and local guidance in relation to the assessment criteria and enquiries to be considered regarding applications for firearm certificates, and for consideration to be given that those enquiries involve the applicant’s family members, or at the very least those living with the applicant.
” 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 Use the statutory power introduced through the Policing and Crime Act 2017 to publish guidance on police firearms licensing functions.
Verbatim wording from the response “The Government introduced a power, through the Policing and Crime Act 2017, for the Home Secretary to publish statutory guidance to the police on their firearms licensing functions. The legislation requires that we consult with the police before publishing the new guidance. We intend to consult on the terms of this shortly. We intend that the draft should go further than the current guidance, in inviting the police to consider whether to conduct interviews with individuals other than the applicant or their referees, including neighbours, partners or representatives of shooting clubs attended by the applicant. We intend that these checks be considered where, following initial enquiries, they believe them to be necessary to assess suitability.” Source location 2018-0195-Responses
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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 police on the terms of new statutory guidance for firearms licensing functions.
Verbatim wording from the response “The Government introduced a power, through the Policing and Crime Act 2017, for the Home Secretary to publish statutory guidance to the police on their firearms licensing functions. The legislation requires that we consult with the police before publishing the new guidance. We intend to consult on the terms of this shortly. We intend that the draft should go further than the current guidance, in inviting the police to consider whether to conduct interviews with individuals other than the applicant or their referees, including neighbours, partners or representatives of shooting clubs attended by the applicant. We intend that these checks be considered where, following initial enquiries, they believe them to be necessary to assess suitability.” Source location 2018-0195-Responses
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Draft statutory guidance inviting police to consider interviewing people beyond applicants and referees where necessary to assess suitability.
Verbatim wording from the response “The Government introduced a power, through the Policing and Crime Act 2017, for the Home Secretary to publish statutory guidance to the police on their firearms licensing functions. The legislation requires that we consult with the police before publishing the new guidance. We intend to consult on the terms of this shortly. We intend that the draft should go further than the current guidance, in inviting the police to consider whether to conduct interviews with individuals other than the applicant or their referees, including neighbours, partners or representatives of shooting clubs attended by the applicant. We intend that these checks be considered where, following initial enquiries, they believe them to be necessary to assess suitability.” Source location 2018-0195-Responses
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A blanket requirement for routine family interviews is unnecessary because intelligence-based and targeted checks are considered sufficient.
Verbatim wording from the response “I have obtained the views of the National Police Chiefs' Council on this issue, which were informed by discussions with members of the Firearms and Explosives Licensing Working Group. The advice that I have received is that there is no need to introduce a new blanket policy of interviewing members of an applicant's family in the case of all applications for firearms certificates, in order to establish whether they have any concerns. The alternative is an intelligence-based approach, which will now be delivered through new accreditation standards for Firearms Enquiry Officers in police forces, which is being developed by the College of Policing. This will encourage “professional curiosity” to ensure that such avenues are pursued whenever they are likely to be relevant.” Source location 2018-0195-Responses
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7 Jun 2018 Kevin Freely · Prevention of Future Deaths report London (West)
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Concerns raised 1 Failure by patients and care organisations to heed safety guidance on fire hazards from paraffin-based skin products 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
Kevin Freely · 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
Kevin Freely, aged 61, died at home on 12 October 2016 after a lighted cigarette caused his bedclothes to catch fire while he was bedbound and unable to escape. The principal concern was that warnings about the fire hazard associated with paraffin-based emollient skin products were not being heeded by patients and care organisations providing care in people’s homes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure by patients and care organisations to heed safety guidance on fire hazards from paraffin-based skin products
Wider context from the report “The NHS National Patient Safety Agency brought out a Rapid Response Report 4 on 26th November 2007 entitled “Fire hazard with paraffin based skin products on dressings and clothing”. I am concerned that this message within the 2007 Safety Report is not being heeded by patients and Care Organisations responsible for caring for patients in their own homes .
” Open source report
18 Dec 2017 Stephen Mark SHAYLOR · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 4 Reliance on continuous CCTV monitoring to detect prisoner self-harm View source Insufficient stabilisation-wing capacity for inmates needing detoxification View source Intermittent night welfare checks and ACCT observations View source Inadequacy of healthcare night welfare checks for determining whether prisoners are breathing or alive 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.
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AI-generated summary
Stephen Mark SHAYLOR · 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
Stephen Mark SHAYLOR was found hanging in his cell at HMP Exeter in the early hours of 1 January 2014 and was pronounced dead at 03:35. He was on a drug stabilisation regime and subject to healthcare night welfare checks. Concerns included the inadequacy of checks conducted through cell-door hatches, the absence of continuous CCTV monitoring, and the failure to carry out the 02:00 check.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Reliance on continuous CCTV monitoring to detect prisoner self-harm
Wider context from the report “(3) Night welfare checks and observations on an ACCT document are at best intermittent and rely on continuous CCTV monitoring could spot a prisoner self-harming .
” Open source report × Source evidence
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 stabilisation-wing capacity for inmates needing detoxification
Wider context from the report “(1) There were 38 places available on a corridor in C4 wing as a stabilisation wing for dealing with inmates subject to Healthcare night welfare checks. Head of Residence and Safety told the Court that the Prison received between 60 – 80 inmates per week needing detox and requiring placement in C4 cells which had doors with larger windows for checking patients at night.
” Open source report × Source evidence
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 Intermittent night welfare checks and ACCT observations
Wider context from the report “(3) Night welfare checks and observations on an ACCT document are at best intermittent and rely on continuous CCTV monitoring could spot a prisoner self-harming.
” Open source report × Source evidence
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 healthcare night welfare checks for determining whether prisoners are breathing or alive
Wider context from the report “(2) Professor Wall, substance misuse expert, said that the system for looking after these inmates was not fit for purpose and that healthcare night welfare checks (looking through a hatch in a cell door) were inadequate because it was not possible to ascertain if a prisoner was breathing/alive by this method .
” Open source report
6 Nov 2017 RYAN JAMES VOUT · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 4 Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant View source Failure to inform family before discharge View source Failure of hospital and community professionals to liaise before discharge View source Lack of a formal briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant 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.
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AI-generated summary
RYAN JAMES VOUT · 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
Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inability to pre-arrange ambulance attendance during execution of a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(2) The inability to pre-arrange attendance of an ambulance when police officers exercise a s.135 (1) MHA Act 1983 warrant;
” Open source report × Source evidence
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 family before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge ;
” Open source report × Source evidence
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 and community professionals to liaise before discharge
Wider context from the report “(1) The lack of a co-ordinated discharge from in-patient psychiatric care into the community, in particular the failure of appropriate professionals from hospital and community to liaise and for family to be informed as a pre-requisite for discharge;
” Open source report × Source evidence
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 briefing or risk assessment before entry under a s.135 (1) MHA Act 1983 warrant
Wider context from the report “(3) The lack of a formality to the ‘briefing’ or risk assessment exercise before officers enter premises with a view to exercising a s.135 (1) MHA Act 1983 warrant.
” Open source report
30 Oct 2017 Jane Allison Powell · Prevention of Future Deaths report Manchester North
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Concerns raised 1 Easy online access to large amounts of medication, including prescription-only drugs 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
Jane Allison Powell · 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
Jane Allison Powell was found deceased at home on 6 December 2016 after last being seen alive between 25 and 28 November 2016. The probable cause of death was multiple drug toxicity, and the report raised concern about the ease of obtaining large amounts of medication, including prescription-only drugs, over the internet and the risk of future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Easy online access to large amounts of medication, including prescription-only drugs
Wider context from the report “1. The evidence in this case demonstrated how easy it is for individuals to obtain large amounts of medication (including those normally deemed to be ‘prescription only’ drugs) over the internet . Whilst this problem has already been recognised by the pharmaceutical profession and its regulatory body, it is unclear what action has been/is being taken in order to address the situation.
My concern is that, if left, there is a significant risk of future deaths.
” Open source report
31 May 2017 Jonathan David Palmer · Prevention of Future Deaths report Inner West London
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Concerns raised 3 Failure to provide an effective pathway for family health information to reach relevant prison welfare teams View source Ineffective control of contraband inflow into the prison View source Failure to maintain comprehensive records of family health-information contacts 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
Jonathan David Palmer · 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
Jonathan David Palmer was found suspended from a ligature in his cell at HMP Wandsworth on 19 November 2015 and was declared dead after resuscitation efforts were abandoned. The Inquest found the cause of death to be hanging. The substantive concerns included the lack of an effective system for families to provide and have health information disseminated within the prison, and apparently ineffective controls on contraband such as Spice.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an effective pathway for family health information to reach relevant prison welfare teams
Wider context from the report “1. There is no effective system by which the family of a prisoner can input information they deem relevant to a prisoner's health needs and be assured this will be disseminated to relevant teams within the prison , with appropriate records being maintained in order to be able to demonstrate this has been done.
Families can be a source of valuable medical information, particularly, where GP records have not been obtained and the individual himself may not be a reliable source. It would be beneficial to have a clear, publicised conduit for a family to provide relevant medical information to a specified department. The Inquest was informed that a single point of contact has now been established, but it remains unclear whether comprehensive records of all contacts will be maintained, or whether this will result in the timely dissemination of information to those with a role in the prisoner's welfare , such as healthcare staff, RAPt or the chaplains. As the Personal Officer scheme appears to have been abandoned at HMP Wandsworth there is no alternative individual for a concerned family to approach.
” Open source report × Source evidence
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 control of contraband inflow into the prison
Wider context from the report “2. The steps taken to control the inflow of contraband material into the prison (such as the illicit drug known as Spice), appear ineffective.
Insidious substances such as Spice can mimic the symptoms of psychotic illness and jeopardise life when unpredictable reactions occur to those using it. Spice is also likely to adversely affect discipline within the prison, create the potential for intra prisoner bullying (arising from drug debts) and stretch already depleted healthcare resources. In order to combat this menace, steps should be taken to identify the entry points in order that they can be more effectively controlled and those involved, deterred.
” Open source report × Source evidence
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 maintain comprehensive records of family health-information contacts
Wider context from the report “1. There is no effective system by which the family of a prisoner can input information they deem relevant to a prisoner's health needs and be assured this will be disseminated to relevant teams within the prison, with appropriate records being maintained in order to be able to demonstrate this has been done .
Families can be a source of valuable medical information, particularly, where GP records have not been obtained and the individual himself may not be a reliable source. It would be beneficial to have a clear, publicised conduit for a family to provide relevant medical information to a specified department. The Inquest was informed that a single point of contact has now been established, but it remains unclear whether comprehensive records of all contacts will be maintained , or whether this will result in the timely dissemination of information to those with a role in the prisoner's welfare, such as healthcare staff, RAPt or the chaplains. As the Personal Officer scheme appears to have been abandoned at HMP Wandsworth there is no alternative individual for a concerned family to approach.
” Open source report
Concerns raised 1 Availability and importation of an unlicensed weight-loss drug associated with fatalities 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
Anna Larissa Elisabeth Phillips · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anna Phillips had a history of mental illness, overdoses and contact with mental health services. On 1 June 2015, after taking an overdose of 2,4 Dinitrophenol obtained over the internet from Turkey, she was admitted to hospital and died later that day. The report raised concerns that the drug was an unlicensed weight-loss compound associated with several fatalities and had been brought into the country by Royal Mail.
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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 Availability and importation of an unlicensed weight-loss drug associated with fatalities
Wider context from the report “Anna took an overdose of a drug called 2,4 Dinitrophenol . This is a compound that I heard is used as an unlicensed weight loss drug . It has been associated with several fatalities in the past and I attach in that regard a report from ████████ with a reference to a relevant article.
Police Investigations revealed that Anna had obtained this drug over the internet from Turkey . It was brought into the country by Royal Mail .
” Open source report
25 Oct 2016 Richard Walsh · Prevention of Future Deaths report Inner South London
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Concerns raised 6 Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion View source Failure of detained organisations to pass risk information consistently between one another View source Inadequate nurse assessment of fitness for segregation View source Lack of an agreed system for transferring health care information from police stations or courts to prisons View source Inadequate standard of Mental Health Act assessments View source Lack of clear responsibility for passing or seeking relevant information 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.
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AI-generated summary
Richard Walsh · 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
Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.
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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 Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
Wider context from the report “There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person , or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns . From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened.
” Open source report × Source evidence
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 detained organisations to pass risk information consistently between one another
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report × Source evidence
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 nurse assessment of fitness for segregation
Wider context from the report “3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk. ████████ was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of assessors that mean that prisoners go to segregation when they should be in the health care wing, or that they go without observation, when they should be on an ACCT and receive extra support.
” Open source report × Source evidence
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 agreed system for transferring health care information from police stations or courts to prisons
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report × Source evidence
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 standard of Mental Health Act assessments
Wider context from the report “2. That the standard of Mental Health Act assessments by these individuals needs to be improved , and, given all three were in complete agreement, that also training and provision for MHA assessments in police stations more widely may need to be reviewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for passing or seeking relevant information
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report
12 Jul 2016 Alice Poppy Madeleine Gross · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 9 Lack of contingency planning for post-EU management of the watch list and Operation Nexus View source Failure to undertake foreign-conviction checks on UK nationals View source Failure to detain persons with serious convictions at UK borders View source Lack of audit systems for regular checking of foreign-conviction and border-control processes View source Deletion of serious convictions from international databases View source Unavailability of a readily referenced international-border database of serious convictions View source Failure to mandate foreign-conviction checks on arrest across all UK police forces View source Non-automated identification of foreign convictions for non-EU foreign nationals View source Risk of loss of access to Europol intelligence View source See 6 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
Alice Poppy Madeleine Gross · 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
Alice Poppy Madeleine Gross, aged 14, was murdered in a sexually motivated attack near the River Brent in Hanwell, Ealing, on or soon after 28 August 2014; her body was discovered concealed and weighted down in the river on 30 September 2014. The principal concerns included inconsistent checking of foreign criminal convictions on arrest, incomplete international conviction data and weaknesses in the border watch-list system.
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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 contingency planning for post-EU management of the watch list and Operation Nexus
Wider context from the report “(5) That contingency plans are considered as to how to manage the “watch list” and Operation Nexus when and if the UK leaves the EU , both in respect of how systems operate when no longer resting on EU Directives and how to maintain international communication and cooperation .
” Open source report × Source evidence
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 undertake foreign-conviction checks on UK nationals
Wider context from the report “(2) That checks for foreign convictions are not undertaken on UK nationals given the current levels of international travel and the potential relevance for such convictions to the matter for which that person may have been arrested.
” Open source report × Source evidence
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 detain persons with serious convictions at UK borders
Wider context from the report “(8) That systems of audit are in place that would allow regular checking of whether (i)checks for foreign convictions are being carried out by all UK police forces on arrest; (ii) that "watch and warning lists" are up to date; (iii) and that persons with serious convictions are detained at UK borders and their potential criminal propensity thus appropriately managed.
” Open source report × Source evidence
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 audit systems for regular checking of foreign-conviction and border-control processes
Wider context from the report “(8) That systems of audit are in place that would allow regular checking of whether (i)checks for foreign convictions are being carried out by all UK police forces on arrest; (ii) that "watch and warning lists" are up to date; (iii) and that persons with serious convictions are detained at UK borders and their potential criminal propensity thus appropriately managed.
” Open source report × Source evidence
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 serious convictions from international databases
Wider context from the report “(4) That the Home Office continues to encourage both EU and non EU countries not to delete serious convictions such as murder from their data bases .
” Open source report × Source evidence
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 readily referenced international-border database of serious convictions
Wider context from the report “(3) That the Home Office continues to encourage both EU and Non EU countries to update the “watch list” such that there is a readily referenced computer database at international borders of matters such as murder convictions .
” Open source report × Source evidence
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 mandate foreign-conviction checks on arrest across all UK police forces
Wider context from the report “(1) That checks for foreign convictions on arrest are not mandatory in all police forces across the UK .
” Open source report × Source evidence
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 Non-automated identification of foreign convictions for non-EU foreign nationals
Wider context from the report “(7) Whether non- EU foreign nationals need special consideration in respect of how to identify their foreign convictions and thus for the UK to manage their criminal propensity, since I understand from the evidence that their convictions are most likely identified by non-automated Interpol or police to police queries .
” Open source report × Source evidence
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 Risk of loss of access to Europol intelligence
Wider context from the report “(6) That the UK does not lose access to Europol intelligence when and if the UK leaves the EU.
” 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 Encourage EU and international partners to retain serious criminal records for longer periods.
Verbatim wording from the response “As you suggest, the UK continues to encourage EU Member States to commit to longer retention periods of criminal records, particularly where the offence is serious. Likewise, the UK continues to encourage our international partners to consider longer retention periods of criminal records for serious offences, setting out the clear public protection arguments as to why this information is needed. However, these matters are of course ultimately for individual countries to decide.” Source location 2016-0488-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 Promote greater criminality-information sharing within the EU and establish robust criminal-record-sharing arrangements for the UK’s future relationship with the EU.
Verbatim wording from the response “Within the EU the UK has been a leading proponent of greater information exchange between countries for public protection reasons, including at the border, supporting an EU ‘Roadmap’, endorsed by the Justice and Home Affairs Council in June this year, which seeks to enhance the sharing and management of criminality information systems. This envisages exchanges of data between the Schengen and non-Schengen countries, which includes the UK.” Source location 2016-0488-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 Promote daily use of Interpol I-24/7 by UK law-enforcement agencies for foreign criminality searches.
Verbatim wording from the response “For non-EU nationals, police forces are increasingly using Interpol I-24/7, a browser-based system, which was made available to the 190 Interpol members in 2002, to search police information across the globe on a 24/7 and 365 days a year basis. Police forces in the UK are able to access information via the secure Police National Network. Usage of the system has rapidly increased in the last few years and work continues with UK law enforcement to promote its use on a daily basis.” Source location 2016-0488-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 Provide UK police with mechanisms to conduct foreign criminal-record checks on arrested foreign nationals through ECRIS and related systems.
Verbatim wording from the response “Since 2010 however, mechanisms have been put in place to allow the police to conduct criminal records checks on all foreign nationals who are arrested in the UK. Since 2012 the European Criminal Record Information System (ECRIS) has provided police forces with access to criminal records information quickly and through an automated system via the ACRO Criminal Records Office (ACRO), which manages criminal records exchange across the European Union for the UK.” Source location 2016-0488-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 Operate the Warnings Index and connect UK law-enforcement and border authorities to SISII criminality information.
Verbatim wording from the response “The UK maintains its own domestic ‘watch list’ known as the Warnings Index and information on that system can and is used to refuse entry to individuals who pose a risk to the UK public. Indeed, over 6,500 individuals from the EU and wider European Economic Area have been refused entry since 2010. Furthermore, the UK’s connection to the EU second generation Schengen Information System (SISII) in April 2015 has enhanced the amount of criminality information which the police and border officers can access. SISII helps to track the movements around Europe of over 10,000 people convicted of sexual or violent offences in the UK as and when they come into contact with law enforcement across the EU, with over 6,000 hits received on these individuals.” Source location 2016-0488-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 Promote foreign criminal-record checks in all relevant cases and improve criminality-data quality with police and police and crime commissioners.
Verbatim wording from the response “The Government sees the use of criminality information as an important tool in protecting the public and continues to engage with law enforcement agencies to ensure that this information is used to the fullest. It is, however, ultimately for individual chief constables to decide how their police force should conduct operational matters. Furthermore it is for police and crime commissioners, as the elected persons responsible for police governance under the Police Reform and Social Responsibility Act 2011, to hold their chief constables to account for their performance in combating crime. That is not to say that there is not more that can be done which is why ACRO has worked with police forces and chief constables to promote the importance of conducting checks in all cases.” Source location 2016-0488-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 Decisions on police operational checks rest with individual chief constables, with police and crime commissioners responsible for holding them to account.
Verbatim wording from the response “The Government sees the use of criminality information as an important tool in protecting the public and continues to engage with law enforcement agencies to ensure that this information is used to the fullest. It is, however, ultimately for individual chief constables to decide how their police force should conduct operational matters. Furthermore it is for police and crime commissioners, as the elected persons responsible for police governance under the Police Reform and Social Responsibility Act 2011, to hold their chief constables to account for their performance in combating crime. That is not to say that there is not more that can be done which is why ACRO has worked with police forces and chief constables to promote the importance of conducting checks in all cases.” Source location 2016-0488-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 Specific future security and intelligence-sharing arrangements cannot be addressed before negotiations with European partners.
Verbatim wording from the response “The Prime Minister has put the whole machinery of Government behind getting the best deal as the UK leaves the EU. A great deal of work is going on across Government to ensure that happens. The Prime Minister has made clear that whilst we are leaving the EU, cooperation on security with our European and global allies will continue and we will do whatever is necessary to keep our citizens safe. Clearly it would be wrong to be drawn on the specifics of any future arrangements in advance of negotiations with our EU partners.” Source location 2016-0488-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 Retention periods for serious criminal convictions are ultimately matters for individual countries to decide.
Verbatim wording from the response “As you suggest, the UK continues to encourage EU Member States to commit to longer retention periods of criminal records, particularly where the offence is serious. Likewise, the UK continues to encourage our international partners to consider longer retention periods of criminal records for serious offences, setting out the clear public protection arguments as to why this information is needed. However, these matters are of course ultimately for individual countries to decide.” Source location 2016-0488-Response-by-Home-Office
Open published response
12 Jul 2016 Steven Thomas Billington · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1 Failure to protect the mains-powered alarm system on/off control-switch from unauthorised switching View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Steven Thomas Billington · 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
Steven Thomas Billington died on 25 March 2015 after inhaling products of combustion from a fire at his home, which began when clothing placed on a maiden in front of a gas fire ignited. The mains-powered fire alarm system had been switched off using an unprotected control switch in an accessible communal area, so it did not warn of the fire. The report raised concern that the switch was not required to be inaccessible to unauthorised people, despite it being simple to protect it, for example in a locked cupboard.
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 protect the mains-powered alarm system on/off control-switch from unauthorised switching
Wider context from the report “The on/off control-switch for the mains powered alarm system was not protected and was therefore able to be switched off. Evidence was given that the relevant regulations do not require the on/off control for such a system to be rendered inaccessible to all but authorised persons.
Further evidence revealed that it would be a simple matter to protect the control by it being placed, for example, in a locked cupboard and this would have no detrimental effect as the control panel for the system that allows it to be reset in the event of false alarm is separately situated from the on/off control-switch.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review relevant standards for installing fire detection and alarm systems.
Verbatim wording from the response “I was very sorry to read about Mr Billington’s death. I understand that the power supply to the fire alarm in the building had been switched off and that this may have contributed to his death. My officials have looked at the relevant standards for the installation of fire detection and alarm systems. It appears that the current guidance in British Standard 5839 already requires that isolators for fire alarm systems are appropriately secured against unauthorised tampering. Perhaps the system in question was an older system that did not meet the current standard.” Source location 2016-0247-Response-by-Department-for-Communities-and-Local-Government
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 Current British Standard guidance already requires fire alarm isolators to be secured against unauthorised tampering.
Verbatim wording from the response “I was very sorry to read about Mr Billington’s death. I understand that the power supply to the fire alarm in the building had been switched off and that this may have contributed to his death. My officials have looked at the relevant standards for the installation of fire detection and alarm systems. It appears that the current guidance in British Standard 5839 already requires that isolators for fire alarm systems are appropriately secured against unauthorised tampering. Perhaps the system in question was an older system that did not meet the current standard.” Source location 2016-0247-Response-by-Department-for-Communities-and-Local-Government
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 Any identified weakness in the standard should be referred to the relevant British Standards Institution committee.
Verbatim wording from the response “However, if the investigations of the fire and rescue service have identified a weakness in the standard, then this should be brought to the attention of the relevant committee at the British Standards Institution. The committee may need more information than is contained in your report. If you or the fire and rescue service need assistance in this respect, please contact my official, ████████ at my address, or email ████████” Source location 2016-0247-Response-by-Department-for-Communities-and-Local-Government
Open published response
1 Jul 2016 Daniel James Paylor · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Lack of peer supervision for drug control View source Insufficient regulatory safeguards and auditing for drugs View source Lack of dual authorisation for unlocking drug safes 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
Daniel James Paylor · 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
Daniel James Paylor, a paramedic with a history of codeine addiction and bipolar disorder, died following an opiate overdose after consuming a bottle of Oramorph kept for his private paramedic work. The report raised concerns about the regulation and control of drugs in secondary paramedic employment, including limited safeguards, auditing, peer supervision and double authorisation.
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 peer supervision for drug control
Wider context from the report “(1) I am concerned when comparing the regulation and control of drugs, say, within an hospital and in Dan’s case insofar as his primary employer is concerned, an ambulance service, that compared to the level of control in relation to his secondary employment that the degree of regulatory control including safeguards and auditing appear to be very much dependent on trust. There appears to be little requirement for peer supervision and say double authorisation for say unlocking a safe comprising of two locks. My experience in relation to local hospitals is that in relation to drugs cabinets procedures have developed that require more than 1 health care professional’s authority to remove drugs to administer them to a patient. There have been instances whereby health care professionals with histories that have had addictions to prescription drugs however at least in that environment there is a stiff regime for supervision which appears absent in the scenario outlined above. I fully accept that even with regulation unless it includes the use of double locked safes with separate key holders that even with the most rigorous regulation that Dan’s death may not have been avoided. I was satisfied on a balance of probabilities that he consumed the whole bottle of Oramorph within that 36 hour period prior to his death. I am, however, of the view that consideration ought to be given as regards improving the regulatory regime and control with a view to the prevention of future deaths in perhaps a slightly different scenario.
” Open source report × Source evidence
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 regulatory safeguards and auditing for drugs
Wider context from the report “(1) I am concerned when comparing the regulation and control of drugs, say, within an hospital and in Dan’s case insofar as his primary employer is concerned, an ambulance service, that compared to the level of control in relation to his secondary employment that the degree of regulatory control including safeguards and auditing appear to be very much dependent on trust . There appears to be little requirement for peer supervision and say double authorisation for say unlocking a safe comprising of two locks. My experience in relation to local hospitals is that in relation to drugs cabinets procedures have developed that require more than 1 health care professional’s authority to remove drugs to administer them to a patient. There have been instances whereby health care professionals with histories that have had addictions to prescription drugs however at least in that environment there is a stiff regime for supervision which appears absent in the scenario outlined above. I fully accept that even with regulation unless it includes the use of double locked safes with separate key holders that even with the most rigorous regulation that Dan’s death may not have been avoided. I was satisfied on a balance of probabilities that he consumed the whole bottle of Oramorph within that 36 hour period prior to his death. I am, however, of the view that consideration ought to be given as regards improving the regulatory regime and control with a view to the prevention of future deaths in perhaps a slightly different scenario.
” Open source report × Source evidence
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 dual authorisation for unlocking drug safes
Wider context from the report “(1) I am concerned when comparing the regulation and control of drugs, say, within an hospital and in Dan’s case insofar as his primary employer is concerned, an ambulance service, that compared to the level of control in relation to his secondary employment that the degree of regulatory control including safeguards and auditing appear to be very much dependent on trust. There appears to be little requirement for peer supervision and say double authorisation for say unlocking a safe comprising of two locks . My experience in relation to local hospitals is that in relation to drugs cabinets procedures have developed that require more than 1 health care professional’s authority to remove drugs to administer them to a patient. There have been instances whereby health care professionals with histories that have had addictions to prescription drugs however at least in that environment there is a stiff regime for supervision which appears absent in the scenario outlined above. I fully accept that even with regulation unless it includes the use of double locked safes with separate key holders that even with the most rigorous regulation that Dan’s death may not have been avoided. I was satisfied on a balance of probabilities that he consumed the whole bottle of Oramorph within that 36 hour period prior to his death. I am, however, of the view that consideration ought to be given as regards improving the regulatory regime and control with a view to the prevention of future deaths in perhaps a slightly different scenario.
” Open source report
8 Jun 2016 Stephen Alan HUNT · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 15 Inadequate guidance and training on the limited reliability of thermal imaging cameras for measuring ambient temperature View source Lack of effective means to ensure fire and rescue services meet expectations and disseminate national learning View source Inadequate training and guidance to recognise the effects of heat and appropriate withdrawal steps View source Failure to record significant hazards and safety control measures within each sector View source Failure to deploy aerial monitors without compromising personnel safety in the risk area View source Failure of incident role handovers to capture and share key safety information View source Inadequate training and guidance to enable personnel to withdraw colleagues adversely affected by heat View source Inadequate training and guidance to enable personnel to withdraw themselves from heat exposure View source Failure to define the circumstances for inspections under section 7(2)(d) of the Fire and Rescue Services Act 2004 View source Loss of communications at operational incidents View source Lack of means for responsible persons to verify fire risk assessor competence View source Failure to control breathing-apparatus wear duration according to relevant heat-exposure factors View source Inadequate training and qualification of fire risk assessors View source Failure to test whether national learning is received, understood, actioned and embedded View source Failure to pass hazard and safety-control information to the incident command team for analytical risk assessment View source See 12 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
Stephen Alan HUNT · 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
Stephen Alan Hunt, a firefighter, died after entering a fire at Paul's Hair and Beauty World in Manchester on 13 July 2013. He was found inside the premises after suffering heat exhaustion and hypoxia. The principal concerns included failures in communication and handover, misinterpretation of instructions, loss of telemetry and radio communications, inadequate fire risk assessments and fire safety measures, and decisions affecting firefighter safety.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidance and training on the limited reliability of thermal imaging cameras for measuring ambient temperature
Wider context from the report “(5) It is suggested that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training in the appropriate use of thermal imaging cameras to include the limited extent to which they can be relied upon to measure ambient temperature .
” Open source report × Source evidence
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 effective means to ensure fire and rescue services meet expectations and disseminate national learning
Wider context from the report “(10) It is understood that there are some 45 Fire and Rescue Services and the findings of the inquest need to be disseminated down to them all. The pressure is upon them to find their own solutions to problems against the backdrop of financial pressures. The Home Office now leads on fire issues and there has been ever increasing decentralisation. Whilst this is not without merit there appear to be difficulties in ensuring that services are meeting expectations and a means of disseminating national learning.
It is suggested that consideration is given to being able to mobilise a national and consistent approach to sharing the learning and testing so that it can be shown to be received, understood, actioned and embedded.
” Open source report × Source evidence
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 and guidance to recognise the effects of heat and appropriate withdrawal steps
Wider context from the report “(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to:
Duration of wears under breathing apparatus;
Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances;
Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal.
Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately.
Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU.
” Open source report × Source evidence
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 significant hazards and safety control measures within each sector
Wider context from the report “(4) It is suggested that all FRSs should ensure that significant hazards and any safety control measures are the responsibility of the incident commander and should be recorded within each sector, to ensure visibility to all on the fireground, and passed/copied for use by the incident commander/command team to assist on the analytical risk assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to deploy aerial monitors without compromising personnel safety in the risk area
Wider context from the report “(6) It is suggested that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training in the deployment of aerial monitors to ensure the safety of any personnel within the risk area is not compromised.
” Open source report × Source evidence
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 incident role handovers to capture and share key safety information
Wider context from the report “(3) It is suggested that all FRSs should undertake a review to ensure the adequacy of standard operating procedures, guidance and training of the handing over and taking over of roles at incidents to ensure all the key areas of information, including safety control measures, are captured and shared.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inadequate training and guidance to enable personnel to withdraw colleagues adversely affected by heat
Wider context from the report “(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to:
Duration of wears under breathing apparatus;
Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances;
Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal.
Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately.
Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU.
” Open source report × Source evidence
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 and guidance to enable personnel to withdraw themselves from heat exposure
Wider context from the report “(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to:
Duration of wears under breathing apparatus;
Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances;
Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal.
Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately.
Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU.
” Open source report × Source evidence
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 define the circumstances for inspections under section 7(2)(d) of the Fire and Rescue Services Act 2004
Wider context from the report “(7) It is suggested that all FRSs should undertake a review to consider the circumstances in which inspections should be carried out under section 7(2)(d) of the Fire and Rescue Services Act 2004.
” Open source report × Source evidence
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 Loss of communications at operational incidents
Wider context from the report “(2) It is suggested that all FRSs should consider the implementation of measures to reduce the risks associated with the loss of communications at operational incidents . For example, to include safety control measures to ensure BA teams can be withdrawn from the risk area if needed .
” Open source report × Source evidence
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 means for responsible persons to verify fire risk assessor competence
Wider context from the report “(9) It is suggested that the Secretary of State for the Home Department considers measures to ensure that:
fire risk assessors are adequately trained and qualified so as to be competent in the role, and
the responsible person has the means to verify the competence of any person holding themselves out to be a fire risk assessor.
” Open source report × Source evidence
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 control breathing-apparatus wear duration according to relevant heat-exposure factors
Wider context from the report “(1) It is suggested that all Fire and Rescue Services (FRS's) should consider the implementation of measures to reduce the risks associated with the physiological affects of working in a hot environment. In particular consideration should be given to:
Duration of wears under breathing apparatus;
Having regard to all relevant factors including, for example the weather, previous exertions of BA teams and individual circumstances;
Training and guidance for all operational personnel to recognize the effects of heat both on themselves and on their colleagues and the appropriate steps to take upon such recognition, including withdrawal and self withdrawal.
Training and guidance for all operational personnel to have the ability and confidence to ensure the withdrawal of others who may be adversely affected by heat whether by calling a BA emergency or otherwise appropriately.
Training and guidance for all operational personnel to have the ability and confidence to withdraw themselves by whatever means appropriate including activating the ADSU.
” Open source report × Source evidence
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 and qualification of fire risk assessors
Wider context from the report “(9) It is suggested that the Secretary of State for the Home Department considers measures to ensure that:
fire risk assessors are adequately trained and qualified so as to be competent in the role , and
the responsible person has the means to verify the competence of any person holding themselves out to be a fire risk assessor.
” Open source report × Source evidence
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 test whether national learning is received, understood, actioned and embedded
Wider context from the report “(10) It is understood that there are some 45 Fire and Rescue Services and the findings of the inquest need to be disseminated down to them all. The pressure is upon them to find their own solutions to problems against the backdrop of financial pressures. The Home Office now leads on fire issues and there has been ever increasing decentralisation. Whilst this is not without merit there appear to be difficulties in ensuring that services are meeting expectations and a means of disseminating national learning.
It is suggested that consideration is given to being able to mobilise a national and consistent approach to sharing the learning and testing so that it can be shown to be received, understood, actioned and embedded.
” Open source report × Source evidence
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 pass hazard and safety-control information to the incident command team for analytical risk assessment
Wider context from the report “(4) It is suggested that all FRSs should ensure that significant hazards and any safety control measures are the responsibility of the incident commander and should be recorded within each sector, to ensure visibility to all on the fireground, and passed/copied for use by the incident commander/command team to assist on the analytical risk assessment.
” Open source report
7 Apr 2016 Joyce Carney · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 4 Lack of agreed police-hospital protocols for joint risk assessments and liaison View source Failure of police-hospital liaison and communication during risk assessment of police-supervised hospital patients View source Failure of risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff View source Failure of senior police officers to reassess risk after concerns about an agitated patient threatening to leave hospital View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joyce Carney · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joyce Carney, who had diabetes and dementia, was knocked to the floor in a hospital corridor by another patient running away from Police Officers. She sustained a fractured neck of femur, underwent surgery, developed infections and deteriorated before dying on 11 February 2015. The principal concerns were the lack of communication and joint risk assessment between Police and Hospital staff, and the absence of protocols to protect other patients, visitors, the public and staff when patients are supervised by Police Officers.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed police-hospital protocols for joint risk assessments and liaison
Wider context from the report “iv. There are no agreed protocols, policies or procedures between the Greater Manchester Police and the Royal Albert Edward Infirmary, Wigan in relation to joint risk assessments for patients detained at the Hospital under arrest or in the presence of or supervised by Police Officers. Furthermore there is no protocol, in relation to liaison and consultation between the Greater Manchester Police and the Hospital to formulate risk assessments in relation to patients detained at the Hospital under arrest or in the presence of or supervised by Police Officers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of police-hospital liaison and communication during risk assessment of police-supervised hospital patients
Wider context from the report “i. When the Patient was moved to Lowton Ward in the Hospital the risk assessment conducted by the Hospital in relation to the location of the Patient in the Ward involved the Bed Manager, the Ward Manager and the Nurses treating the Patient. The risk assessment did not involve, nor include, the Police Officers who were observing a patient. The risk assessment conducted by the Hospital focussed on the safety of the Patient and did not extend to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and members of staff employed in the Hospital.
ii. The risk assessment conducted by Police Officers, in relation to the Patient at the Hospital, focussed on the Patient and the fact that the Patient may seek to leave the Hospital but the assessment did not include any discussions or liaison with Hospital staff. The risk assessment did not include the protection of other patients in the Hospital, visitors to the Hospital, members of the public or staff employed in the Hospital.
iii. There was no liaison or communication between the Police Officers observing the Patient and the Hospital treating the Patient in relation to the layout of the Hospital or with regard to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff
Wider context from the report “i. When the Patient was moved to Lowton Ward in the Hospital the risk assessment conducted by the Hospital in relation to the location of the Patient in the Ward involved the Bed Manager, the Ward Manager and the Nurses treating the Patient. The risk assessment did not involve, nor include, the Police Officers who were observing a patient. The risk assessment conducted by the Hospital focussed on the safety of the Patient and did not extend to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and members of staff employed in the Hospital.
ii. The risk assessment conducted by Police Officers, in relation to the Patient at the Hospital, focussed on the Patient and the fact that the Patient may seek to leave the Hospital but the assessment did not include any discussions or liaison with Hospital staff. The risk assessment did not include the protection of other patients in the Hospital, visitors to the Hospital, members of the public or staff employed in the Hospital.
iii. There was no liaison or communication between the Police Officers observing the Patient and the Hospital treating the Patient in relation to the layout of the Hospital or with regard to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of senior police officers to reassess risk after concerns about an agitated patient threatening to leave hospital
Wider context from the report “Furthermore the Officers at the Hospital raised concerns with their Supervising Officer, namely a Sergeant at the Police Station, in relation to the Patient being agitated and threatening to leave the Hospital during the afternoon of the 21st December 2014 but neither the Sargent nor any other senior Officer attended the Hospital to conduct any further risk assessment or to reassess the situation .
” Open source report
×
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 Request that the National Policing Lead raise with chief constables whether hospital detention procedures and risk assessments are in place.
Verbatim wording from the response “It is important that the police adhere to Authorised Professional Practice in these circumstances to avoid these sorts of tragedies. It is for this reason that I have asked the Minister for Policing, Fire, Criminal Justice and Victims to write to the National Policing Lead for Custody, Chief Constable ████████, to raise this matter with Chief Constables across England and Wales. They must be able to satisfy themselves that the relevant procedures, including risk assessments, are in place.” Source location 2016-0140-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 Raise with police and NHS organisations the need for local relationships and precautions to manage risks safely in health settings.
Verbatim wording from the response “Police officers regularly attend health settings, for a variety of purposes, and you raise the important issue of how they work with NHS organisations to manage any risks in those settings safely. I agree with you that it is important for those agencies to come together to make sure that the right relationships and precautions are in place in their locality. This case highlights the importance of that joint working, and the Minister will also be raising this.” Source location 2016-0140-Response-by-Home-Office
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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 Responsibility for arrest, detention and supervision of hospital patients rests operationally with each police force’s chief officer.
Verbatim wording from the response “The arrest, detention and supervision of individuals by police whilst they are patients in hospital is an operational consideration for the chief officer of each police force. In carrying out their duties, the police should follow the College of Policing Authorised Professional Practice (APP) - Detention and Custody, which covers risk assessments when a person is detained in non-police custody settings, including hospitals. The College have also produced dedicated APP on risk, which focuses on planning for, and anticipating, risk in a variety of operational contexts.” Source location 2016-0140-Response-by-Home-Office
Open published response
13 Jan 2016 Arenijus Nedzelskis · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 2 Lack of regulatory control over 5F AKB-48 and 5F PB-22 View source Failure to report chronic misuse of cannabinoid receptor agonists to the DVLA Medical Branch View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Arenijus Nedzelskis · 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
Arenijus Nedzelskis, a lorry driver experiencing financial difficulties linked to spending on synthetic cannabinoids, was found hanging after an argument with his partner. The concerns were that 5F AKB-48 and 5F PB-22 were not controlled under the Misuse of Drugs Act 1971 and that he had not reported his chronic misuse of cannabinoid receptor agonists to the DVLA Medical Branch.
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 regulatory control over 5F AKB-48 and 5F PB-22
Wider context from the report “1 That neither 5F AKB-48 nor 5F PB-22 are currently controlled by regulations made under the Misuse of Drugs Act 1971
” Open source report × Source evidence
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 report chronic misuse of cannabinoid receptor agonists to the DVLA Medical Branch
Wider context from the report “2 That the deceased had not reported his chronic misuse of cannabinoid receptor agonists to the DVLA Medical Branch .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish statutory restrictions on the production, supply and importation of psychoactive substances.
Verbatim wording from the response “The landmark Act to end the trade in harmful psychoactive substances and protect young people from the dangers of these drugs achieved Royal Assent on 28 January. The Psychoactive Substances Act 2016 will restrict the production, supply and importation of these potentially dangerous drugs. The new legislation will give police and other law enforcement agencies greater powers to tackle the reckless trade in psychoactive substances, and will see offenders face up to seven years in prison.” Source location 2016-0010-Response-by-Home-Office
Open published response
13 Oct 2015 Catherine Mary Findlay · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Uncontrolled internet availability of research chemicals View source Consumption of research chemicals posing potentially life-threatening danger View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Catherine Mary Findlay · 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
Catherine Mary Findlay, aged 37, was found unresponsive and not breathing at her home on 24 May 2015 and was pronounced dead by paramedics. The post-mortem and inquest attributed her death to Methoxyphenidine (MXP) and cocaine toxicity. The report raised concerns that MXP was freely available online as a “research chemical” despite being misused and potentially life-threatening, and requested a review of its status and control.
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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 Uncontrolled internet availability of research chemicals
Wider context from the report “2. MXP is not a controlled substance but related to Ketamine (a dis-associative anaesthetic) and is thought to be a replacement for another substance – Methoxetomine – which is now a controlled substance under the Misuse of Drugs Act.
3. I have concerns that such substances - freely marketed as “research chemicals” are generally available over the internet . They are sold with a warning that they are not for human consumption but are misused and consumed by people and are consequently dangerous and potentially life threatening.
” Open source report × Source evidence
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 Consumption of research chemicals posing potentially life-threatening danger
Wider context from the report “2. MXP is not a controlled substance but related to Ketamine (a dis-associative anaesthetic) and is thought to be a replacement for another substance – Methoxetomine – which is now a controlled substance under the Misuse of Drugs Act.
3. I have concerns that such substances - freely marketed as “research chemicals” are generally available over the internet. They are sold with a warning that they are not for human consumption but are misused and consumed by people and are consequently dangerous and potentially life threatening .
” 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 clinical guidelines supporting detection, assessment and management of New Psychoactive Substance users.
Verbatim wording from the response “We are also taking forward a comprehensive action plan on NPS to enhance further our response to prevention, treatment and information sharing. For example, we have launched a toolkit to help local areas prevent and respond to the use of NPS and published clinical guidelines to aid in the detection, assessment and management of NPS users.” Source location 2015-0372-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with internet providers to ensure compliance with laws governing online drug advertising and sales.
Verbatim wording from the response “The Government and law enforcement agencies take the issue of unlawful advertising and sales of drugs on the internet very seriously, and we continue to work with internet providers to ensure that they comply with the law. This can” Source location 2015-0372-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Psychoactive Substances Bill to establish a blanket ban on supplying psychoactive substances for human consumption.
Verbatim wording from the response “On 28 May, we introduced the Psychoactive Substances Bill to create a blanket ban on the supply of New Psychoactive Substances (NPS). This landmark Bill will ban the sale, supply, production and distribution of psychoactive substances for human consumption, including MXP, and give police and local authorities greater powers to tackle this reckless trade.” Source location 2015-0372-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 international partnerships and regulatory cooperation to address overseas websites trading controlled drugs and emerging supply threats.
Verbatim wording from the response “Considerable illegal activity takes place on the internet outside of UK jurisdiction. The UK continues to work with international partners to develop an effective response to the supply of controlled drugs and to react swiftly to emerging threats. In order to tackle illegally trading websites identified overseas, we are building strong partnerships with international partners. There is also ongoing work with the EU and other international regulatory agencies to ensure that, wherever possible, offending websites are amended to comply with the law.” Source location 2015-0372-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 Launch a toolkit helping local areas prevent and respond to New Psychoactive Substance use.
Verbatim wording from the response “We are also taking forward a comprehensive action plan on NPS to enhance further our response to prevention, treatment and information sharing. For example, we have launched a toolkit to help local areas prevent and respond to the use of NPS and published clinical guidelines to aid in the detection, assessment and management of NPS users.” Source location 2015-0372-Response
Open published response
5 Aug 2015 Rubel Ahmed · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 6 Failure to ensure detention staff awareness of significant changes in detainees' circumstances View source Failure to prevent overnight locking of detainees in their rooms View source Lack of regular detention awareness refresher training View source Provision of electrical items with leads that can be used as ligatures View source Insufficiently robust detention awareness training View source Lack of protected time for personal officers to carry out assigned duties View source See 3 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
Rubel Ahmed · 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
Rubel Ahmed, who was detained at Morton Hall Immigration Removal Centre, was found hanging in his room on the evening of 5 September 2014 and was pronounced deceased shortly after midnight on 6 September 2014. The concerns included overnight locking of detainees in rooms, the adequacy of detention-awareness training, staff awareness of changes in detainees’ circumstances, insufficient protected time for personal officers, and the use of electrical leads that could be used as ligatures.
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 ensure detention staff awareness of significant changes in detainees' circumstances
Wider context from the report “iii. STAFF AWARENESS OF CHANGES IN DETAINEES CIRCUMSTANCES INCLUDING REMOVAL DIRECTIONS:
It was disclosed at the Inquest that staff members, who dealt with Mr Ahmed on the evening of 5th September, 2014 were not aware that he had been served with removal directions . Had staff been aware of this information it may have resulted in Mr Ahmed being monitored more comprehensively than was the case.
My concerns relate to there being a need to implement a robust system to ensure that all relevant detention staff at Morton Hall IRC are aware of significant changes in detainees circumstances, including the service of removal directions upon them .
” Open source report × Source evidence
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 overnight locking of detainees in their rooms
Wider context from the report “i. THE LOCKING OF SOME DETAINEES IN THEIR ROOMS OVERNIGHT:
In 2013, H.M Inspectorate of Prisons inspected IRC Morton Hall and recommended that detainees should not be locked into cells (rooms) and should not be restricted to units in the early evening. Despite this recommendation, those in the Windsor Unit, in which Mr Ahmed resided, were locked into their rooms from 8:30pm to 8:00am on the following morning . This situation prevailed at the time of Mr Ahmeds death. Whilst it was clear that significant efforts had been made to comply with the above HMIP recommendation, detainees in the Windsor Unit were still being locked into their rooms overnight at the time of the Inquest . My concern relates to whether the above HMIP recommendation has now been fully complied with and if not when compliance will be achieved. I consider that the practice of locking detainees in their rooms in the evenings and/or overnight should be discontinued as soon as is practically possible at Morton Hall I.R.C.
” Open source report × Source evidence
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 detention awareness refresher training
Wider context from the report “ii. DETENTION AWARENESS TRAINING:
I am concerned that the detention awareness training given to the staff at Morton Hall I.R.C was not sufficiently robust to be of continuing assistance to staff in their understanding of detainees needs or to have an ongoing impact on their working practices. Further, little or no provision had been made to provide regular refresher training . I consider that there is a need for an urgent review of the provision of detention awareness training to detention staff at Morton Hall IRC with a view to effective training and refresher training courses being provided.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Provision of electrical items with leads that can be used as ligatures
Wider context from the report “v. USE OF ELECTRICAL ITEMS IN ROOMS:
Evidence at the Inquest established that Mr Ahmed utilised the electrical lead on his kettle to form a ligature with which he hanged himself. The electrical lead was noted to be two feet six inches in length. The lead could have been very much shorter and thus have avoided the risk of it being utilised as a ligature . This issue needs to be reviewed throughout Morton Hall IRC.
” Open source report × Source evidence
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 Insufficiently robust detention awareness training
Wider context from the report “ii. DETENTION AWARENESS TRAINING:
I am concerned that the detention awareness training given to the staff at Morton Hall I.R.C was not sufficiently robust to be of continuing assistance to staff in their understanding of detainees needs or to have an ongoing impact on their working practices . Further, little or no provision had been made to provide regular refresher training. I consider that there is a need for an urgent review of the provision of detention awareness training to detention staff at Morton Hall IRC with a view to effective training and refresher training courses being provided.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of protected time for personal officers to carry out assigned duties
Wider context from the report “iv. PERSONAL OFFICER DETAIL:
Despite the fact that Mr Ahmed had been allocated a Personal Officer it was abundantly clear that the officer had spent very little time with him, owing to other work pressures. It was also evident that there was no adequate system at Morton Hall for ensuring that staff have protected time to carry out this important work to enable detainees to discuss sensitive or distressing issues with an officer who was familiar to them.
I consider that this situation needs to be reviewed to ensure that personal officers at Morton Hall IRC assigned to detainees are given protected time to carry out these duties.
” 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 Implement regular refresher Detention Awareness training for Morton Hall staff.
Verbatim wording from the response “We agree that it is important that all staff working in an IRC have a broad understanding of the needs of detainees. There is a comprehensive Detention Awareness training package in place for all staff at Morton Hall IRC and work is underway to implement a programme of regular refresher training.” Source location 2015-0308-Response-by-Home-Office
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish the costs of major fire-safety changes required to keep Windsor Unit rooms unlocked overnight.
Verbatim wording from the response “principle following an inspection of the centre by Her Majesty’s Chief Inspector of Prisons (HMCIP) in 2013. Windsor Unit, where Mr Ahmed was accommodated, was originally designed, fitted and approved for use as a custodial building in which prisoners were locked in their rooms overnight. In order to operate a new regime in which rooms in Windsor Unit remain unlocked overnight, major changes to the fire safety measures are required to ensure detainee and staff safety and compliance with Crown Premises Inspectorate Group requirements. There is ongoing work to establish the costs of these measures.” Source location 2015-0308-Response-by-Home-Office
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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 Manage and monitor detainees at risk of self-harm or suicide through ACDT and take steps such as limiting access to potentially harmful items.
Verbatim wording from the response “There is a robust safer detention system in place across the detention estate to identify and manage detainees who are at risk of self-harm or suicide, which includes Assessment, Care in Detention and Teamwork (ACDT) and Vulnerable Adult Care Plans. The large majority of detainees who are monitored on an ACDT are assessed as vulnerable as a result of their concerns about being deported or because of a change in circumstances. This is kept under review.” Source location 2015-0308-Response-by-Home-Office
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide comprehensive Detention Awareness training to all Morton Hall staff.
Verbatim wording from the response “We agree that it is important that all staff working in an IRC have a broad understanding of the needs of detainees. There is a comprehensive Detention Awareness training package in place for all staff at Morton Hall IRC and work is underway to implement a programme of regular refresher training.” Source location 2015-0308-Response-by-Home-Office
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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 Secure accommodation remains necessary for detainees whose risk assessments make them unsuitable for more open conditions.
Verbatim wording from the response “principle following an inspection of the centre by Her Majesty’s Chief Inspector of Prisons (HMCIP) in 2013. Windsor Unit, where Mr Ahmed was accommodated, was originally designed, fitted and approved for use as a custodial building in which prisoners were locked in their rooms overnight. In order to operate a new regime in which rooms in Windsor Unit remain unlocked overnight, major changes to the fire safety measures are required to ensure detainee and staff safety and compliance with Crown Premises Inspectorate Group requirements. There is ongoing work to establish the costs of these measures.” Source location 2015-0308-Response-by-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 Shortening electrical leads would not eliminate the risk of detainee self-harm or suicide.
Verbatim wording from the response “The use of electrical items in rooms has also been reviewed by officials at the National Offender Management Service. The electric leads on the kettles at Morton Hall are standard issue for the type of kettle in use in custodial settings as are all other electrical items in rooms at Morton Hall such as TVs and DVD players. Shortening electrical leads would unfortunately not eliminate the risk of self-harm or suicide. Instead, when a detainee presents a risk of self-harm or suicide, he will continue to be managed and monitored on an ACDT document and any necessary” Source location 2015-0308-Response-by-Home-Office
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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 Effective detainee management and care do not require positive engagement to be limited to a single personal officer.
Verbatim wording from the response “At Morton Hall all staff operate on the basis that every contact matters: every interaction between a member of staff and a detainee contributes to their effective management and care, and positive engagement is not limited to a relationship with a single personal officer. Welfare services are provided by specialist staff from Children’s Links, and each detainee has a welfare booklet opened during induction which is regularly reviewed and updated during their stay at Morton Hall. Again, I must stress that in the case of Mr Ahmed there were no indications prior to his death that he was at risk of self-harm or suicide.” Source location 2015-0308-Response-by-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 Existing ACDT management and monitoring, including limiting access to risky items, is relied on to reduce self-harm or suicide risk.
Verbatim wording from the response “The use of electrical items in rooms has also been reviewed by officials at the National Offender Management Service. The electric leads on the kettles at Morton Hall are standard issue for the type of kettle in use in custodial settings as are all other electrical items in rooms at Morton Hall such as TVs and DVD players. Shortening electrical leads would unfortunately not eliminate the risk of self-harm or suicide. Instead, when a detainee presents a risk of self-harm or suicide, he will continue to be managed and monitored on an ACDT document and any necessary” Source location 2015-0308-Response-by-Home-Office
Open published response
15 May 2015 Jacques Gerard Lakeman and Torin Callan Lakeman · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 5 Lack of protection for Internet-based drug delivery and importation through the UK postal system View source Lack of regulation of Internet-based drug supply View source Unknown and potentially contaminated composition of Internet-supplied drugs View source Ease of access to illicit drug supply through Internet websites View source Lack of traceability of Internet-based illicit drug suppliers View source See 2 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
Jacques Gerard Lakeman and Torin Callan Lakeman · 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
Jacques Gerard Lakeman and Torin Callan Lakeman, brothers, died at The Grapes Public House, Stoneclough, Bolton, on 1 December 2014. The medical cause of death for both was recorded as fatal MDMA toxicity, with the inquest conclusion being misuse of Ecstasy. The report raised concerns about the online supply and postal delivery of illicit drugs, including the unknown strength and contents of substances and the lack of regulation.
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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 protection for Internet-based drug delivery and importation through the UK postal system
Wider context from the report “1. During the Inquest evidence was heard that:
i. Torin had received supplies of drugs, prior to November 2014, by use of the Internet using the “Dark Internet” or “Dark Web”.
The Inquest heard that access to the “Dark Internet” or “Dark Web” would be difficult without having knowledge or expertise in relation to Internet access but young persons, particular intelligent University students, would find access to the websites to be relatively easy and it would not be difficult for such persons to obtain access to illicit activities, including the supply of illicit drugs.
The websites are anonymous and there is no contact information with regard to the address or location of the owners of the website nor with regard to the suppliers of illicit drugs.
ii. The constituent parts of the drugs, including the strength and content of the drugs, are unknown and may contain contaminants and further illicit substances creating an additional risk.
iii. There is no regulation of the supply of drugs by use of the Internet and there is no protection in place in relation to the delivery or importation of drugs using the Internet and delivery to a United Kingdom postal address by use of the Postal System .
iv. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit drugs, including Class A drugs, by use of the Internet.
v. On the 30th March 2015 I reported a similar concern to you relating to the death of Jason Houghton, who died on the 30th June 2014 from the combined toxic effects of illicit drugs obtained by use of the Internet.
2. I request that you consider the above concerns particularly in regard to the following:-
i. The supply and importation of drugs, including Class A drugs, in the manner and in the form described in this report, by use of the Internet.
ii. The regulation of the Internet, which may be difficult if not impossible, in relation to the supply of drugs and delivery of drugs to addresses in the United Kingdom by use of the Postal 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 Lack of regulation of Internet-based drug supply
Wider context from the report “1. During the Inquest evidence was heard that:
i. Torin had received supplies of drugs, prior to November 2014, by use of the Internet using the “Dark Internet” or “Dark Web”.
The Inquest heard that access to the “Dark Internet” or “Dark Web” would be difficult without having knowledge or expertise in relation to Internet access but young persons, particular intelligent University students, would find access to the websites to be relatively easy and it would not be difficult for such persons to obtain access to illicit activities, including the supply of illicit drugs.
The websites are anonymous and there is no contact information with regard to the address or location of the owners of the website nor with regard to the suppliers of illicit drugs.
ii. The constituent parts of the drugs, including the strength and content of the drugs, are unknown and may contain contaminants and further illicit substances creating an additional risk.
iii. There is no regulation of the supply of drugs by use of the Internet and there is no protection in place in relation to the delivery or importation of drugs using the Internet and delivery to a United Kingdom postal address by use of the Postal System.
iv. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit drugs, including Class A drugs, by use of the Internet.
v. On the 30th March 2015 I reported a similar concern to you relating to the death of Jason Houghton, who died on the 30th June 2014 from the combined toxic effects of illicit drugs obtained by use of the Internet.
2. I request that you consider the above concerns particularly in regard to the following:-
i. The supply and importation of drugs, including Class A drugs, in the manner and in the form described in this report, by use of the Internet.
ii. The regulation of the Internet, which may be difficult if not impossible, in relation to the supply of drugs and delivery of drugs to addresses in the United Kingdom by use of the Postal 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 Unknown and potentially contaminated composition of Internet-supplied drugs
Wider context from the report “1. During the Inquest evidence was heard that:
i. Torin had received supplies of drugs, prior to November 2014, by use of the Internet using the “Dark Internet” or “Dark Web”.
The Inquest heard that access to the “Dark Internet” or “Dark Web” would be difficult without having knowledge or expertise in relation to Internet access but young persons, particular intelligent University students, would find access to the websites to be relatively easy and it would not be difficult for such persons to obtain access to illicit activities, including the supply of illicit drugs.
The websites are anonymous and there is no contact information with regard to the address or location of the owners of the website nor with regard to the suppliers of illicit drugs.
ii. The constituent parts of the drugs, including the strength and content of the drugs, are unknown and may contain contaminants and further illicit substances creating an additional risk .
iii. There is no regulation of the supply of drugs by use of the Internet and there is no protection in place in relation to the delivery or importation of drugs using the Internet and delivery to a United Kingdom postal address by use of the Postal System.
iv. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit drugs, including Class A drugs, by use of the Internet.
v. On the 30th March 2015 I reported a similar concern to you relating to the death of Jason Houghton, who died on the 30th June 2014 from the combined toxic effects of illicit drugs obtained by use of the Internet.
2. I request that you consider the above concerns particularly in regard to the following:-
i. The supply and importation of drugs, including Class A drugs, in the manner and in the form described in this report, by use of the Internet.
ii. The regulation of the Internet, which may be difficult if not impossible, in relation to the supply of drugs and delivery of drugs to addresses in the United Kingdom by use of the Postal 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 Ease of access to illicit drug supply through Internet websites
Wider context from the report “1. During the Inquest evidence was heard that:
i. Torin had received supplies of drugs, prior to November 2014, by use of the Internet using the “Dark Internet” or “Dark Web”.
The Inquest heard that access to the “Dark Internet” or “Dark Web” would be difficult without having knowledge or expertise in relation to Internet access but young persons, particular intelligent University students, would find access to the websites to be relatively easy and it would not be difficult for such persons to obtain access to illicit activities, including the supply of illicit drugs .
The websites are anonymous and there is no contact information with regard to the address or location of the owners of the website nor with regard to the suppliers of illicit drugs.
ii. The constituent parts of the drugs, including the strength and content of the drugs, are unknown and may contain contaminants and further illicit substances creating an additional risk.
iii. There is no regulation of the supply of drugs by use of the Internet and there is no protection in place in relation to the delivery or importation of drugs using the Internet and delivery to a United Kingdom postal address by use of the Postal System.
iv. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit drugs, including Class A drugs, by use of the Internet.
v. On the 30th March 2015 I reported a similar concern to you relating to the death of Jason Houghton, who died on the 30th June 2014 from the combined toxic effects of illicit drugs obtained by use of the Internet.
2. I request that you consider the above concerns particularly in regard to the following:-
i. The supply and importation of drugs, including Class A drugs, in the manner and in the form described in this report, by use of the Internet.
ii. The regulation of the Internet, which may be difficult if not impossible, in relation to the supply of drugs and delivery of drugs to addresses in the United Kingdom by use of the Postal 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 Lack of traceability of Internet-based illicit drug suppliers
Wider context from the report “1. During the Inquest evidence was heard that:
i. Torin had received supplies of drugs, prior to November 2014, by use of the Internet using the “Dark Internet” or “Dark Web”.
The Inquest heard that access to the “Dark Internet” or “Dark Web” would be difficult without having knowledge or expertise in relation to Internet access but young persons, particular intelligent University students, would find access to the websites to be relatively easy and it would not be difficult for such persons to obtain access to illicit activities, including the supply of illicit drugs.
The websites are anonymous and there is no contact information with regard to the address or location of the owners of the website nor with regard to the suppliers of illicit drugs .
ii. The constituent parts of the drugs, including the strength and content of the drugs, are unknown and may contain contaminants and further illicit substances creating an additional risk.
iii. There is no regulation of the supply of drugs by use of the Internet and there is no protection in place in relation to the delivery or importation of drugs using the Internet and delivery to a United Kingdom postal address by use of the Postal System.
iv. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit drugs, including Class A drugs, by use of the Internet.
v. On the 30th March 2015 I reported a similar concern to you relating to the death of Jason Houghton, who died on the 30th June 2014 from the combined toxic effects of illicit drugs obtained by use of the Internet.
2. I request that you consider the above concerns particularly in regard to the following:-
i. The supply and importation of drugs, including Class A drugs, in the manner and in the form described in this report, by use of the Internet.
ii. The regulation of the Internet, which may be difficult if not impossible, in relation to the supply of drugs and delivery of drugs to addresses in the United Kingdom by use of the Postal System.
” 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 Continue operations targeting online marketplaces trading controlled drugs and other illegal commodities.
Verbatim wording from the response “Simultaneously, partners from the European Cybercrime Centre, acting on intelligence developed by US counterparts, took out technical infrastructure which was key to the hosting of illegal market places on the dark web, in total over 400 hidden services taken down. The action was part of continuing operations to target the use of online market places to trade in illegal commodities such as class A drugs, firearms and false documents.” Source location 2015-0191-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 enhancing border security and coordinating enforcement against serious, organised and complex crime.
Verbatim wording from the response “In addition, as I stated in my previous letter to you, Border Force officers are on constant alert to keep controlled drugs from entering the country. The associated enforcement response includes intelligence-led examination of packages and letters sent by post to intercept the importation of controlled substances. Working together with law enforcement partners, this activity is co-ordinated by the NCA who are continuing to enhance the security of our borders and lead the fight against serious, organised and complex crime.” Source location 2015-0191-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 Remove technical infrastructure hosting illegal dark-web marketplaces.
Verbatim wording from the response “Simultaneously, partners from the European Cybercrime Centre, acting on intelligence developed by US counterparts, took out technical infrastructure which was key to the hosting of illegal market places on the dark web, in total over 400 hidden services taken down. The action was part of continuing operations to target the use of online market places to trade in illegal commodities such as class A drugs, firearms and false documents.” Source location 2015-0191-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 Monitor online controlled-drug offers and act with industry partners to close websites trading illegally.
Verbatim wording from the response “The National Crime Agency (NCA) and the police routinely monitor controlled drugs being offered for sale on the internet and take action with industry partners to close websites trading illegally in these substances. Where it has been identified, or where there is reasonable suspicion to suggest, that controlled drugs are being sold on websites, law enforcement agencies have the relevant powers under the Misuse of Drugs Act 1971 to act against suppliers of controlled drugs, whether on controlled drug charges or on suspicion of wider drug-related offences.” Source location 2015-0191-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 Arrest suspected administrators and vendors involved in online drug marketplaces and illegal drug supply.
Verbatim wording from the response “In November 2014, the NCA, working with police forces across the UK, arrested six people in strikes coordinated with international partners. Those arrested included suspected administrators for the online market place Silk Road 2.0 and another online drug market place, as well as significant vendors of illegal drugs through the dark web.” Source location 2015-0191-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 Examine packages and letters through intelligence-led enforcement to intercept controlled-drug imports.
Verbatim wording from the response “In addition, as I stated in my previous letter to you, Border Force officers are on constant alert to keep controlled drugs from entering the country. The associated enforcement response includes intelligence-led examination of packages and letters sent by post to intercept the importation of controlled substances. Working together with law enforcement partners, this activity is co-ordinated by the NCA who are continuing to enhance the security of our borders and lead the fight against serious, organised and complex crime.” Source location 2015-0191-Response-by-Home-Office
Open published response
12 May 2015 Paul Mc Guigan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 16 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment View source Lack of recording of pre-conviction disclosures View source Lack of understanding of overseas armed close protection work View source Lack of guidance and transfer arrangements for MAPPA-triggering offenders View source Lack of computer categorisation for close protection occupations View source Lack of clear procedure and funding responsibility for independent forensic psychiatric reports View source Lack of training for officers and civilian employees on disclosure procedures View source Failure to understand and operate the Notifiable Occupation Scheme View source Failure to consider disclosure to employers View source Inadequate and infrequent formal supervision of newly qualified offender managers View source Lack of a national system and contact point for obtaining military information View source Failure to record discussions among key professionals View source Failure of agencies to check and share available information before multi-agency meetings View source Incomplete and unclear procedure for the Common Law Police Disclosure Scheme View source Misunderstanding of residence conditions for offender monitoring View source Lack of recording of offenders' bail conditions View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Mc Guigan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Unavailability of enhanced criminal-record disclosures for overseas armed private security employment
Wider context from the report “I also have a concern that an employer on a private security contract at home has regulated by the SIA and a private security employed overseas [unregulated save for voluntary schemes such as International Code of Conduct for Private Security Service Providers 2010 [ICoC] and accredited certification to the standard ANSI/ SSlS PSC. 1-2012] is not entitled or able to obtain an enhanced CRB and would only ever receive a Standard disclosure on a pre employment check.
It concerns me in particular that in respect of employing on individual on an armed contract then consideration should be given to enabling Private Security Companies a route to obtaining an enhanced disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of recording of pre-conviction disclosures
Wider context from the report “It is clear that within GMP there was no recording anywhere as to when / if any pre convictions disclosures were made . It is important that there is a system of recording in this scenario and also to whom the disclosure is made. At present no-one can provide any information as to the number of detail of pre-conviction disclosures. In addition this means that officers who may be dealing with someone who has been arrested have no way of knowing if such a pre-conviction disclosure has ever been made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of overseas armed close protection work
Wider context from the report “In addition I have a concern that there is a complete lack of understanding by the Police and Probation / NOMS as to what close protection work overseas involves and in particular when this involves work on armed contracts .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and transfer arrangements for MAPPA-triggering offenders
Wider context from the report “It concerns me to ensure that there is clear guidance given by NOMS to the private community rehabilitation companies [e.g. in Manchester Purple Futures] as to assessment of risk and for offenders who then do trigger MAPPA concerns that should be being supervised or assessed for eligibility under MAPPA to be transferred to be supervised by the National Probation Service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of computer categorisation for close protection occupations
Wider context from the report “In respect of the GMP computer system and in respect of occupations that are regulated and require licensing by the SIA, there is no categorisation on the computer for “CLOSE PROTECTION” . Indeed the Court heard that there was some confusion and lack of understanding from many people as to what this occupation actually meant. Close protection work is a separate category of employment within the UK that the SIA regulates and the police system should reflect the occupations subject to regulation. It is important that the police and NOMS have a clear understanding as to what close protection work is to inform risk and risk assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of clear procedure and funding responsibility for independent forensic psychiatric reports
Wider context from the report “It concerns me that there is not a clear practice and procedure operating within the Court or probation system, including funding responsibility, for obtaining an Independent Forensic Psychiatric Report , particularly in circumstances where a defendant is remanded on bail in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of training for officers and civilian employees on disclosure procedures
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees . The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and operate the Notifiable Occupation Scheme
Wider context from the report “In my judgment there was a complete misunderstanding by GMP in respect of the operation of the Notifiable Occupation Scheme HOC 6/2006 .
Of immense concern also the complete failure for a period of approximately 18 months to make any post conviction notifications under the Notifiable Occupation Scheme , which was it transpired, formally withdrawn by the Home Secretary Theresa May MP in March 2015.
I heard and received evidence from the SIA that they were not aware that a regulatory gap existed in respect of the Police’s understanding of the scheme and notifications to themselves . The evidence I heard suggests that such a gap exists at GMP and has done so for in excess of 18 months.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to consider disclosure to employers
Wider context from the report “In respect of the period of time when Post conviction disclosures were made [before this “back office” function ceased 18 months ago] these were only ever disclosures made to the Regulatory body and consideration never appears to have been given within GMP to disclosure to employers . Given the lack of understanding as to whom some regulatory bodies have responsibility for, this is important.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inadequate and infrequent formal supervision of newly qualified offender managers
Wider context from the report “I heard evidence that the Offender Manager was newly qualified and her formal supervision was inadequate and infrequent . This concerns me. It is important that newly qualified offender managers receive appropriate formal supervision .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a national system and contact point for obtaining military information
Wider context from the report “My concern is to ensure that there is a system, protocol and point of contact for every offender manager nationally [including the private rehabilitation companies now operating as offender managers] that is well known as to who to contact to within the Ministry of Defence to obtain military information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussions among key professionals
Wider context from the report “In addition I heard evidence and it concerns me that in advance of the Multi Agency meeting convened due to concerns as to the Offenders risk, key professionals had had discussions, telephone calls and meetings and I was concerned by the failure to record and document these important discussions , to ensure clarity, understanding and consistency. It is important when key professionals have discussions that these are documented and recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to check and share available information before multi-agency meetings
Wider context from the report “It is important irrespective of who is the lead agency at a Multi Agency Meeting that each agency invited to attend checks information held on systems and records to which they have access and provides all this information to a multi agency meeting to ensure that a full and informed assessment of risk takes place and the fullest possible informed information sharing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Incomplete and unclear procedure for the Common Law Police Disclosure Scheme
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees. The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding of residence conditions for offender monitoring
Wider context from the report “I also heard evidence that a GMP officer believed that Bail with a condition of residence was different to “bail live and sleep each night”. It is of concern that there is a misunderstanding within GMP as to what a condition of residence means and how this relates to the monitoring of offenders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of recording of offenders' bail conditions
Wider context from the report “I heard evidence that in respect of GMP systems and processes there was nowhere on the GMP computer system where bail conditions are recorded , although this used to be possible. It is of concern that there is no system of recording on the GMP computer of offenders bail conditions so that this information can be known by officers and appropriately shared.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete an extensive review of the Notifiable Occupations Scheme, including consultation and legal advice on disclosure changes.
Verbatim wording from the response “As you will know the events concerned took place in 2009. At that time the NOS was the mechanism through which information on the conviction of an individual working in a sensitive area could be disclosed by the police. The Secretary recognised that disclosure of conviction and only exceptionally an arrest could present a public protection risk and asked for a review. The review involved extensive consultation and was informed by legal advice focused on ensuring that any changes took proper account of proportionality and human rights considerations in reaching decisions on disclosure. In March 2015, the Home Secretary decided to withdraw the NOS in favour of a new police-led scheme which provides greater consistency across forces in the disclosure of information.” Source location 2015-0185-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 Withdraw the Notifiable Occupations Scheme in favour of the Common Law Police Disclosure scheme.
Verbatim wording from the response “As you will know the events concerned took place in 2009. At that time the NOS was the mechanism through which information on the conviction of an individual working in a sensitive area could be disclosed by the police. The Secretary recognised that disclosure of conviction and only exceptionally an arrest could present a public protection risk and asked for a review. The review involved extensive consultation and was informed by legal advice focused on ensuring that any changes took proper account of proportionality and human rights considerations in reaching decisions on disclosure. In March 2015, the Home Secretary decided to withdraw the NOS in favour of a new police-led scheme which provides greater consistency across forces in the disclosure of information.” Source location 2015-0185-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 Greater Manchester Police is responsible for responding specifically about its handling of the individual’s bail conditions.
Verbatim wording from the response “Finally, you raise a concern in relation to the recording and sharing of the bail conditions imposed on Daniel Fitzwilliam in May 2009. Greater Manchester Police will need to respond specifically in relation to their handling of this. More generally, all bail conditions are recorded by the court. Where necessary, agencies are informed immediately of the nature of such conditions. The conditions and their practical effect should be made clear to the defendant.” Source location 2015-0185-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 Employment of security and close protection personnel outside the United Kingdom falls outside the Home Office’s and SIA’s jurisdiction.
Verbatim wording from the response “You may be aware that the employment of security or close protection personnel for posts outside the United Kingdom is governed by an International Code of Conduct for Private Security Providers (which the UK joined as a founding member) setting out obligations for the providers, particularly with regard to international humanitarian law and human rights law. However, neither the SIA nor the Home Office has jurisdiction over the employment of security or close protection personnel for posts outside the United Kingdom.” Source location 2015-0185-Response-by-Home-Office
Open published response
Concerns raised 2 Dangerous and potentially life-threatening effects of consuming synthetic cannabinoids View source Readily available synthetic cannabinoids legally and commonly sold as herbal incense View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Anthony Peter Kristian Garrett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Peter Kristian Garrett collapsed after smoking Cherry Bomb, a substance marketed as herbal incense, after drinking alcohol throughout the day. He was transported to hospital, never regained consciousness, and died the following day. The report raised concerns that synthetic cannabinoids are readily available, commonly sold as herbal incense, and can be dangerous and potentially life-threatening when misused.
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 Dangerous and potentially life-threatening effects of consuming synthetic cannabinoids
Wider context from the report “2. I have concerns that Synthetic Cannabinoids are readily available substances in the community, which are legally and commonly sold as herbal incense. They are sold with a warning that they are not for human consumption, but are misused and consumed by people. Consequently they can be dangerous and potentially life threatening to those who use them in this way .
” Open source report × Source evidence
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 Readily available synthetic cannabinoids legally and commonly sold as herbal incense
Wider context from the report “2. I have concerns that Synthetic Cannabinoids are readily available substances in the community, which are legally and commonly sold as herbal incense . They are sold with a warning that they are not for human consumption, but are misused and consumed by people . Consequently they can be dangerous and potentially life threatening to those who use them in this way.
” Open source report
16 Apr 2015 Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 28 Failure of the youth diversion project to provide diversion before criminal justice processing View source Failure to record and explain incomplete medical assessments View source Failure to return completed Appropriate Adult forms to Social Services View source Interagency confusion about safeguarding roles and access to information View source Failure to initiate youth offending and mental health monitoring after case transfer View source Failure to pass complete incident information to attending officers View source Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs View source Insufficient availability of accommodation for children under 17 View source Insufficient recording of safeguarding information by Appropriate Adults View source Failure of youth offending teams to transfer and oversee cases after relocation View source Failure to assess police information when selecting an Appropriate Adult View source Lack of legally required accommodation for 17-year-olds refused bail View source Failure to make safeguarding referrals from custody medical information View source Failure to record safeguarding intelligence on nominal profiles View source Failure to conduct police database checks on standard-risk DASH referrals View source Failure to route domestic violence cases involving 17-year-old children to child protection review View source Lack of shared understanding between police and MEDACS about requested medical assessments View source Lack of interagency understanding for sharing safeguarding information between police and CPS View source Failure to provide Appropriate Adults with relevant custody risk information View source Failure to provide differentiated mental health assessments for children in custody View source Failure to document information provided to MEDACS before medical assessments View source Failure to check and update Prisoner Escort Records before release View source Custody handovers dependent on officers’ and staff’s unpaid free time View source Lack of consistent child safeguarding coverage across Manchester local authorities View source Lack of clear officer guidance for raising safeguarding concerns View source Unclear referral routes for non-criminal safeguarding concerns View source Lack of a process for recording safeguarding concerns View source Lack of a non-criminal safeguarding policy View source See 25 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of the youth diversion project to provide diversion before criminal justice processing
Wider context from the report “The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway . There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to record and explain incomplete medical assessments
Wider context from the report “It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to return completed Appropriate Adult forms to Social Services
Wider context from the report “Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Interagency confusion about safeguarding roles and access to information
Wider context from the report “Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles , what they are able and not able to do and also where to access important and effective information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate youth offending and mental health monitoring after case transfer
Wider context from the report “This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside . The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to pass complete incident information to attending officers
Wider context from the report “The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife . The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
Wider context from the report “This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of accommodation for children under 17
Wider context from the report “The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available . Attempts are being made to address this issue but at present the figure remains approximately 20% and the Inquest heard evidence that this was, “not good enough”.
Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities . The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe to do so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient recording of safeguarding information by Appropriate Adults
Wider context from the report “The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of youth offending teams to transfer and oversee cases after relocation
Wider context from the report “There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to assess police information when selecting an Appropriate Adult
Wider context from the report “It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of legally required accommodation for 17-year-olds refused bail
Wider context from the report “There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to make safeguarding referrals from custody medical information
Wider context from the report “Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to record safeguarding intelligence on nominal profiles
Wider context from the report “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers . It is a core function of the police to submit such intelligence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct police database checks on standard-risk DASH referrals
Wider context from the report “when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out . The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report “For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between police and MEDACS about requested medical assessments
Wider context from the report “It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of interagency understanding for sharing safeguarding information between police and CPS
Wider context from the report “There was a lack of understanding between GMP and the CPS as to how such important information should be shared between agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Appropriate Adults with relevant custody risk information
Wider context from the report “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS , nor that she had threatened to jump off a bridge on her release.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide differentiated mental health assessments for children in custody
Wider context from the report “The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to document information provided to MEDACS before medical assessments
Wider context from the report “there was no clarity as to whether this included previous risk assessments , whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to check and update Prisoner Escort Records before release
Wider context from the report “The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Custody handovers dependent on officers’ and staff’s unpaid free time
Wider context from the report “The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent child safeguarding coverage across Manchester local authorities
Wider context from the report “This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of clear officer guidance for raising safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Unclear referral routes for non-criminal safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for recording safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns . There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of a non-criminal safeguarding policy
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal . There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend PACE to require 17-year-olds detained after charge to be treated as children and transferred to local authority accommodation.
Verbatim wording from the response “Your report sets out that PACE legislation should be amended so that 17 year olds are always treated as children. Following a review of the provisions concerning the treatment of 17 year olds under the Police and Criminal Evidence Act 1984, the Government has committed to changing the law to ensure that 17 year olds are treated in the same way as 10 to 16 year olds as soon as a legislative opportunity arises. In November 2014 we were able to work closely with the Ministry of Justice to use the Third Reading of the Criminal Justice and Courts Bill to make a partial change to the current provisions in PACE, specifically in respect to Part IV of PACE (including Section 38(6)), relating to police detention.” Source location 2015-0143-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 Plan amendments to the remaining PACE provisions that treat 17-year-olds as adults.
Verbatim wording from the response “Your report sets out that PACE legislation should be amended so that 17 year olds are always treated as children. Following a review of the provisions concerning the treatment of 17 year olds under the Police and Criminal Evidence Act 1984, the Government has committed to changing the law to ensure that 17 year olds are treated in the same way as 10 to 16 year olds as soon as a legislative opportunity arises. In November 2014 we were able to work closely with the Ministry of Justice to use the Third Reading of the Criminal Justice and Courts Bill to make a partial change to the current provisions in PACE, specifically in respect to Part IV of PACE (including Section 38(6)), relating to police detention.” Source location 2015-0143-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 Remind English local authorities of their duty to provide accommodation for children denied bail under PACE section 38(6).
Verbatim wording from the response “Your report sets out that the provision of local authority accommodation is insufficient. As part of the work to extend Section 38(6) of PACE my officials became aware of issues concerning the operation of this provision. This is deeply concerning and in January the Secretary of State for Education and I wrote to local authorities in England reminding them of their absolute duty of care under Section 21(2)(b) of the Children Act 1989 to provide accommodation for children denied bail under Section 38(6) of PACE.” Source location 2015-0143-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 Establish a multi-agency working group to understand section 38(6) accommodation issues and develop solutions.
Verbatim wording from the response “In March, the National Policing Lead for Custody wrote to all forces reminding them of their responsibilities to ensure that as few children as possible are spending time detained in police custody. I have commissioned the establishment of a multi-agency working group to better understand the issues and develop solutions. No child should be spending time in custody unnecessarily.” Source location 2015-0143-Response-by-Home-Office
Open published response
30 Mar 2015 Jason Houghton · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Lack of protection against internet-enabled international drug importation through the United Kingdom postal system View source Lack of regulation of internet-based drug supply View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jason Houghton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jason Houghton died on 30 June 2014 in a hotel room with a cannula connected to a homemade drip, alongside syringes, Valium vials and other drug-related items. The inquest recorded that his death involved the combined toxic effects of ketamine, heroin, diazepam and dextromethorphan and concluded misadventure. Concerns were raised about the unregulated internet supply and international importation of illicit drugs, including heroin in the form of diacetyl morphine.
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 protection against internet-enabled international drug importation through the United Kingdom postal system
Wider context from the report “iii. There is no regulation of the supply of drugs by use of the internet and there is no protection in place in relation to the importation of drugs using the internet with delivery from an international source to a United Kingdom postal address by use of the postal system .
iv. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit Class A Drugs, being Heroin, in the form of Diacetyl Morphine, by use of the internet.
2. I request for you to consider the above concerns particularly in regard to the following:-
i. The supply and importation of Class A Drugs, in the manner and form described in this report, by use of the internet.
ii. The regulation of the internet, if possible, in relation to the supply of drugs and the delivery of the drugs using International Shipping and the United Kingdom postal 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 Lack of regulation of internet-based drug supply
Wider context from the report “iii. There is no regulation of the supply of drugs by use of the internet and there is no protection in place in relation to the importation of drugs using the internet with delivery from an international source to a United Kingdom postal address by use of the postal system.
iv. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit Class A Drugs, being Heroin, in the form of Diacetyl Morphine, by use of the internet.
2. I request for you to consider the above concerns particularly in regard to the following:-
i. The supply and importation of Class A Drugs, in the manner and form described in this report, by use of the internet.
ii. The regulation of the internet, if possible, in relation to the supply of drugs and the delivery of the drugs using International Shipping and the United Kingdom postal system.
” 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 Work with EU and international regulatory agencies to bring offending websites into legal compliance where possible.
Verbatim wording from the response “As in this case, considerable illegal activity takes place on the internet outside of UK jurisdiction. The UK continues to work with international partners to develop an effective response to the supply of controlled drugs and to react swiftly to emerging threats. In order to tackle illegally trading websites identified overseas, we are building strong partnerships with international partners. There is also ongoing work with the EU and other international regulatory agencies to ensure that, wherever possible, offending websites are amended to comply with the law.” Source location 2015-0127-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 enhancing border security to combat serious, organised and complex crime involving controlled-drug imports.
Verbatim wording from the response “In addition, Border Force officers are on constant alert to keep controlled drugs from entering the country. The associated enforcement response includes intelligence-led examination of packages and letters sent by post to intercept the importation of controlled substances. Working together with law enforcement partners, this activity is co-ordinated by the NCA who are continuing to enhance the security of our borders and lead the fight against serious, organised and complex crime.” Source location 2015-0127-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 Examine the Medipk website, liaise with its internet service provider, and secure its closure for unlawful medicine sales.
Verbatim wording from the response “I can confirm that, since Mr Houghton’s death, the MHRA has examined the website www.medipk.com and found that other prescription-only medicines were being offered without a required prescription and liaised with the internet service provider to close it down.” Source location 2015-0127-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 international partners to develop responses to overseas controlled-drug supply and emerging threats.
Verbatim wording from the response “As in this case, considerable illegal activity takes place on the internet outside of UK jurisdiction. The UK continues to work with international partners to develop an effective response to the supply of controlled drugs and to react swiftly to emerging threats. In order to tackle illegally trading websites identified overseas, we are building strong partnerships with international partners. There is also ongoing work with the EU and other international regulatory agencies to ensure that, wherever possible, offending websites are amended to comply with the law.” Source location 2015-0127-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 working with internet providers to ensure compliance with drug-control law.
Verbatim wording from the response “Law enforcement agencies and I take the issue of unlawful advertising and sales of drugs on the internet very seriously, and we continue to work with internet providers to ensure that they comply with the law. This can include” Source location 2015-0127-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 Build partnerships with international counterparts to address illegally trading websites identified overseas.
Verbatim wording from the response “As in this case, considerable illegal activity takes place on the internet outside of UK jurisdiction. The UK continues to work with international partners to develop an effective response to the supply of controlled drugs and to react swiftly to emerging threats. In order to tackle illegally trading websites identified overseas, we are building strong partnerships with international partners. There is also ongoing work with the EU and other international regulatory agencies to ensure that, wherever possible, offending websites are amended to comply with the law.” Source location 2015-0127-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 monitoring, enforcement powers, website closures and international partnerships are considered sufficient to address illegal online drug sales.
Verbatim wording from the response “The National Crime Agency (NCA), the police and the Medicines and Healthcare products Regulatory Agency (MHRA) routinely monitor controlled drugs and medicines being offered for sale on the internet and take action with industry partners to close websites trading illegally in these substances. Where it has been identified, or where there is reasonable suspicion to suggest, that controlled drugs or medicines containing controlled drugs are being sold on websites, law enforcement agencies have the relevant powers under the Misuse of Drugs Act 1971 to act against suppliers of controlled drugs, whether on controlled drug charges or on suspicion of wider drug-related offences.” Source location 2015-0127-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 Intelligence-led postal examinations and coordinated border enforcement are considered sufficient to address the importation of controlled drugs.
Verbatim wording from the response “In addition, Border Force officers are on constant alert to keep controlled drugs from entering the country. The associated enforcement response includes intelligence-led examination of packages and letters sent by post to intercept the importation of controlled substances. Working together with law enforcement partners, this activity is co-ordinated by the NCA who are continuing to enhance the security of our borders and lead the fight against serious, organised and complex crime.” Source location 2015-0127-Response-by-Home-Office
Open published response
25 Mar 2015 Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3 Lack of a requirement for GPs and Mental Health Trusts to notify police of mental health concerns about firearms licence holders View source Failure to refer firearms licence holders with deteriorating mental health to the police View source Failure to record and flag firearms licence information in medical records and systems 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
Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Harold Ambrose shot his wife, Mrs Wendy Ambrose, and then himself; police found both bodies. Mr Ambrose had a shotgun licence and developed worsening mixed dementia, but neither his GP nor the mental health trust referred the matter to the police firearms department. The report identified that there was no requirement for them to notify police about mental health concerns when aware that a patient held a firearms licence.
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 requirement for GPs and Mental Health Trusts to notify police of mental health concerns about firearms licence holders
Wider context from the report “Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18th November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system.
In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012.
In May 2013 he was prescribed Alzheimer’s medication and was advised not to drive due to his cognitive impairment. In January 2014 it was clear that there had been a decline in his mental abilities and this decline continued.
Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department. In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about patients mental health when they are aware that they have a firearms licence.
” Open source report × Source evidence
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 refer firearms licence holders with deteriorating mental health to the police
Wider context from the report “Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18th November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system.
In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012.
In May 2013 he was prescribed Alzheimer’s medication and was advised not to drive due to his cognitive impairment. In January 2014 it was clear that there had been a decline in his mental abilities and this decline continued.
Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department . In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about patients mental health when they are aware that they have a firearms licence.
” Open source report × Source evidence
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 and flag firearms licence information in medical records and systems
Wider context from the report “Mr Ambrose had held a shotgun licence since November 1987. This was renewed every 5 years at which time there was a full review. The last review was in 2011. On 18th November 2011 a letter from Essex Police Firearms Department was sent to his GPs surgery notifying them that he was a shotgun holder. No further details from this letter were entered onto his medical record and the fact that he was a firearms holder was not flagged on their system .
In 2011 Mr Ambrose did not have any mental health problems. In September 2012 he was diagnosed with mixed dementia and this gradually worsened. He was receiving some input from the North Essex Partnership University NHS Foundation Trust (NEPT) following a referral from the GP in October 2012. Mr Ambrose made NEPT aware that he had a shotgun license in his initial assessment in November 2012.
In May 2013 he was prescribed Alzheimer’s medication and was advised not to drive due to his cognitive impairment. In January 2014 it was clear that there had been a decline in his mental abilities and this decline continued.
Although his mental health was clearly deteriorating neither the GP or NEPT referred this case to Essex Police Firearms Department. In evidence a representative of Essex Police said had they been made aware of his Mental Health problems they would have initiated a review of Mr Ambrose’s fitness to hold a shotgun licence. There is no requirement that GPs or Mental Health Trusts notify the police of concerns about patients mental health when they are aware that they have a firearms licence.
” Open source report
19 Mar 2015 Mrs Anne Elizabeth Fowler · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Installation of alarms in locations inaccessible to elderly or immobile occupiers View source Failure to remove protective covers from alarms before occupier possession 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
Mrs Anne Elizabeth Fowler · 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
Mrs Anne Elizabeth Fowler died in a house fire. A dust cover had been left over the smoke alarm nearest the fire and the deceased, preventing it from sounding as early as it otherwise would have; the report also raised concern that alarms may be inaccessible to elderly or immobile occupiers and that protective covers should be removed before properties are occupied.
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 Installation of alarms in locations inaccessible to elderly or immobile occupiers
Wider context from the report “The cover was in place. The alarm was as is usual, installed on the ceiling where it would be inaccessible to many elderly or other immobile occupiers.
It was stated that the cover was left in place to protect the alarm from the ingress of dust etc following fitting.
Therefore, you may consider that legislation should be enacted to require builders, landlords and others to remove such covers, cleaning around the alarm where necessary, prior to allowing the occupier to take possession.
” Open source report × Source evidence
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 remove protective covers from alarms before occupier possession
Wider context from the report “The cover was in place. The alarm was as is usual, installed on the ceiling where it would be inaccessible to many elderly or other immobile occupiers.
It was stated that the cover was left in place to protect the alarm from the ingress of dust etc following fitting.
Therefore, you may consider that legislation should be enacted to require builders, landlords and others to remove such covers, cleaning around the alarm where necessary, prior to allowing the occupier to take possession.
” Open source report
23 Oct 2014 Maria Christina Stubbings · Prevention of Future Deaths report Essex
View report summary
Concerns raised 5 Absence of a mechanism notifying local police when a person with a foreign murder conviction resides in their area View source Failure to ensure police awareness and protective conditions when individuals with foreign murder convictions enter the UK View source Exclusion of foreign murder convictions from the Notification Order framework View source Ineligibility of individuals with foreign murder convictions for a Violent Offender Order where the specified-offence risk threshold is not met View source Failure of the Central Authority to identify UK nationals serving sentences for serious crimes in EU prisons under the non-retrospective notification system 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
Maria Christina Stubbings · 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
Maria Christina Stubbings was murdered in December 2008 by a man who had previously served a life sentence in Germany for murder and had been arrested for assaulting her. The principal concerns relate to gaps in the identification, notification, monitoring and control of people with serious foreign convictions entering or residing in the UK.
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 mechanism notifying local police when a person with a foreign murder conviction resides in their area
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area .
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” Open source report × Source evidence
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 awareness and protective conditions when individuals with foreign murder convictions enter the UK
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence , until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” Open source report × Source evidence
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 Exclusion of foreign murder convictions from the Notification Order framework
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder . With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply .
” Open source report × Source evidence
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 Ineligibility of individuals with foreign murder convictions for a Violent Offender Order where the specified-offence risk threshold is not met
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of. Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” Open source report × Source evidence
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 Central Authority to identify UK nationals serving sentences for serious crimes in EU prisons under the non-retrospective notification system
Wider context from the report “Notwithstanding the changes that have occurred (i) enabling a Violent Offender Order to be made in relation to someone who has a conviction for murder (including murder abroad) in May 2014 and (ii) the EU Directive which requires EU member states to notify the UK of foreign convictions of UK Nationals, at the time of conviction (as opposed to later than this which occurred in the ████████ case) and (iii) the electronic system now in place at the Central Authority – it seems that there are further opportunities that might be considered which would reduce the likelihood of another individual (with a murder conviction like ████████) entering the UK without conditions and without any police force being made aware of that person’s existence, until arrested for different offence.
I ask the Home Office/MoJ to give consideration to further steps that could be taken to address the issues, including those detailed below. In making the suggestion below it is recognised that the issues are complex.
(i) The Central Authority needs to be notified now of all EU nationals currently serving a sentence for serious crimes such as murder in those countries. We understand the new notification system which obliges an EU state to notify at the time of conviction, is not retrospective. Accordingly, there are likely to be a pool of older prisoners who are UK nationals, serving sentences in EU prisons, which the Central Authority is not yet aware of . Further consideration could be given to making a request of each country in order to identify who these individuals are and the offences for which they have been convicted;
(ii) Consideration could be given to some form of “warning marker” which could be placed on an individual’s passport which would alert the authorities to the entry of a UK national convicted of murder, back into the UK. Furthermore, it might be possible for the Immigration Rules to be amended to enable a passport officer to request details from that individual as to the address they are going to stay at in UK; details of any car to be used by them; details of relatives; people they intend to stay with etc. The police are aware from the evidence disclosed in the Inquest (notably pre-sentence reports on ████████ that he was told by the German authorities upon his deportation that he would be met by Security Officers in the UK, who would ensure that he was given advice and keep an eye on him. It appears that this did not happen and he was free to enter the UK at Heathrow airport of 24th January, 2008 and met his father who was waiting for him;
(iii) Consideration needs to be given to putting in place a mechanism which notifies local police that someone with a conviction like the murder conviction ████████ has come to reside in their area.
(iv) There could be an amendment to allow for a Notification Orders to be applied for. The principle response of the Home Office/MoJ was to amend the law to allow for the police to apply for the Violent Offender Order (VOO) However, as you are aware such orders will only be granted if there is a risk that the individual is likely to commit one of more of the specified offences in Section 98(3) of the Criminal Justice and Immigration Act 2008. Those offences are 6 types of serious violent offences from Section 20 OAPA 1861 upwards to manslaughter.
It is doubtful that a VOO would have been granted in the case of ████████ following the incident in July 2008, as he had only been convicted of the offence of common assault and the circumstances of the sexual offence left on file would not be relevant.
(v) It may be possible for an amendment to be made to Schedule 3 of the Sexual Offences Act 2003 to include a foreign conviction for murder. With the benefit of hindsight this would allow the police to have applied for a Notification Order against ████████ as soon as they were aware of his existence. This would require him to comply with the notification requirements under section 83(5) of that Act requiring him to state his date of birth; national insurance number; home address and specify any address at which he stays on a periodic basis. It would be a useful mechanism to monitor an individual’s movements when no licence conditions would apply.
” Open source report
Concerns raised 2 Delays in proscription of MDAI as an illegal drug View source Fatal risk from MDAI use, particularly for people with cardiac problems 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
Matthew Alexander Flatman · 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
Matthew Alexander Flatman died at Queen Alexandra Hospital, Portsmouth, on 5 July 2013 after experiencing chest, jaw and arm pain, followed by a cardiac arrest. The inquest recorded that he had taken MDAI, a so-called legal high, the previous evening, and concluded that its consumption precipitated a myocardial infarction and subsequent cardiac arrest in the context of severe coronary artery disease. The report raised concerns about the fatal risk posed by MDAI and the slow process of proscribing it as an illegal drug.
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 proscription of MDAI as an illegal drug
Wider context from the report “(1) The "legal high" taken by Matthew Flatman was a substance known as Gogaine or MDAI. This substance is in the process of being proscribed as an illegal drug but the process is so very slow.
(2) MDAI presents a fatal risk to all its users but particularly to those with cardiac problems and its proscription should be accelerated.
” Open source report × Source evidence
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 Fatal risk from MDAI use, particularly for people with cardiac problems
Wider context from the report “(1) The "legal high" taken by Matthew Flatman was a substance known as Gogaine or MDAI. This substance is in the process of being proscribed as an illegal drug but the process is so very slow.
(2) MDAI presents a fatal risk to all its users but particularly to those with cardiac problems and its proscription should be accelerated.
” 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