18 Sep 2014 Brian Christopher Dalrymple · Prevention of Future Deaths report West London
View report summary
Concerns raised 6 Absence of a comprehensive and accessible computerised clinical record for each detainee View source Employment of medical practitioners without knowledge necessary to their role View source Inadequate routine medical assessment of segregated detainees View source Lack of detention staff awareness and recognition of mental-health indicators View source Failure to actively communicate relevant observations to healthcare staff View source Failure to bring potential mental-health indicators to responsible healthcare staff 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
Brian Christopher Dalrymple · 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
Brian Christopher Dalrymple died at Colnbrook Immigration Removal Centre on 31 July 2011 after a fatal rupture associated with extreme hypertension, which he declined to have treated and monitored for most of his detention. The report raised concerns that indicators of his deteriorating mental health were not recognised or communicated to healthcare staff, that medical practitioners lacked necessary knowledge, that medical visits to segregated detainees were inadequate, and that clinical records were not comprehensive or accessible.
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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 Absence of a comprehensive and accessible computerised clinical record for each detainee
Wider context from the report “(5)
The absence of a comprehensive and accessible (computerised) clinical record relating to each detainee at IRCs Harmondsworth and Colnbrook.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Employment of medical practitioners without knowledge necessary to their role
Wider context from the report “(3)
Medical practitioners may be employed at Harmondsworth IRC without knowledge necessary to that role.
The locum GP who gave evidence at the inquest was unaware of Detention Centre Rules 2001 or of the duties imposed on him- rule 35, for example. He was also unaware that healthcare staff had access to wing history documents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 routine medical assessment of segregated detainees
Wider context from the report “(4)
Routine medical visits to segregated detainees are inadequate properly to assess detainees' healthcare needs.
The evidence was that each detainee would be asked through the wicket “Any medical problems?”, and if the answer was negative, there would be no further interaction- witness ████████ described the practice as “not fit for purpose” ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 detention staff awareness and recognition of mental-health indicators
Wider context from the report “(1)
There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia ; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare.
Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth.
The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth.
It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 actively communicate relevant observations to healthcare staff
Wider context from the report “(2)
Relevant and significant observations recorded by detention centre staff and others are not actively brought to the attention of relevant healthcare staff.
In the present case, custody officers' entries in wing history records were sufficient (alone or in combination) to alert a reader to the possibility of mental health issues affecting Mr Dalrymple whilst detained at Harmondsworth IRC; these indicators were missed. In the terms of Witness ████████ the overall picture of developing (relapsing) mental disorder was not available to any one set of people.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to bring potential mental-health indicators to responsible healthcare staff
Wider context from the report “(1)
There is a lack of awareness amongst detention staff at Harmondsworth of: (i) behaviours (and reported experiences) which may indicate the existence of mental health issues affecting particular detainees- particularly in relation to schizophrenia; and (ii) the need to ensure that such potential indicators are brought to the attention of those responsible for the particular detainee's healthcare.
Despite the training which had been received by such staff prior to Mr Dalrymple's detention, indications of his mental ill-health were not recognised as such. Witness ████████ identified events and circumstances from the point of Mr Dalrymple's presentation at port and throughout his period of detention that he said “should have been picked up” and triggered a psychiatric assessment (for which there was an “overwhelming need”). In Mr Dalrymple's case such concerns were not properly acknowledged at Harmondsworth.
The DCOs had not received sufficient training in the recognition of relevant indicators. The evidence was that officers were and remain unclear whether particular behaviours, unusual in local society at large, should be regarded as significant amongst the population at Harmondsworth.
It was clear from the evidence given by the Deputy Immigration Manager, and that of a clinical Contract Manager / Interim Healthcare Manager that significant reliance is placed on the detention officers to raise concerns over a detainee's mental heath.
” Open source report
9 Jul 2014 David Reginald Giles · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 5 Increasing suicides involving helium View source Failure to fit helium canisters with a control valve restricting gas release View source Sale of helium gas canisters containing a sizable volume of helium View source Unrestricted sale of helium gas canisters to the general public View source Immediate and accessible online guidance on suicide by helium inhalation 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.
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AI-generated summary
David Reginald Giles · 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
David Reginald Giles was discovered at home on 31 March 2014 with a plastic bag over his head connected to a helium gas canister, and paramedics confirmed his death that morning. The concerns included the unrestricted availability and standard size of helium canisters, the absence of modified control valves, and readily accessible online information about suicide by helium inhalation. The report also noted an increase in deaths mentioning helium in England between 2008 and 2012.
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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 Increasing suicides involving helium
Wider context from the report “(7) The latest statistical update on Suicide report issued in January 2014 by the Department for Health suggests that there were 51 deaths mentioning helium in 2012 in England , almost five times higher than the 11 deaths recorded in 2008 . Although the number of deaths involving these substances is still relatively small, the large increases are of particular interest as almost all of these deaths were suicides .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 fit helium canisters with a control valve restricting gas release
Wider context from the report “(3) Helium canisters are not fitted with any modified control valve which if in place could restrict the volume of gas being released and are generally sold in standard sizes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Sale of helium gas canisters containing a sizable volume of helium
Wider context from the report “(2) Helium gas canisters appear to be sold in a standard size which contains a sizable volume of Helium .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Unrestricted sale of helium gas canisters to the general public
Wider context from the report “(1) The sale of Helium gas canisters is readily available to members of the general public with no apparent restrictions or conditions on sale or place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Immediate and accessible online guidance on suicide by helium inhalation
Wider context from the report “(4) The type of immediate and easily accessible information through internet search engines which provides clear and detailed guidance on how to commit suicide by inhalation of helium gas .
” Open source report
2 Jul 2014 Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 11 Lack of required training or knowledge on restraint and asphyxia dangers View source Failure to audit accredited door-supervisor training on restraint and asphyxia View source Deaths related to or following restraint by door supervisors View source Failure to review restraint-related deaths for licensing and responsibility lessons View source Failure of existing bubble-car design to enable easy monitoring of rear-seat detainees View source Failure to integrate asphyxia training into restraint training View source Failure of new bubble-car design to enable officers to hear detainees’ breathing difficulties View source Repeated coronial concern about door-supervisor training on restraint and asphyxia View source Uncertainty about completion of physical intervention training by licensed door supervisors View source Lack of police training guidance on the significance of snoring during positional asphyxia View source Lack of a first-aid qualification requirement for door-supervisor licensing View source See 8 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
Mr Hywel Llewelyn Hughes · 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 Hywel Llewelyn Hughes was forcibly removed from a nightclub, restrained face down by door staff, and later declared deceased in hospital on 3 May 2003. The inquest concluded that the medical cause of death was traumatic asphyxia and that police actions were inappropriate and more probably than not contributed more than minimally to his death. Concerns included training and monitoring of detainees during restraint and transport, and shortcomings in the licensing, training, auditing and review of door supervisors.
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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 required training or knowledge on restraint and asphyxia dangers
Wider context from the report “(6) The SIA’s standards of conduct, training and levels of supervision issued pursuant to their statutory responsibilities under section 1(2)(e) of the 2001 Act, namely the “Specification for Learning and Qualifications for Door Supervisors” (Feb 2010) and the “Specifications for Learning and Qualifications for Physical Intervention Skills” (Aug 2010), do not include a requirement for training or knowledge on the dangers inherent in restraint, specific modes of restraint, positional asphyxia or traumatic asphyxia .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 audit accredited door-supervisor training on restraint and asphyxia
Wider context from the report “(7) The SIA does not audit the training provided to door supervisors by accredited training providers , particularly on issues of restraint and asphyxia (traumatic and positional).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Deaths related to or following restraint by door supervisors
Wider context from the report “(4) Twenty deaths apparently related to and/or following restraint by door supervisors have occurred since the introduction in 2004 of (rolled out) compulsory licensing of door supervisors, by the Security Industry Authority (“SIA”) (established by the Private Security Act 2001, in 2003). There have been four restraint related deaths involving twelve door supervisors (all of whom have been charged with either murder or manslaughter) since April 2013, that is, following the introduction (in February 2013) of mandatory training as a condition for the awarding (or renewal) of a licence to work as a door supervisor anywhere in 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 Failure to review restraint-related deaths for licensing and responsibility lessons
Wider context from the report “(5) The SIA does not undertake any review or inquiry into those deaths indicated by Inquest or criminal findings to be related to restraint by door supervisors to determine whether there are any lessons to be learnt in so far as their licensing or other responsibilities are concerned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 existing bubble-car design to enable easy monitoring of rear-seat detainees
Wider context from the report “(2) The design of the ‘bubble cars’ in existence at the time of Mr Hughes’ death and apparently still in use pending their phasing out, is such that the condition of a detainee held in the rear of the vehicle may not be easily monitored (because of the presence of a Perspex screen that may affect the ability to see and hear a detainee ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 integrate asphyxia training into restraint training
Wider context from the report “(8) The mandatory training that door supervisors are required to undertake as a condition of the award of a licence by the SIA does not integrate training on asphyxia into the training on restraint (it is addressed by a limited and discrete element ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 new bubble-car design to enable officers to hear detainees’ breathing difficulties
Wider context from the report “(3) The design of the new ‘bubble cars’ may impede an officer’s ability to hear a detainee (and thus identify irregularities or difficulties in breathing ) because of the presence of a (albeit smaller) Perspex screen .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Repeated coronial concern about door-supervisor training on restraint and asphyxia
Wider context from the report “(11) There have already been four ‘Rule 43’ reports to the SIA by Coroners concerning the training of door supervisors on restraint and asphyxia .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about completion of physical intervention training by licensed door supervisors
Wider context from the report “(10) It is not clear that all persons presently working as door supervisors have yet undertaken physical intervention training (it appears that those who already have a licence will only be required to undertake ‘top training’ when they seek renewal of a 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 Lack of police training guidance on the significance of snoring during positional asphyxia
Wider context from the report “(1) The training on positional asphyxia presently provided to police officers by the North Wales Police Force does not include guidance on the significance of ‘snoring’ and in particular that it is not inconsistent with deep unconsciousness and obstruction to breathing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 first-aid qualification requirement for door-supervisor licensing
Wider context from the report “(9) The licensing requirements for door supervisors do not include a requirement for a first aid qualification .
” Open source report
Concerns raised 10 Lack of fully independent control over fatal shooting scenes during investigation View source Failure to video record fatal police shooting scenes View source Failure to consider pursuing a planned weapons-seizure operation after a fatal shooting View source Failure to record armed police operations after State Red View source Lack of access to all relevant intelligence for fatal-operation investigations View source Failure to review operational strategy in response to developing events View source Failure to devise a coordinated strategy capable of seizing guns before collection View source Failure to develop and share operational intelligence between the MPS and SOCA View source Failure to obtain prompt comprehensive statements from all police witnesses to fatal shootings View source Lack of an agreed protocol between the IPCC, coronial and prosecution bodies View source See 7 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
Mark Duggan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 4 August 2011, Mark Duggan was shot by an armed police officer during an enforced vehicle stop in London and was pronounced dead at the scene. The report raises concerns about intelligence sharing and operational decisions before the shooting, the investigation and preservation of evidence at the scene, the recording of the operation, and the coordination and access to intelligence during the investigation and inquest.
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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 fully independent control over fatal shooting scenes during investigation
Wider context from the report “Concern 3: The IPCC had primacy at the scene but did not have the resources to conduct all relevant activities there
I am concerned that no scene of a fatal shooting should be the subject of any confusion about the purpose of the investigation, or about what should be done to further that investigation. There is a tension, in a case such as this, between the duty of the MPS to obtain and secure evidence at the scene, its position as being under investigation, and the IPCC’s obligation to investigate independently. The pragmatic approach adopted of the MPS consulting the IPCC about what should happen may not always resolve that tension. My primary concern is whether that position should persist. If it does then I am concerned that the police service has the practical control of many aspects of the scene and what happens there despite being under investigation , without the public realising that the investigation does not have full independence which the IPCC’s role appears to safeguard . This concern is addressed to the IPCC, the Home Secretary and the MPS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 video record fatal police shooting scenes
Wider context from the report “Concern 4: The scene of the fatal police shooting was not video recorded
I believe that it is important to minimise distrust in the police in connection with fatal shootings, as that distrust can then permeate the entire investigation which follows and may mean that civilian witnesses will not come forward. That plainly has the capacity to prevent lessons being learned which could prevent deaths in the future. This concern is addressed to the MPS, the IPCC and ACPO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 pursuing a planned weapons-seizure operation after a fatal shooting
Wider context from the report “Concern 5: The planned operation to seize weapons was not pursued after the fatal shot was fired
My concern is that no consideration appears to have been given to the prospect . A starting point should have been that one of the Trident officers saw the minicab turn into Burchell Road for the handover, and that was a short cul-de-sac. This concern is addressed to the MPS, the IPCC and ACPO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 armed police operations after State Red
Wider context from the report “Concern 6: The armed police operation was not recorded after State Red was called
I am therefore concerned that the cars involved in stopping the minicab containing Mr Duggan had data available to be downloaded or that the technology was not as effective in 2011 as it was in 2005. I expect to be told the actual position. In the circumstances I address these concerns to the MPS and ACPO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of access to all relevant intelligence for fatal-operation investigations
Wider context from the report “Concern 8: The IPCC and Counsel to an inquest do not have access to all intelligence
These limitations not only give rise to understandable suspicions in the minds of those not party to the intelligence but also plainly create a risk that an intelligence-led operation which results in death will not be fully investigated so that lessons may be learned. This concern is addressed to the Home Secretary.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to review operational strategy in response to developing events
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA, and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so, in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him . The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan. This concern is directed to the MPS and NCA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 devise a coordinated strategy capable of seizing guns before collection
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA, and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so, in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him. The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan . This concern is directed to the MPS and NCA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 develop and share operational intelligence between the MPS and SOCA
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA , and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so , in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him. The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan. This concern is directed to the MPS and NCA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 obtain prompt comprehensive statements from all police witnesses to fatal shootings
Wider context from the report “Concern 2: Comprehensive accounts were not taken from police witnesses at the first possible opportunity
I am concerned that fatal police shootings are not as rigorously examined as they could be and that doubts about the accuracy of police accounts are not minimised. Lessons learned after a death should be as complete as possible. My concern is that not all witnesses to a fatal shooting are asked to give full statements as soon as possible after the event, giving a detailed account of what they saw . I am also concerned about whether there is any purpose in seeking to distinguish between “principal officers” and other police officers save that, where there is any reason to caution an officer, then of course that must be done. I am concerned that witnesses who perceived a threat from the person who was shot did not set that out in their statements . I therefore invite ACPO and the MPS to deal with what I have said when they respond to the IPCC consultation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 protocol between the IPCC, coronial and prosecution bodies
Wider context from the report “Concern 7: The IPCC does not have a protocol agreed with the Chief Coroner, ACP and the CPS
With a view to coroners holding effective inquests as soon as practicable I address this concern to the IPCC and ask it to consider approaching the Crown Prosecution Service, the Association of Chief Police Officers, the Chief Coroner and the Coroner’s Society with a view to integrating its memorandum with theirs.
” 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 Strengthen the IPCC’s access to third-party data while applying safeguards to sensitive intelligence and government information.
Verbatim wording from the response “Section 137 of the Anti-social Behaviour, Crime and Policing (ASB C&P) Act 2014 contains additional powers for the IPCC that it has requested in order to strengthen its ability to improve public confidence in the police complaints system.” Source location 2014-0182-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 Increase IPCC resources to enable it to handle all serious and sensitive police-related cases.
Verbatim wording from the response “If the IPCC were to take primacy in the crucial minutes and hours after such an incident (which occurs rarely) its staff would need the capability to deploy with the necessary expertise to any location within minutes of being notified. The Home Office has committed to increasing the resources of the IPCC to enable it to deal with all serious and sensitive cases involving the police. However it is clear that, for practical reasons, the IPCC will continue to require at times the support of police forces, given their specialist skills and coverage.” Source location 2014-0182-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 A formal transfer of scene responsibility to the IPCC is constrained because it lacks crime scene managers and relies on police expertise and coverage.
Verbatim wording from the response “In the report you suggested that there should be a formal handover of responsibility from police to the IPCC once the police duty to preserve evidence and secure the scene has been discharged. This is a question of practicality rather than resources. The IPCC does not have its own crime scene managers and therefore relies on police forces to supply trained staff to attend the scene and conduct much of the searching, seizure and exhibiting of evidence.” Source location 2014-0182-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 Sensitive intelligence cannot always be disclosed because statutory national security and public safety safeguards restrict onward disclosure and public release.
Verbatim wording from the response “The ASB C&P Act 2014 has strengthened the IPCC’s power to obtain data from third parties. The new third party data provision provides the IPCC with the power to serve an information notice on a person where it reasonably requires information for the purposes of an investigation it is carrying out. These information notices are subject to restrictions on onward disclosure that would have to be agreed with the Security and Intelligence Agencies, Cabinet Office and FCO.” Source location 2014-0182-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 The Chief Officer, not the IPCC, is responsible for preserving evidence and securing scenes of deaths or serious injury.
Verbatim wording from the response “As you will be aware, the Police Reform Act 2002 makes clear that the duty to preserve evidence at the scene of a death or serious injury (DSI) is the responsibility of the Chief Officer.” Source location 2014-0182-Response-by-Home-Office
Open published response
Concerns raised 7 Absence of formal regular night checks for vulnerable prisoners View source Lack of medical or hospital treatment information in the Person Escort Record View source Insufficient efforts to find a suitable shared-cell prisoner for a first night prisoner with identified risk factors View source Inadequate handover arrangements for identifying prisoners requiring increased observations View source Failure to securely attach warning documents to the Person Escort Record View source Failure to review all available risk information in the Person Escort Record View source Reliance on prisoner interview instead of balanced assessment of all known risk factors View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christopher Shapley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Shapley was arrested on 17 September 2013, remanded in custody, and taken to HMP Cardiff after treatment at hospital for alcohol withdrawal symptoms and fitting. He was placed alone in a cell and found hanged during morning checks on 20 September 2013. Concerns included incomplete transfer of information about his hospital treatment and self-harm risks, insufficient assessment of risk factors, inadequate efforts to arrange a shared cell, and inadequate handover and night-time observations.
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 formal regular night checks for vulnerable prisoners
Wider context from the report “(4) The jury were concerned that the handover arrangements for Christopher Shapley were not adequate to identify him as a prisoner who might benefit from increased observations, and that formal regular checks should have been put in place during the night . The jury were told of new arrangements that had come into force very shortly after Christopher Shapley’s death (such as an A4 warning sheet on the cell door of every first night prisoner). The risks to vulnerable prisoners such as Christopher Shapley have been highlighted in a number of previous reports from the Cardiff Coroner to HMP Cardiff (e.g. into the death of Andrew Paul Hawkins – inquest 12th and 14th June 2012) and such arrangements should be robust and permanent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 medical or hospital treatment information in the Person Escort Record
Wider context from the report “(1) The jury found it of concern that the information that Christopher Shapley had been in Prince Charles Hospital after arrest was not known to the prison . Had it been known his condition may, they felt, have been treated more seriously and he would have been kept under greater observation. There would seem to be no reason why the PER (Person Escort Record) could not contain a section dealing with medical or hospital treatment received while in police custody prior to remand (e.g. the section at the foot of page 2 could also include a prompt for any health treatment received). This information will not only advise prison staff of the current medical circumstances of the prisoner but will also prompt them to call for any hospital discharge notes (or consult with the Force Medical Examiner) so that effective treatment can be continued.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 efforts to find a suitable shared-cell prisoner for a first night prisoner with identified risk factors
Wider context from the report “(3) Despite the recommendation that he be put in a shared cell because of his alcohol withdrawal no non-smoker could be found to share with him and therefore the decision was made to put him in a cell alone. The jury found that insufficient efforts had been made to find a suitable prisoner to share with him . The jury was told that it is very rare to find a non-smoking prisoner and that it was against the regulations to ask a trusted inmate to share and desist from smoking. The risks to a first night prisoner alone in a cell with identified risk factors however go well beyond health and safety concerns and a reasoned recommendation that such a prisoner be in a shared cell should not be defeated by practicalities .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 handover arrangements for identifying prisoners requiring increased observations
Wider context from the report “(4) The jury were concerned that the handover arrangements for Christopher Shapley were not adequate to identify him as a prisoner who might benefit from increased observations , and that formal regular checks should have been put in place during the night. The jury were told of new arrangements that had come into force very shortly after Christopher Shapley’s death (such as an A4 warning sheet on the cell door of every first night prisoner). The risks to vulnerable prisoners such as Christopher Shapley have been highlighted in a number of previous reports from the Cardiff Coroner to HMP Cardiff (e.g. into the death of Andrew Paul Hawkins – inquest 12th and 14th June 2012) and such arrangements should be robust and permanent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 securely attach warning documents to the Person Escort Record
Wider context from the report “(2) The PER form had a number of staple holes where extra documents had been attached. It is evident that one of these documents was a warning form prepared by a police officer enumerating the risk factors affecting Christopher Shapley. This document would have been material assistance to the prison staff, but had become detached before it reached them . A system of stapling documents to the PER is prone to human error and accidental detachment . It would appear possible for a system to be devised that ensured that any such warning form should stay securely with the PER.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to review all available risk information in the Person Escort Record
Wider context from the report “(1) The Health Care Assistant who interviewed Christopher Shapley conceded that she did not look at all the pages in the PER and that she had never seen the “self-harm” form sent by Pontypridd magistrates court (and had never in fact seen any such form in all her experience in the prison). Had she seen and recognised the importance of all this information her assessment would have been broader and she would have taken into account all the risk factors rather than just alcohol withdrawal .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prisoner interview instead of balanced assessment of all known risk factors
Wider context from the report “(2) The reception prison officer was aware of the self-harm form and the alcohol withdrawal risk factor but relied heavily on the interview with Christopher Shapley in determining his care . Reliance on interview by prison staff, rather than undertaking a balanced assessment of all the known risk factors , was a feature of the evidence before the jury. The jury did however find that it was appropriate not to have raised an ACCT.
” Open source report
21 Jan 2014 William Howard DOWLING and Victoria Elaine ROSE · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Lack of arrangements enabling doctors to report relevant information during firearms licence terms View source Failure to enable General Practitioners to share public-safety information with relevant authorities View source Lack of independent and transparent firearms licensing decisions for current or former police employees View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
William Howard DOWLING and Victoria Elaine ROSE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 2 March 2013, William Howard Dowling shot Victoria Elaine Rose twice in the head before shooting himself in the head. The report raised concerns about information sharing between general practitioners and firearms licensing authorities, the wider public-safety implications of confidentiality, and the independence and transparency of firearms licensing decisions involving current or former police employees.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements enabling doctors to report relevant information during firearms licence terms
Wider context from the report “(1) During the course of the hearing I heard evidence from ███████ Wiltshire Police Firearms Licensing Manager, who indicated to me that at the present moment in time aside from a letter (copy attached marked A – since July 2011) which is sent to General Practitioners when firearms licence applications are successful or where they are renewed, giving a doctor the opportunity to relay relevant information in relation to their patient within 14 days, there is currently no memorandum of understanding or legislation that allows doctors the ability during the duration of the term of a firearms license, which stands at 5 years, to report matters which may have a bearing on that patient’s suitability to hold a firearms license and possess firearms . Doctors of course are bound at the present moment in time by patient confidentiality. I am concerned that this restriction may impede the firearms authority from making crucial decisions as regards individuals possessing firearms and continuing to hold a firearms licence in circumstances which, at present, may not come before the attention of the Firearms Authority unless the matter has ordinarily come before the police’s attention as a consequence of other aspects of their duties.
In evidence from ███████ she made me aware that Wiltshire Police through the cooperation of NHS Wiltshire Clinical Commissioning Group and two Doctor’s Surgeries were piloting a scheme (directly prompted Victoria’s two sons as a result of his tragedy) effective from September 2013, to allow an increase in the sharing of information in particular having a bearing on the suitability of an individual to hold a firearms licence. She indicated that as a result of this pilot scheme an individual’s firearms were taken away at short notice as a result of the information received from the General Practitioner. This pilot scheme seems to me to be an utterly sensible idea although at present it is a pilot scheme and is not a national concept . This ought to be urgently reviewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to enable General Practitioners to share public-safety information with relevant authorities
Wider context from the report “(2) I am also concerned that any review arising out of this letter should not be singularly restricted as regards sharing information solely related to the suitability of somebody to hold a firearms licence. Information sharing with a view to public safety should be a reason for General Practitioners to make relevant authority(s) aware and I have in mind here the example of a driver whose eyesight is failing and where advice given from a GP to inform the DVLA, however that driver chooses not to do so as it will mean their licence may be revoked. If it is a matter of public safety then I am concerned at present moment in time that confidentiality appears to outweigh the concept of public safety .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of independent and transparent firearms licensing decisions for current or former police employees
Wider context from the report “(3) I am also concerned as regards decisions being made relating to firearms licensing in respect of current employees within that licensing organisation’s (ie the Police) employment or even former employees . Licensing and the determination of such matters should be seen to be transparent and independent . In evidence although relating to matters some 16 years previously there were issues raised by family concerning complaints by Mr Dowling’s ex wife at the time they were getting divorced that appeared to have been “brushed under the carpet” by the police in respect of which Bill was a serving officer. In any event those concerns were not dealt with satisfactorily from the complainant’s perspective. I am concerned that to have a firearms licensing authority dealing with applications from existing police employees or even former employees of that police force is open to possible abuse . Bill Dowling was an exceptionally well known and respected former police employee and my concern is that such matters relative to firearms are so serious that consideration ought to be given to introducing an independent layer so as to ensure independence and transparency .
” Open source report
13 Jan 2014 JASON NOCK · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Lack of product regulation View source Unrestricted availability of the product View source Lack of information about safe dosage and potential consequences View source Failure to provide consumers with information about product contents 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
JASON NOCK · 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 NOCK acquired the synthetic designer drug AH-7921 on the internet and died from its toxic effects. Concerns included that the product was unregulated, consumers might not know what they were taking, and it was readily available with little or no information about safe dosage or potential consequences.
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 product regulation
Wider context from the report “The matters of concern are that this product appears to be entirely unregulated , consumers do not know what they are taking, it is readily available to anyone with apparently little or no information as to safe dosage and potential consequences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Unrestricted availability of the product
Wider context from the report “The matters of concern are that this product appears to be entirely unregulated, consumers do not know what they are taking, it is readily available to anyone with apparently little or no information as to safe dosage and potential consequences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 information about safe dosage and potential consequences
Wider context from the report “The matters of concern are that this product appears to be entirely unregulated, consumers do not know what they are taking, it is readily available to anyone with apparently little or no information as to safe dosage and potential consequences .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consumers with information about product contents
Wider context from the report “The matters of concern are that this product appears to be entirely unregulated, consumers do not know what they are taking , it is readily available to anyone with apparently little or no information as to safe dosage and potential consequences.
” 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 Monitor controlled drugs, new psychoactive substances and medicines offered for sale on the internet.
Verbatim wording from the response “Action to restrict new psychoactive substance supply is a priority for UK law enforcement and other regulatory agencies. This activity includes the monitoring of controlled drugs, new psychoactive substances and medicines for sale on the internet and action with industry partners to close UK-based websites trading illegally in these substances. There is also ongoing work with the EU and other international regulatory authorities to ensure that, wherever possible, offending websites are amended to reflect the law.” Source location 2014-0013-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 Request independent expert advice on whether AH-7921 should be controlled under the Misuse of Drugs Act 1971.
Verbatim wording from the response “I note your request for further action to determine if AH-7921 should be made a controlled drug under the Misuse of Drugs Act 1971 and your concerns about its availability over the internet.” Source location 2014-0013-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 European Union and international regulatory authorities to ensure offending websites reflect the law.
Verbatim wording from the response “Action to restrict new psychoactive substance supply is a priority for UK law enforcement and other regulatory agencies. This activity includes the monitoring of controlled drugs, new psychoactive substances and medicines for sale on the internet and action with industry partners to close UK-based websites trading illegally in these substances. There is also ongoing work with the EU and other international regulatory authorities to ensure that, wherever possible, offending websites are amended to reflect the law.” Source location 2014-0013-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 Lead an expert-panel review of how the UK response to new psychoactive substances can be enhanced, including legal and policy options.
Verbatim wording from the response “We know that there is more to be done in this area, especially given that the market continues to evolve with the rapid development of new drugs. For this reason, I am currently leading a review, being undertaken by an expert panel, to look at how the UK’s response to new psychoactive substances can be enhanced beyond existing measures. This will include considering the adequacy or otherwise of the Misuse of Drugs Act 1971 to deal with these new substances, but also what other policy levers, for example in health or education policy, might be available to Government. When I launched this review on the 27th February I highlighted my concerns regarding the availability of AH-7921 to the expert panel and media. The panel will report their findings in spring 2014. The terms of reference for the review can be found on the Home Office website.” Source location 2014-0013-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 industry partners to close UK-based websites trading these substances illegally.
Verbatim wording from the response “Action to restrict new psychoactive substance supply is a priority for UK law enforcement and other regulatory agencies. This activity includes the monitoring of controlled drugs, new psychoactive substances and medicines for sale on the internet and action with industry partners to close UK-based websites trading illegally in these substances. There is also ongoing work with the EU and other international regulatory authorities to ensure that, wherever possible, offending websites are amended to reflect the law.” Source location 2014-0013-Response-by-Home-Office
Open published response
27 Nov 2013 Christopher Michael SCOTT · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 2 Unrestricted availability of AMT through the internet and community View source Deadly effects of AMT View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christopher Michael SCOTT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Michael SCOTT took pills containing AMT on 21 July 2013 and was admitted to hospital on 22 July 2013. He died on 24 July 2013 after developing multiorgan failure and bronchopneumonia attributable to the toxic effects of AMT. The principal concern was that AMT was a readily available legal drug whose effects could be deadly, with other deaths also appearing to involve AMT.
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 Unrestricted availability of AMT through the internet and community
Wider context from the report “(1) During the course of the evidence I read out a toxicology report that referred to other deaths involving AMT. I exhibited 2 Internet research results that related to other AMT deaths. Slightly unconventionally I exhibited these internet results as ‘C2’ and ‘C3’ (copies attached) to further support this report with a view to the prevention of future deaths. The first report ‘C2’ referred to the death of Adam Weeks in November 2011. His Inquest in March 2012 confirmed his death due to AMT intoxication and whilst the report makes reference to the Coroner writing to appropriate authorities prior to Christopher's inquest I did speak with that Coroner who indicated that he had not make such a report (r43 report under the Coroners Rules 1984). Document ‘C3’ refers to three other deaths in respect of which AMT appears to have been involved during 2012 and 2013. As it stands at the moment AMT is a “legal high” and I am concerned that as it is currently a legal drug that it is readily available to be purchased for example over the internet and in the community at large . The effects of AMT can vary from person to person but clearly the effects can be deadly as the examples show including of course Christopher's death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Deadly effects of AMT
Wider context from the report “(1) During the course of the evidence I read out a toxicology report that referred to other deaths involving AMT. I exhibited 2 Internet research results that related to other AMT deaths. Slightly unconventionally I exhibited these internet results as ‘C2’ and ‘C3’ (copies attached) to further support this report with a view to the prevention of future deaths. The first report ‘C2’ referred to the death of Adam Weeks in November 2011. His Inquest in March 2012 confirmed his death due to AMT intoxication and whilst the report makes reference to the Coroner writing to appropriate authorities prior to Christopher's inquest I did speak with that Coroner who indicated that he had not make such a report (r43 report under the Coroners Rules 1984). Document ‘C3’ refers to three other deaths in respect of which AMT appears to have been involved during 2012 and 2013. As it stands at the moment AMT is a “legal high” and I am concerned that as it is currently a legal drug that it is readily available to be purchased for example over the internet and in the community at large. The effects of AMT can vary from person to person but clearly the effects can be deadly as the examples show including of course Christopher's death.
” Open source report
20 Nov 2013 LUKE JACOB GOODWIN · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 5 Availability of clear and detailed internet guidance on how to commit suicide View source Failure to fit Helium canisters with modified control valves restricting gas release View source Internet advertisements and links enabling purchase of products to commit suicide View source Unrestricted sale of Helium canisters to the general public View source Sale of Helium canisters containing a sizable volume of Helium 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
LUKE JACOB GOODWIN · 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
Luke Goodwin, a 21-year-old university student, was found dead at home on 18 January 2013 after inhaling helium using a plastic bag, tubing and a helium canister. The report raised concerns about the ready availability and design of helium canisters, and about clear, detailed online information and links facilitating suicide methods and purchases.
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 Availability of clear and detailed internet guidance on how to commit suicide
Wider context from the report “(4) The type of information which is readily available on the internet. Such information provides clear and detailed guidance on how to commit suicide. Internet sites also provide advertisements and links to enable the viewer to order and purchase appropriate products to commit suicide. Two sites in particular, ████████ and ████████ appear to provide clear and comprehensive details.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 fit Helium canisters with modified control valves restricting gas release
Wider context from the report “(3) Helium canisters are not fitted with any modified control valve which if in place could restrict the volume of gas being released.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Internet advertisements and links enabling purchase of products to commit suicide
Wider context from the report “(4) The type of information which is readily available on the internet. Such information provides clear and detailed guidance on how to commit suicide. Internet sites also provide advertisements and links to enable the viewer to order and purchase appropriate products to commit suicide. Two sites in particular, ████████ and ████████ appear to provide clear and comprehensive details.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Unrestricted sale of Helium canisters to the general public
Wider context from the report “(1) The sale of Helium canisters is readily available to members of the general public. There appears to be no restrictions or conditions on sale or place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Sale of Helium canisters containing a sizable volume of Helium
Wider context from the report “(2) Helium canisters appear to be sold in a standard size which contains a sizable volume of Helium.
” Open source report
1 Nov 2013 Rachael Claire Slack and 2 others · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1 Failure to exchange relevant information between Police and Mental Health Services 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
Rachael Claire Slack and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 2 June 2010, Andrew David Cairns entered Rachael Claire Slack’s home, stabbed their son Auden George Slack and Rachael Slack to death, and then stabbed himself to death. The principal concerns were failures in information-sharing between Police and Mental Health Services, and failures to communicate the assessed risk and safety measures to Rachael regarding the threat posed by Andrew.
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 exchange relevant information between Police and Mental Health Services
Wider context from the report “1. At the time of arrest of Mr Cairns, the Police were aware of his assessment under Section 136 of the Mental Health Act the previous day. The Custody Nurse had contacted the Crisis Team to obtain information regarding the 136 assessment which was duly given by the Mental Health Team. However, there was no reciprocal exchange of information and the Mental Health Team were not informed that Mr Cairns had been arrested with regards to Threats to Kill his partner.
2. At the conclusion of the Inquest and after all the evidence was heard, it came to light that there was in existence a policy for mutual sharing of information between the Police and Mental Health Services if each respective organisation requested information from the other.
3. This document was not disclosed prior to the Inquest or during the Inquest itself and it would have been critical to ask witnesses from the Police and Mental Health Services about their knowledge of this document.
” 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