Concerns raised 2 Increasing number of young people presenting with potentially fatal health problems linked to drug use View source Highly addictive and harmful nature of a Class B drug 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
Joshua William Leatham-Prosser · 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
Joshua William Leatham-Prosser was found unresponsive at his home on 5/6/24 and pronounced dead at the scene. The inquest recorded a drug-related death, with urinary sepsis, severe acute on chronic cystitis and pyelonephritis, and chronic ketamine use identified in the medical cause of death; concerns were raised about ketamine’s addictive and harmful nature and the increasing number of young people presenting with potentially fatal health problems linked to its use.
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 Increasing number of young people presenting with potentially fatal health problems linked to drug use
Wider context from the report “2. I have concerns with regard to the following:
i. The highly addictive and harmful nature of a drug with a classification of Class B.
ii. The increasing number of young people presenting with potentially fatal health problems linked to its 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 Highly addictive and harmful nature of a Class B drug
Wider context from the report “2. I have concerns with regard to the following:
i. The highly addictive and harmful nature of a drug with a classification of Class B.
ii. The increasing number of young people presenting with potentially fatal health problems linked to its use.
” 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 working with health, policing and wider public services to reduce drug use and associated harms.
Verbatim wording from the response “I am very aware ketamine can cause significant harm when misused, and this Government is concerned that the harms – including its degree of addictiveness and the possibility of irreversible bladder damage – may be significantly underestimated by those who use the drug. It is also particularly worrying that the misuse of ketamine amongst young people has grown in recent times. Through the Government’s Plan for Change and mission to make our streets safer, we will continue to work closely with health, policing and wider public services to drive down drug use and its associated harms. Also, the Home Office will continue to work with our partners to discourage drug misuse and to alert people, particularly young people, about the dangers of ketamine.” Source location Response from the 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 partners to discourage drug misuse and alert people, particularly young people, to ketamine’s dangers.
Verbatim wording from the response “I am very aware ketamine can cause significant harm when misused, and this Government is concerned that the harms – including its degree of addictiveness and the possibility of irreversible bladder damage – may be significantly underestimated by those who use the drug. It is also particularly worrying that the misuse of ketamine amongst young people has grown in recent times. Through the Government’s Plan for Change and mission to make our streets safer, we will continue to work closely with health, policing and wider public services to drive down drug use and its associated harms. Also, the Home Office will continue to work with our partners to discourage drug misuse and to alert people, particularly young people, about the dangers of ketamine.” Source location Response from the 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 Carefully consider the Advisory Council’s recommendations before deciding how to proceed on ketamine classification.
Verbatim wording from the response “As you may be aware, the Government is required to consider the advice of the Advisory Council on the Misuse of Drugs (“ACMD”) before making any changes to the classification of a controlled drug. I should also like to inform you that I wrote to the Chair of the ACMD, Professor Owen Bowden-Jones, to formally commission an updated harms assessment of ketamine on 14 January. The ACMD is independent of the Government, but I have full confidence that it will consider the issue with due care and provide valuable advice. The Government will carefully consider the ACMD’s recommendations before making any decision on how to proceed.” Source location Response from the 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 Commission an updated Advisory Council on the Misuse of Drugs assessment of ketamine harms.
Verbatim wording from the response “As you may be aware, the Government is required to consider the advice of the Advisory Council on the Misuse of Drugs (“ACMD”) before making any changes to the classification of a controlled drug. I should also like to inform you that I wrote to the Chair of the ACMD, Professor Owen Bowden-Jones, to formally commission an updated harms assessment of ketamine on 14 January. The ACMD is independent of the Government, but I have full confidence that it will consider the issue with due care and provide valuable advice. The Government will carefully consider the ACMD’s recommendations before making any decision on how to proceed.” Source location Response from the Home Office
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Changes to ketamine’s classification cannot be made until the legally required ACMD advice has been considered.
Verbatim wording from the response “As you may be aware, the Government is required to consider the advice of the Advisory Council on the Misuse of Drugs (“ACMD”) before making any changes to the classification of a controlled drug. I should also like to inform you that I wrote to the Chair of the ACMD, Professor Owen Bowden-Jones, to formally commission an updated harms assessment of ketamine on 14 January. The ACMD is independent of the Government, but I have full confidence that it will consider the issue with due care and provide valuable advice. The Government will carefully consider the ACMD’s recommendations before making any decision on how to proceed.” Source location Response from the Home Office
Open published response
6 Dec 2024 Champagauri Bhatt and Dipak Bhatt · Prevention of Future Deaths report North London
View report summary
Concerns raised 8 Inadequate information management for analysis and learning from white goods fires View source Failure by fire-investigating companies to notify authorities of investigation outcomes View source Lack of sharing of recall and replacement decision data and rationale for condensate pumps and RFI filters View source Moisture ingress into condensate pumps causing tracking faults, resistive heating and fire View source Failure of product risk assessments to account for occupants and their actions View source Lack of sharing of warranty replacement data for condensate pumps and RFI filters View source Failure to provide fire-durable identification plates on appliances View source Inadequate manufacturing standards for mains- and sub-mains-operated condensate pumps and RFI filters View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Champagauri Bhatt and Dipak Bhatt · 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 29 March 2023, a fire caused by an electrical fault in a tumble dryer led to inhalation injuries and the deaths of Champagauri and Dipak Bhatt. Concerns included moisture ingress into condensate pumps causing faults and fire, and the need for improved data sharing, product safety standards, fire investigation reporting, risk assessment, and appliance identification.
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 information management for analysis and learning from white goods fires
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires .
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 fire-investigating companies to notify authorities of investigation outcomes
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations .
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 sharing of recall and replacement decision data and rationale for condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Moisture ingress into condensate pumps causing tracking faults, resistive heating and fire
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire .
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 product risk assessments to account for occupants and their actions
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates .
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 sharing of warranty replacement data for condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters .
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 fire-durable identification plates on appliances
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 manufacturing standards for mains- and sub-mains-operated condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards .
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” Open source report
×
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 specific response to changes in information management cannot be provided without further detail about which aspects need to change.
Verbatim wording from the response “I understand from your report that the inquest concluded that Champagauri and Dipak Bhatt died from inhalation injuries following a fire caused by an electrical fault in a tumble dryer. You have suggested that changes in information management would result in better analysis of, and learning from, white goods fires, but there is no explanation in your report as to which aspects of information management need to change.” Source location Response from the Home Office
Open published response
Concerns raised 6 Lack of active consideration of controls on public access to the substances View source Lack of central monitoring of poisoning incidents involving the substances View source Unrestricted domestic sale of the substances View source Lack of regulation and monitoring of use of the substances outside the Poisons Act 1972 View source Lack of consideration of controls on the quantities and purity in which the substances are sold View source Unrestricted import of the substances View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hannah Mary AITKEN · 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
Hannah Mary Aitken died at her supported accommodation on 14 September 2023 after taking an overdose of a poisonous substance obtained with the intention of ending her life. The report raises concerns about the unrestricted domestic and international availability of the substance, the quantities and purity in which it is sold, and the lack of central monitoring or clear responsibility for regulating its use in relation to self-harm.
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 active consideration of controls on public access to the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department .
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 central monitoring of poisoning incidents involving the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning .
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 domestic sale of the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions ;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and monitoring of use of the substances outside the Poisons Act 1972
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972 , and it is not clear which Government department would be responsible for this .
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consideration of controls on the quantities and purity in which the substances are sold
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold , against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use , for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 import of the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad .
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions ;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” 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 Strengthen controls on reportable poisons, including suspicious-transaction reporting, online-marketplace obligations, and supplier personnel awareness requirements.
Verbatim wording from the response “The substance described in your report is a “reportable” poison listed in Part 4 of Schedule 1A of the Poisons Act. For the avoidance of doubt, this means that whilst it can be bought by members of the public, suspicious transactions need to be reported by retailers if there are questionable grounds for suspecting it is intended for any illicit use. The Poisons Act was amended in October 2023 to strengthen controls, and enhance our suspicious activity reporting requirements, including new obligations for online marketplaces. As well as the requirement to report suspicious transactions, economic operators supplying any reportable substances must now demonstrate that their personnel are aware about which of their products contain listed substances, and are instructed on their obligations.” Source location Response from the 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 the Department of Health and Social Care and relevant stakeholders to assess the benefits and proportionality of further regulation addressing overseas sales, purity, and quantities.
Verbatim wording from the response “On the issue of further regulation, an aspect of the concern you have raised relates to individuals based in Great Britain, purchasing this substance from overseas retailers. As the Poisons Act only applies to Great Britain (i.e. England, Scotland, and Wales), there is no obligation for retailers based outside the specified jurisdiction to report transactions which they believe to be suspicious. The Department is seeking to address this, as well as” Source location Response from the 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 work to ensure suppliers meet their obligations under the Poisons Act.
Verbatim wording from the response “Specifically, HSG have engaged with online platforms to encourage them to voluntarily remove the sale to individuals in its pure form. Government expertise in relation to substances of concern is also shared to inform retailer sales practices. This includes encouraging suppliers to use declaration of use forms for sales of such substances. This work will continue to ensure suppliers are meeting their requirements under the Poisons Act. Furthermore, if during the processing of suspicious activity reports a safeguarding concern is identified by Counter Terrorism Policing, consideration will be given to disseminating this intelligence to police forces to consider a welfare check.” Source location Response from the 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 Introduce Border Force guidance on responding to detected goods potentially intended to assist suicide.
Verbatim wording from the response “Similarly, Border Force has introduced guidance for its officers (operating within its existing legal provisions). This guidance provides instructions on the action they can take if they are in receipt of information, in any form or manner, that leads to a detection of goods at the border containing an item that may be intended to assist with suicide. This of course relies on Border Force working closely with police forces and other relevant agencies to safeguard vulnerable individuals to the full extent possible. This work is complex, and Border Force will continue to monitor its policies, exploring opportunities to improve its ability to take action. Where possible, Border Force will also continue to ensure that frontline staff who may encounter these items know what action to take, and are supported on a case-by-case basis when required.” Source location Response from the 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 Improve retailer awareness of legal reporting duties and engage online platforms to encourage removal of pure-form sales and use of declarations of intended use.
Verbatim wording from the response “As your report captures, the Home Office is aware of the issues relating to this substance. My officials have been undertaking work across Government to both reduce access to this substance, and raise awareness to suppliers of the dangers of this substance. To this end, the Homeland Security Group (HSG) have been working to improve retailer awareness of their legal obligation to report suspicious activity for regulated and reportable substances.” Source location Response from the 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 Border Force policies, explore improvements to operational responses, and support frontline staff to identify and respond to relevant items.
Verbatim wording from the response “Similarly, Border Force has introduced guidance for its officers (operating within its existing legal provisions). This guidance provides instructions on the action they can take if they are in receipt of information, in any form or manner, that leads to a detection of goods at the border containing an item that may be intended to assist with suicide. This of course relies on Border Force working closely with police forces and other relevant agencies to safeguard vulnerable individuals to the full extent possible. This work is complex, and Border Force will continue to monitor its policies, exploring opportunities to improve its ability to take action. Where possible, Border Force will also continue to ensure that frontline staff who may encounter these items know what action to take, and are supported on a case-by-case basis when required.” Source location Response from the Home Office
Open published response
Concerns raised 3 Maintaining ketamine as a Class B drug despite its serious harms View source Illicit ketamine use causing severe long-term and potentially fatal health problems View source Lack of user understanding of ketamine’s health risks 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
James Patrick Boland · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Patrick Boland, known as Jamie, was found unresponsive at home on 19 June 2024 and died from sepsis caused by acute pyelonephritis, against a background of chronic ketamine use. The report raised concerns that ketamine use can cause severe long-term health problems, that users may perceive it as safer because it is classified as a Class B drug, and that increasing illicit use is linked to potentially fatal health problems.
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 Maintaining ketamine as a Class B drug despite its serious harms
Wider context from the report “The inquest heard that previously Mr Boland had used cocaine a class A drug but, had switched to ketamine a class B drug on the basis that he perceived it to be less harmful. His perception that it was less harmful was based on the fact it is designated as a class B rather than Class A drug. The evidence before the inquest was that Ketamine is a deeply harmful substance when used outside the purposes for which it is licenced for prescribing by clinicians and that users such as Mr Boland are unable to give it up despite knowing how dangerous it is to their health. Maintaining its classification as a Class B drug was likely to encourage others to start to use it or continue to use it under the false impression it is “safer”.
The evidence at the inquest was that Ketamine use causes huge long term life changing health problems. In Mr Boland’s case it had caused long term urological damage and liver damage. It was the damage to his urological system caused by Ketamine that led to his death.
The inquest was told that there is a significant increase in the illicit use of Ketamine and that this has led to clinicians seeing a rise in potentially fatal health problems linked to its use. The extent of these risks rarely understood by users until the damage has been done to their health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Illicit ketamine use causing severe long-term and potentially fatal health problems
Wider context from the report “The inquest heard that previously Mr Boland had used cocaine a class A drug but, had switched to ketamine a class B drug on the basis that he perceived it to be less harmful. His perception that it was less harmful was based on the fact it is designated as a class B rather than Class A drug. The evidence before the inquest was that Ketamine is a deeply harmful substance when used outside the purposes for which it is licenced for prescribing by clinicians and that users such as Mr Boland are unable to give it up despite knowing how dangerous it is to their health. Maintaining its classification as a Class B drug was likely to encourage others to start to use it or continue to use it under the false impression it is “safer”.
The evidence at the inquest was that Ketamine use causes huge long term life changing health problems . In Mr Boland’s case it had caused long term urological damage and liver damage. It was the damage to his urological system caused by Ketamine that led to his death.
The inquest was told that there is a significant increase in the illicit use of Ketamine and that this has led to clinicians seeing a rise in potentially fatal health problems linked to its use . The extent of these risks rarely understood by users until the damage has been done to their health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of user understanding of ketamine’s health risks
Wider context from the report “The inquest heard that previously Mr Boland had used cocaine a class A drug but, had switched to ketamine a class B drug on the basis that he perceived it to be less harmful. His perception that it was less harmful was based on the fact it is designated as a class B rather than Class A drug. The evidence before the inquest was that Ketamine is a deeply harmful substance when used outside the purposes for which it is licenced for prescribing by clinicians and that users such as Mr Boland are unable to give it up despite knowing how dangerous it is to their health. Maintaining its classification as a Class B drug was likely to encourage others to start to use it or continue to use it under the false impression it is “safer”.
The evidence at the inquest was that Ketamine use causes huge long term life changing health problems. In Mr Boland’s case it had caused long term urological damage and liver damage. It was the damage to his urological system caused by Ketamine that led to his death.
The inquest was told that there is a significant increase in the illicit use of Ketamine and that this has led to clinicians seeing a rise in potentially fatal health problems linked to its use. The extent of these risks rarely understood by users until the damage has been done to their health.
” Open source report
25 Oct 2024 Natasha Johnston · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Lack of regulation restricting the number and weight of dogs an individual may walk in a public place 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
Natasha Johnston · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Natasha Johnston died on 12 January 2023 after being viciously attacked by an unknown number of dogs from a group of eight that she had been walking. The principal concern was the lack of local and national regulation restricting the number and weight of dogs that one person may walk in a public place.
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 regulation restricting the number and weight of dogs an individual may walk in a public place
Wider context from the report “1. The lack of regulation, both locally and nationally, that restricts the number and weight of dogs that an individual person can walk on their own in a public place.
” Open source report
25 Oct 2024 Frank Steve Rios OSPINA · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Failure to provide accessible multilingual communications for arranging visits View source Restriction of Rule 35(2) report generation to general practitioners View source Failure to make Rule 35(2) reports when detainees are suspected of suicidal intentions View source Failure to control and document access to closed visits 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
Frank Steve Rios OSPINA · 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
Frank Steve Rios OSPINA died by suicide in detention, with the cause of death recorded as ligature compression of the neck and coronary heart disease. The report raised concerns about the failure to make a Rule 35(2) report after apparent suicide attempts, inconsistent understanding of the reporting process, the conduct and oversight of a closed family visit, and difficulties faced by his non-English-speaking mother in arranging visits and telephone calls.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accessible multilingual communications for arranging visits
Wider context from the report “(3) Frank's mother does not speak English and found it very difficult to arrange a visit . In fact rather than successfully navigate the system, she just turned up and was permitted to see her son as set out above. Telephone calls were not facilitated with an interpreter. The web site where visits should be booked is entirely and only in English. This is a facility that by definition detains foreign nationals and predictably some of the family members do not speak English. A quick check of the local authority website (Hammersmith and Fulham) revealed a full immediate translation facility into over 100 languages, and so this is readily available technology. The Home Office and MITIE should consider the communications currently available to relatives trying to visit their loved ones and whether these can be improved by reasonable adjustments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Restriction of Rule 35(2) report generation to general practitioners
Wider context from the report “(1) During the inquest evidence was heard about the use of Detention services order 09/2016 Detention centre rule 35 (2)
The purpose of rule 35 of the Detention Centre Rules 2001, as set out in Detention - general guidance (chapter 55), is “to ensure that particularly vulnerable detainees are brought to the attention of those with direct responsibility for authorising, maintaining and reviewing detention.
Rule 35 (2) states
2. ‘The medical practitioner shall report to the manager on the case of any detained person he suspects of having suicidal intentions, and the detained person shall be placed under special observation for so long as those suspicions remain, and a record of his treatment and condition shall be kept throughout that time in a manner to be determined by the Secretary of State.
‘The manager shall send a copy of any report under paragraphs (1), (2) or (3) to the Secretary of State without delay.
Despite Frank Ospina being witnessed as having made an attempt to take his life, and self-reporting a further attempt during his detention, no R35 report was made.
The GP evidence was that there was a long waiting list of 4 weeks of over 100 individuals who were dealt with in separate dedicated surgeries, that he had only made "a small number" of R35 (2) reports and that he would usually await and rely on additional evidence such as that from a Consultant Psychiatrist before submitting a R35 (2) report. In contrast, the Home Office evidence was that they were "surprised" that a R35 report had not been submitted. If it had been it would have been considered by a responsible officer within 2 working days.
There was a clear mismatch between the healthcare and Home Office expectations and practical application of the R35 provisions. HMC was advised that this is under review currently by the Home Office and NHS England and so this report is written to inform and assist that review process by raising the concerns from this inquiry. HMC would also question the restriction of the report having to be generated by a general practitioner, although detainees were seen by a multi-disciplinary team of healthcare professionals, many of whom could potentially carry out this task.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Rule 35(2) reports when detainees are suspected of suicidal intentions
Wider context from the report “(1) During the inquest evidence was heard about the use of Detention services order 09/2016 Detention centre rule 35 (2)
The purpose of rule 35 of the Detention Centre Rules 2001, as set out in Detention - general guidance (chapter 55), is “to ensure that particularly vulnerable detainees are brought to the attention of those with direct responsibility for authorising, maintaining and reviewing detention.
Rule 35 (2) states
2. ‘The medical practitioner shall report to the manager on the case of any detained person he suspects of having suicidal intentions, and the detained person shall be placed under special observation for so long as those suspicions remain, and a record of his treatment and condition shall be kept throughout that time in a manner to be determined by the Secretary of State.
‘The manager shall send a copy of any report under paragraphs (1), (2) or (3) to the Secretary of State without delay.
Despite Frank Ospina being witnessed as having made an attempt to take his life, and self-reporting a further attempt during his detention, no R35 report was made.
The GP evidence was that there was a long waiting list of 4 weeks of over 100 individuals who were dealt with in separate dedicated surgeries, that he had only made "a small number" of R35 (2) reports and that he would usually await and rely on additional evidence such as that from a Consultant Psychiatrist before submitting a R35 (2) report. In contrast, the Home Office evidence was that they were "surprised" that a R35 report had not been submitted. If it had been it would have been considered by a responsible officer within 2 working days.
There was a clear mismatch between the healthcare and Home Office expectations and practical application of the R35 provisions. HMC was advised that this is under review currently by the Home Office and NHS England and so this report is written to inform and assist that review process by raising the concerns from this inquiry. HMC would also question the restriction of the report having to be generated by a general practitioner, although detainees were seen by a multi-disciplinary team of healthcare professionals, many of whom could potentially carry out this task.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and document access to closed visits
Wider context from the report “(2) Visits. The inquest was advised that Frank Ospina's mother visited him in the Heathrow Immigration Removal Centre on one occasion, and that was conducted as a "closed" visit.
Her son was accompanied by 2 Officers and their meeting held behind a glass screen where no physical contact was possible. The Officers were overhearing the family conversation and making notes.
MITIE who are responsible for the day to day running of the IRC were unaware that a "closed" visit had occurred and apologised for this, confirming it was inappropriate and Frank Ospina and his mother should have been allowed to meet in the usual communal area where they could have embraced and had a private conversation. This was the last time Frank Ospina was seen alive by his mother and the visit greatly distressed her.
HMC is concerned that any "closed" visits could take place seemingly without the knowledge and consent of the Duty Manager , that no documentation had to be presented and the "closed visit" room was accessible even though rarely required (the inquest was advised it had not been used at all during the past few months).
” 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 Update and publish visits guidance introducing annual self-audits and quarterly assurance reviews of closed and banned visits, incorporating learning from the estate review.
Verbatim wording from the response “Officials have also considered longer term assurance and revised the draft DSO on visits to introduce annual self-audits and quarterly assurance reviews of both closed and banned visits. Learning from the recent review of closed visits is currently being considered and will be incorporated into the DSO. The updated DSO is expected to be published before March 2025.” Source location Response from 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 Translate IRC and residential holding facility visitor information into the top 20 languages and develop supporting translation-enabled webpages.
Verbatim wording from the response “My officials have taken action to explore options to translate the visitor information for IRCs and Residential Short-Term Holding Facilities on Gov.uk and the development of web pages to enable translation is underway. Officials have commissioned the translation of the current visitor information into the top 20 languages of those in detention. Allowing time to translate the relevant information and the development of relevant web pages, we expect this work to be complete by the end of January 2025.” Source location Response from 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 Develop and publish interim DSO 09/2016 guidance requiring healthcare staff to report suicidal-intention concerns and clarifying relevant indicators.
Verbatim wording from the response “The first issue relates to a mismatch in the healthcare provider and Home Office expectations and practical application of the Rule 35 provisions. This is being addressed through the development of an interim update to the published guidance Detention Services Order (DSO) 09/2016. The interim guidance will make clear that healthcare staff must inform the doctor of a detained person if staff have concerns of suicidal intention.” Source location Response from 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 Issue staff communications clarifying when closed visits may be used and associated responsibilities.
Verbatim wording from the response “In line with published Home Office guidance DSO 04/2012 ‘Visitors and visiting procedures for detained individuals’, ‘closed visits’ (those which take place behind glass, with no physical contact between the detained individual and the visitor) should only take place in certain circumstances, such as suspicion of drug smuggling, or risk to visitors or children. Any decision to impose a closed visit should be taken on a case-by-case basis, following a documented risk assessment by the IRC supplier. In response to this concern, officials have undertaken a review of closed visits across the estate covering the past 4 months and have issued communications to staff to ensure understanding of when a closed visit can be used and responsibilities around doing so.” Source location Response from Home Office
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Adults at Risk policy and Rules 34 and 35, including whether eligible healthcare professionals should produce Rule 35 reports.
Verbatim wording from the response “In terms of the limitations on the production of a Rule 35 report, where only a General Practitioner can produce a Rule 35 report, the Home Office is currently conducting a review of the statutory Adults at Risk (AaR) policy and Rules 34 and 35 of the Detention Centre Rules 2001. The option to remove this restriction and extend the production of Rule 35 reports to other relevant healthcare professionals is being considered and will form part of an external engagement process. The review is expected to be completed in Spring 2025. Any changes would require new statutory instruments to be laid before Parliament.” Source location Response from 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 Share translation-project learning with suppliers and endorse translated visitor-information pages on supplier websites.
Verbatim wording from the response “Learning from this undertaking will be shared with our suppliers, and we will be endorsing the translation of visitor information pages on their respective websites.” Source location Response from Home Office
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review closed visits across the detention estate for the preceding four months.
Verbatim wording from the response “I am aware that a closed visit was imposed for Mr Ospina and his mother, which the inquest found to be inappropriate and unnecessary. Work has been undertaken in relation to your concern that under current practices, closed visits could potentially take place without the knowledge or consent of the Duty Manager, or without the necessary documentation being completed.” Source location Response from 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 NHS England will respond separately regarding concerns about the operation of Detention Centre Rule 35.
Verbatim wording from the response “I am aware that officials from NHS England will write to you separately with regards to your concerns about the operation of Detention Centre Rule 35. I understand that Mittie Care and Custody will also be writing to you, and their response may touch on some of the issues which I address below.” Source location Response from Home Office
Open published response
2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure carers are informed of Mental Health Act admissions within 24 hours View source Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository View source Failure to provide mental health patients with access to an independent mental health advocate View source Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks View source Failure to determine when police are the appropriate agency for mental health-related enquiries View source Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Sean Heath · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
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 carers are informed of Mental Health Act admissions within 24 hours
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 establish agreed communication means and maintain relevant patient information in an accessible central repository
Wider context from the report “The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 mental health patients with access to an independent mental health advocate
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 officers are trained to assess mental health-related calls and associated immediate risks
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature , the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 determine when police are the appropriate agency for mental health-related enquiries
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists
Wider context from the report “That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care ; and
” Open source report
×
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 Local partners are responsible for determining which agency responds when the police threshold is not met.
Verbatim wording from the response “If the described RCRP threshold is not met, local partners should agree what the best response would be, taking into account local arrangements. It is for partners to work together to determine who will respond to what type of situation. This is why partnership working is important, to ensure partners are clear on each of their roles and responsibilities, and local areas will need plans to be put in place to improve their local response. The police will always maintain the discretion to deploy based on the circumstances and risk assessment of the call.” Source location Response from Home Office
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The College of Policing and Greater Manchester Police are responsible for addressing the specific police working practices raised.
Verbatim wording from the response “Firstly, I should advise that police forces are operationally independent and, as such, it is for the College of Policing and Greater Manchester Police (GMP) to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Heath.” Source location Response from Home Office
Open published response
8 Aug 2024 Emma Pattison and 2 others · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour View source Failure to ensure full disclosure of shotgun certificate applicants’ medical history View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emma Pattison 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
Between 22:49 on 4 February 2023 and 00:40 on 5 February 2023, George Pattison shot and killed his wife, Emma Pattison, and daughter, Ellette Pattison, before shooting himself. The report raises concerns about online medical consultations potentially bypassing disclosure safeguards for shotgun licensing and about obtaining full information concerning coercive controlling behaviour.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour
Wider context from the report “3. Consideration should be given as to how a licensing authority can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour towards another / others .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 full disclosure of shotgun certificate applicants’ medical history
Wider context from the report “1. An applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP , giving rise to a risk that a licensing authority might grant a shotgun certificate to an applicant who has a relevant previous medical history about which the authority is not aware .
2. In consulting an on-line doctor, it is possible for an applicant for a shotgun certificate to avoid the current safeguards relating to full disclosure of their previous and current medical history .
” 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 Issue refreshed firearms guidance strengthening police assessment of domestic abuse, coercive control and other violence allegations, including sensitive confidential interviews.
Verbatim wording from the response “In your report you have also proposed that consideration is given to how the police can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour. The Home Office publishes Statutory Firearms Guidance for Chief Officers of Police which sets out the processes and criteria for assessing an applicant’s suitability to possess firearms. This assists the police in their firearms licensing functions and promotes high standards and consistency between forces. We are intending to issue a refreshed version of the Statutory Guidance early in 2025 which will include additional guidance for the police to help ensure that those who are the perpetrators of domestic abuse, coercive or controlling behaviour, do not have access to firearms.” Source location Response from The 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 Amend firearm and shotgun application forms to require disclosure of consultations with online or third-party prescribers.
Verbatim wording from the response “I have taken careful note of the issue you raise in relation to the medical checks, that there is no requirement for an online or third-party doctor to inform a patient’s GP about medication they have prescribed for them. This is an issue which the Government is considering. In the meantime, in order to further strengthen the firearms licensing process I intend to make arrangements to amend the firearms and shotgun licence application form so that in future applicants are required to provide details if they have consulted an online or third party prescriber who is not their GP. This will enable further enquiries to be made with the online or third-party prescriber, and the police may require the applicant to provide a completed medical proforma from their prescriber in relation to any relevant medical conditions.” Source location Response from The 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 Amend firearm certificates to require holders to notify police about relevant medical consultations with online or third-party doctors.
Verbatim wording from the response “I also intend to amend the firearm certificate to include a new condition requiring the holder to inform the police if they consult an online or third-party doctor about a relevant medical condition during the five years the licence is valid. These changes will” Source location Response from The 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 Consider measures to address online or third-party prescribers not informing applicants’ GPs about prescribed medication.
Verbatim wording from the response “I have taken careful note of the issue you raise in relation to the medical checks, that there is no requirement for an online or third-party doctor to inform a patient’s GP about medication they have prescribed for them. This is an issue which the Government is considering. In the meantime, in order to further strengthen the firearms licensing process I intend to make arrangements to amend the firearms and shotgun licence application form so that in future applicants are required to provide details if they have consulted an online or third party prescriber who is not their GP. This will enable further enquiries to be made with the online or third-party prescriber, and the police may require the applicant to provide a completed medical proforma from their prescriber in relation to any relevant medical conditions.” Source location Response from The Home Office
Open published response
26 Jul 2024 Zara Natasha Aleena · Prevention of Future Deaths report East London
View report summary
Concerns raised 25 Failure to provide prison risk intelligence to Integrated Offender Management meetings View source Threshold for reflective practice set too high View source Unclear understanding of when to request emergency recall View source Lack of mandatory and refreshed risk assessment training View source Lack of supervision for prison offender managers View source Failure to examine local intelligence and Computer Aided Dispatch systems in sufficient detail View source Lack of systems to support staff supervising key decisions View source Lack of alerts for handover from prison to community offender managers View source Lack of checks on sharing up-to-date and accurate risk assessments View source Failure of prison offender managers to implement sentence plans and facilitate rehabilitation View source Lack of focused risk assessment training for prison offender managers View source Lack of rigour, detail and independence in MPS investigations View source Unclear and incomplete sharing of risk information between probation and the MPS View source Failure to conduct timely risk assessments with complementary risk management plans View source Societal acceptance of unreported following behaviour View source Unclear CCTV operator training on identifying sexual predators and stalking behaviour View source Lack of assurance and refresher training for CCTV operators View source Failure to holistically assess indicators of serious harm View source Failure of alert systems to highlight restraining orders View source Lack of reporting guidance and training for business owners on sexualised or predatory behaviour View source OASYS risk assessment tool failing to support extraction and analysis of key risk areas View source Understaffing of probation delivery units View source Failure to probe information relevant to risk View source Obstacles inhibiting increases in assessed risk levels View source Failure of prison offender managers to gather and share evidence relevant to risk formulation View source See 22 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Zara Natasha Aleena · 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
Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prison risk intelligence to Integrated Offender Management meetings
Wider context from the report “(15)The Integrated Offender Management meetings did not receive the necessary intelligence from the prison setting . There was no system in place to ensure that either the prison offender manager was invited to attend, or that the prison offender manager was asked to provide written information around risk incidents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Threshold for reflective practice set too high
Wider context from the report “(18)There were clearly learning points for the police constables, police sergeants and the local intelligence team. The MPS rejected the DPS recommendation for reflective learning, “as there was no failing in performance or conduct”. It is of concern that the threshold for reflective practice is set too high .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 understanding of when to request emergency recall
Wider context from the report “(10) The evidence revealed a difference of opinion and understanding around when an emergency recall should be requested . A senior probation officer and probation services officer erroneously believed that an emergency recall could only be requested out of hours .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory and refreshed risk assessment training
Wider context from the report “(4) Risk assessment training is not part of the mandatory training framework within the probation service. Risk assessment training is not refreshed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 supervision for prison offender managers
Wider context from the report “(12)There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender. They did not attempt to facilitate any rehabilitative interventions. There was no evidence of supervision for the prison offender manager .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to examine local intelligence and Computer Aided Dispatch systems in sufficient detail
Wider context from the report “(17)The Fast Time Review did not probe into sufficient detail into the systems of the local intelligence team and the Computer Aided Dispatch process . A more detailed, independent review should have been carried out.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 systems to support staff supervising key decisions
Wider context from the report “(2) There were no systems in place devised to assist the staff working in these stretched circumstances , such as easy reference checklists for supervising key decisions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 alerts for handover from prison to community offender managers
Wider context from the report “(13)There was no system in place to alert the prison offender manager to handover an offender to the community offender manager when a period of sentence ended and where the offender remained in prison, on remand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of checks on sharing up-to-date and accurate risk assessments
Wider context from the report “(5) There were no checks to ensure the provision of up to date and accurate risk assessments to partner agencies (such as the housing team).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of prison offender managers to implement sentence plans and facilitate rehabilitation
Wider context from the report “(12)There was no evidence that the prison offender manager from February 2021 to October 2021 paid any attention to the sentence plan in place for the offender . They did not attempt to facilitate any rehabilitative interventions . There was no evidence of supervision for the prison offender manager.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of focused risk assessment training for prison offender managers
Wider context from the report “(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training . Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk. There were multiple intelligence logs and records that should have been obtained by them. The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 rigour, detail and independence in MPS investigations
Wider context from the report “(16)I am concerned about the lack of rigour, detail and independence of the MPS investigation into this case. The unit involved in this case was the East Area BCU. An independent, rapid investigation (Fast Time Review) was carried out by the Directorate of Professional Standards. Despite the very limited time to complete the review, the DPS officer reached clear and valuable findings. The findings of the DPS investigator were however rejected by more senior officers within the MPS. The officers who rejected the findings were not independent and all worked within the East Area BCU. This lack of independence is of concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and incomplete sharing of risk information between probation and the MPS
Wider context from the report “(14)The system in place for sharing risk information between the probation service and the MPS was unclear . Only very limited intelligence was shared with the MPS . There was no explanation as to why that information was shared, when more concerning risk related information was not 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 Failure to conduct timely risk assessments with complementary risk management plans
Wider context from the report “(3) The understanding around risk assessment was poor , at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times , and the assessment of risk was not accompanied by a complementary risk management plan . Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm, to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Societal acceptance of unreported following behaviour
Wider context from the report “(21) At least two other members of the public were followed by the offender before he attacked Zara Aleena. The members of the public appear to have seen the offender and appear to be aware that he was following them. This was not brought to the attention of the emergency services. I am concerned that there is a societal acceptance that such conduct does not need to be reported .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 CCTV operator training on identifying sexual predators and stalking behaviour
Wider context from the report “(19)The details of training for CCTV operators includes “training on sexual harassment”, but it is not clear whether this includes identifying sexual predators and stalking type behaviour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 assurance and refresher training for CCTV operators
Wider context from the report “(20)I am unclear from the evidence provided, whether LBR have a system for checking that training provided to CCTV operators is fully understood , or whether refresher training is provided to 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 holistically assess indicators of serious harm
Wider context from the report “(3) The understanding around risk assessment was poor, at all levels of staffing. The practical application of risk assessment was poor at all levels of staffing. Risk was not assessed at appropriate times, and the assessment of risk was not accompanied by a complementary risk management plan. Risk management plans were once prepared before risk was fully assessed (as occurred with the setting of licence conditions). One practitioner was advised to set a risk level to match other completed documents (without analysis of risk itself). Practitioners did not holistically assess risk and take account of potential indicators of serious harm , to include use of weapons; attitudes supportive of violence; callousness and high increased frequency of lower-level violence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 alert systems to highlight restraining orders
Wider context from the report “(8) The globe system and alert systems did not work effectively in this case. A restraining order had been put in place against the offender, but this was not highlighted , as it should have been. Key staff involved in assessing and managing the offender were unaware of the restraining order .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 reporting guidance and training for business owners on sexualised or predatory behaviour
Wider context from the report “(22)Business owners were aware of the offender’s concerning conduct on the night of Zara Aleena’s murder. For example, a public house had refused to provide more drinks to him. It is not clear whether business owners are encouraged to report such concerning behaviour to the authorities or whether they are offered any training to assist them and their staff to recognise sexualised or predatory behaviour .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation OASYS risk assessment tool failing to support extraction and analysis of key risk areas
Wider context from the report “(7) The OASYS risk assessment tool is unwieldy and difficult to navigate . It was challenging to extract the most relevant material. The content of the OASYS assessment was so dense that the probation officers seemed to get lost in the detail and failed to pull together and formulate/analyse key risk areas . One senior probation officer stated that she would not look at the OASYS when allocating cases, because OASYS assessments were “not always accurate and up to date”. It is noted that a new risk assessment tool within the probation service is a work in progress. It is hoped that the new tool will take into account the above concerns.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Understaffing of probation delivery units
Wider context from the report “(1) The probation delivery unit responsible for the offender was understaffed at the time of relevant oversight. The staffing levels were 61% in 2022 . The staffing levels at the time of the inquest in June 2024 was 58% . The inquest heard that this is a national problem and that there are other probation delivery units that have even lower levels of staffing. The low staffing level had an impact upon quality and depth of assessments; quality of supervision of junior staff (supervision was wholly reactive); excessively high workloads for probation officers and senior probation officers; lack of cover during annual leave for probation officers and poor record keeping.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 probe information relevant to risk
Wider context from the report “(6) There was a lack of professional curiosity and a lack of sufficient probing into information relevant to risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Obstacles inhibiting increases in assessed risk levels
Wider context from the report “(9) There may be obstacles to increasing risk levels . The inquest heard that senior probation staff would have to approve increases in risk. As staffing levels are so stretched, there may be reticence of junior probation officers to trouble the senior team . The risk assessment policy also includes a statement that staff “should not use risk levels to inflate risk because of anxiety or to access resources”. It is a concern that this provision may inhibit decisions to increase risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of prison offender managers to gather and share evidence relevant to risk formulation
Wider context from the report “(11) The role of the prison offender manager is to gather evidence to assist with the formulation of risk. Prison offender managers do not however receive focussed risk assessment training. Neither of the prison offender managers in this case gathered evidence to assist with the formulation of risk . There were multiple intelligence logs and records that should have been obtained by them . The logs included findings of possession of weapons, drug taking, threats to harm others and a sustained assault on a servery worker using an improvised weapon. This information was not gathered and shared appropriately .
” 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 Consider further measures to encourage business owners and staff to report sexualised and predatory behaviour.
Verbatim wording from the response “I would also like to respond to concerns relating to business owners not doing enough to report sexualised and predatory behaviour, and concerns relating to staff training. All business owners are encouraged to report such concerning behaviour to the authorities. Additionally, the licensed sector often provides training to assist staff to recognise sexualised or predatory behaviour and to take the necessary action. However, your report illustrates clearly that there were failings and that much more work needs to be done to ensure this is happening in practice. I have asked my officials to consider how we can go further to encourage business owners and staff to report such predatory behaviour. As a” Source location Response from 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 across government to ensure reporting responsibilities are understood and reporting pathways are created.
Verbatim wording from the response “I would also like to respond to concerns relating to business owners not doing enough to report sexualised and predatory behaviour, and concerns relating to staff training. All business owners are encouraged to report such concerning behaviour to the authorities. Additionally, the licensed sector often provides training to assist staff to recognise sexualised or predatory behaviour and to take the necessary action. However, your report illustrates clearly that there were failings and that much more work needs to be done to ensure this is happening in practice. I have asked my officials to consider how we can go further to encourage business owners and staff to report such predatory behaviour. As a” Source location Response from 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 Fund active-bystander training for night-time-economy staff and community members to support intervention and reporting.
Verbatim wording from the response “The Home Office has funded a range of interventions to help tackle violence against women and girls in public spaces, including within the night-time economy. These interventions have included capable guardianship initiatives such as Street Angels or Street Pastors and educational programmes with a focus on changing attitudes and perceptions and raising awareness on these issues, as well as active bystander training, which was targeted at night-time economy staff and other members of the community. The independent evaluations of educational programmes have shown that they can have a positive influence on training beneficiaries’, including improvements in their awareness and understanding of these crimes, likelihood to report VAWG and improvements in confidence in their ability to support victims and ability to intervene in incidents.” Source location Response from Home Office
Open published response
3 Jun 2024 Tcherno Bari · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 12 Failure to ensure police access to the written risk assessment View source Failure to provide attending police officers with the written risk rating View source Failure to maintain an accurate and up-to-date missing person policy View source Lack of police officer awareness of the required risk rating View source Failure to communicate the RCRP challenge process to BSMHFT View source Delays in communicating police disagreement with the reported risk category View source Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise View source Lack of formal notification of police disagreement about risk category View source Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients View source Failure to inform BSMHFT when missing patient investigations are closed View source Failure to invite police representatives to daily appraisal meetings View source Failure of routine monitoring to ensure completion of the risk rating View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tcherno Bari · 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
Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police access to the written risk assessment
Wider context from the report “(7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment , or require attending constables, or later the Locate team, to request a copy of the risk assessment . In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 attending police officers with the written risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy . I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’ , and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 an accurate and up-to-date missing person policy
Wider context from the report “(5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP . I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 officer awareness of the required risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’ . Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’ .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the RCRP challenge process to BSMHFT
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT . Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it . However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process . Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 communicating police disagreement with the reported risk category
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later , and WMP often close missing patient investigations without informing BSMHFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 require attending constables to give particular regard to mental health clinicians’ risk expertise
Wider context from the report “(8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. RCRP and APP appear to regard reports from mental health clinicians no differently to those from members of the public, and family and friends of the missing person . Context: police witnesses agreed that BSMHFT clinicians were the experts on mental health diagnosis, including identifying those conditions that carry an increased risk of suicide, and assessing the risk of suicide generally. However, this case demonstrates how in the heat of the moment an (inexperienced) attending constable can overlook that expertise and quickly dismiss it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of formal notification of police disagreement about risk category
Wider context from the report “(6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category . BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients , and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case, and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 BSMHFT when missing patient investigations are closed
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 invite police representatives to daily appraisal meetings
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case , and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’ .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 routine monitoring to ensure completion of the risk rating
Wider context from the report “(2) A ‘monitoring tool’ in the BSMHFT Missing Patient Policy requires routine monitoring to ensure nurses are completing ‘appendix A’ and ‘appendix B’, but not ‘appendix C – risk rating’ . Context: I was told this is under review, however I was concerned this is still outstanding 9 months following the death .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the National Partnership Agreement setting principles and guidance for applying Right Care Right Person at the policing–mental health interface.
Verbatim wording from the response “It may help if I outline the rationale and purpose of the National Partnership Agreement (NPA), as the Home Office was one of the signatories when it was published in July 2023.” Source location Response from the Home Office
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.
Verbatim wording from the response “As you are aware, police forces are operationally independent and so it is for the National Police Chiefs’ Council, the College of Policing and West Midlands Police to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Bari, and I know they have written to you separately on this matter.” Source location Response from the Home Office
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Each Chief Constable decides whether and when to implement Right Care Right Person and which elements of the national framework to adopt.
Verbatim wording from the response “As Policing is operationally independent, each Chief Constable has to decide whether and when to implement Right Care Right Person and how much of the framework set out in the National Partnership Agreement and supporting guidance they wish to adopt.” Source location Response from the Home Office
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Missing Persons is outside Right Care Right Person, so existing police procedures for police involvement should continue.
Verbatim wording from the response “healthcare facilities. Missing Persons is not a part of this and existing police procedure regarding police involvement should continue to operate.” Source location Response from the Home Office
Open published response
30 May 2024 Katie MADDEN · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 7 Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children View source Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations View source Failure of the funding pathway to provide access to specialist psychological treatment View source Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS View source Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification View source Lack of independent Social Services support for vulnerable parents View source Lack of independent professional holistic case review for vulnerable parents View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Katie MADDEN · 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
Katie Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children
Wider context from the report “4. Safeguarding referrals made the Multi-Agency Safeguarding Hub in respect of Kate’s children were viewed in isolation , with no system in place to assess any additional risks posed to Kate herself . There were no additional steps, or risk assessments undertaken in relation to Kate , even though she was a recipient of a ‘Claires Law’ Domestic Violence Disclosure and therefore known to be more vulnerable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations
Wider context from the report “1. No evidence was seen that recipients of a ‘Claires Law’ Domestic Violence Disclosure are treated as being of greater vulnerability, or at a higher risk, when Child Services are undertaking investigations regarding the provision of children’s care, and removal of the children from a parent is being considered . It was heard in evidence that the Social Worker appointed to this case, quite properly focused on what was in the best interest of Kate’s children. There was however no formal system in place to provide additional support for Kate herself, even though she was known to be vulnerable.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 funding pathway to provide access to specialist psychological treatment
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS.
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved .
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding ’. In addition, funding was very rarely made available , and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Schema-based Cognitive Behavioural Therapy on the NHS
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS .
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved.
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding’. In addition, funding was very rarely made available, and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification
Wider context from the report “2. It was identified that when Kate was informed there may be an application to the Family Court to place her children into care (using the Public Law Outline process), the impact of such a decision on her mental health, or physical wellbeing was not taken into consideration . As a recipient of a ‘Claires Law’ Domestic Violence Disclosure, it was acknowledged that she was of greater vulnerability, but no system is currently in place which allows a risk assessment to be undertaken at the time the Public Law Outline notification is given to a parent . The day after Kate was told of the Public Law Outline notification, she had intentionally crashed her car in an unsuccessful attempt to end her life, requiring 4 weeks in an Intensive Treatment Unit to recover from the serious injuries she received.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Social Services support for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services , and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities. It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of independent professional holistic case review for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services, and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities . It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” Open source report
29 May 2024 Elizabeth Sarah Jayne McCann · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 19 Inadequate management structure and oversight in the health and wellbeing college View source Failure to comply with GDPR in the health and wellbeing college View source Inadequate safeguarding provisions in health and wellbeing colleges View source Insufficient probation staffing capacity View source High proportion of probation officers with limited service and experience View source Limited information-sharing protocols between probation and partner services View source Lack of professional curiosity by senior GMP officers View source Poor-quality GMP investigations and reports View source Insufficient staffing of sexual offender management units View source Poor-quality investigations failing to generate organisational learning View source Failure to provide adequate supervision and support to newly qualified probation staff View source Insufficient professional curiosity among staff dealing with high-risk offenders View source Ineffective information-sharing protocols in health and wellbeing colleges View source Sexual offender management caseloads exceeding safe levels View source Insufficiently clear and understood risk-management protocols in health and wellbeing colleges View source Failure to escalate investigation reports for senior consideration View source Referrals to health and wellbeing services without risk-management protocols View source Inadequate systems for managing risk in the health and wellbeing college View source Lack of an information-sharing protocol between the health and wellbeing college and probation View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth Sarah Jayne McCann · 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
Elizabeth Sarah Jayne McCann was raped and murdered on 25 August 2022 at the home address of her murderer. The report identifies failures in risk assessment, information sharing, safeguarding, and management of a high-risk offender by the Health and Wellbeing College, Probation, and Greater Manchester Police. It also identifies concerns about excessive caseloads, inadequate staffing, supervision, recording, and organisational learning.
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 management structure and oversight in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight , lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 comply with GDPR in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 safeguarding provisions in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 probation staffing capacity
Wider context from the report “1. The inquest heard evidence that the probation staff were carrying significant caseloads . This was due to challenges in recruiting sufficient staff . The evidence was that there is still a national shortage of probation officers . Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation High proportion of probation officers with limited service and experience
Wider context from the report “1. The inquest heard evidence that the probation staff were carrying significant caseloads. This was due to challenges in recruiting sufficient staff. The evidence was that there is still a national shortage of probation officers. Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Limited information-sharing protocols between probation and partner services
Wider context from the report “4. Clear Information Sharing protocols between Probation and such groups as drug and alcohol services were limited . Without clear agreements understood by both sides there was a significant risk that crucial information that impacted risk assessments would not be 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 Lack of professional curiosity by senior GMP officers
Wider context from the report “8. There was no evidence before the inquest of any professional curiosity by senior GMP officers as to the role of GMP and if lessons could be learnt . It was unclear as to why senior officers were unsighted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Poor-quality GMP investigations and reports
Wider context from the report “7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report. The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 staffing of sexual offender management units
Wider context from the report “5. The inquest was told that nationally a significant number of police forces were struggling to adequately staff their Sexual Offender Management Units . As a consequence, the level of supervision of sex offenders in the community was being risk managed posing a risk to communities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Poor-quality investigations failing to generate organisational learning
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed . This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 adequate supervision and support to newly qualified probation staff
Wider context from the report “2. The evidence before the inquest was that it was important that newly qualified probation staff were closely supervised and supported by their managers . Without that supervision performance issues identified by the trackers were not being tackled . Ensuring this had been and was challenging as the number of staff line managed by senior probation officers had been too high . This was being addressed but was only achievable if sufficient senior staff were retained.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 professional curiosity among staff dealing with high-risk offenders
Wider context from the report “9. It was accepted that there needed to be a level of professional curiosity by staff dealing with high-risk offenders such as in this case and that training for probation officers and police staff needed to reinforce that.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 information-sharing protocols in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place. There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Sexual offender management caseloads exceeding safe levels
Wider context from the report “6. In the case of Greater Manchester Police, the staffing issues had been known by senior managers for a number of years (many years before Covid) and a decision taken to risk mange far below the appropriate staffing numbers taken. The consequence was that the staff in the unit could not effectively manage their caseloads that were far in excess of the recommended level . The numbers in the unit were increasing but the caseloads were still high.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clear and understood risk-management protocols in health and wellbeing colleges
Wider context from the report “10. The inquest was told that Health and Well Being Colleges could provide effective support for the communities they served. They were a national model. However, if they were to be open to all it was essential that they were structured in such a way that risk was effectively managed with clear, documented protocols understood by all in place . There was also a need for effective information sharing protocols and effective well understood safeguarding provisions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 escalate investigation reports for senior consideration
Wider context from the report “7. The GMP investigation into their role in relation to Elizabeth’s death was poor in quality and there was no evidence that any senior officer had considered the report . The inquest was told that the quality and lack of referral upwards of a report was not unique to Elizabeth’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Referrals to health and wellbeing services without risk-management protocols
Wider context from the report “3. Evidence before the inquest was that if probation referred clients under supervision to places such as the Health and Wellbeing College this would, if not implemented effectively pose a significant risk to vulnerable users of such institutions. If referrals were made without a protocol being in place that dealt with managing risk then the risk posed increased further.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 systems for managing risk in the health and wellbeing college
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation, the systems in the college for managing risk and sharing information and compliance with GDPR.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 information-sharing protocol between the health and wellbeing college and probation
Wider context from the report “11. The Health and Wellbeing College in Tameside served 5 boroughs of Greater Manchester and was run by the Mental Health Trust. It was accepted by the Trust that the investigation report was of poor quality and an opportunity to learn lessons missed. This included the management structure, oversight, lack of an information sharing protocol with probation , the systems in the college for managing risk and sharing information and compliance with GDPR.
” 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 working with police forces to improve the effectiveness and efficiency of systems for managing sex offenders and preventing further harm.
Verbatim wording from the response “Once again, we would like to take the opportunity to thank you for highlighting these matters of concern, and for giving us the opportunity to respond. We will continue to work with police forces to make sure we continue to improve the effectiveness and efficiency of the system that supports policing to manage sex offenders and prevent them from committing further harm.” Source location Response from 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 Develop a multi-agency public protection system with improved offender-management functionality and information sharing.
Verbatim wording from the response “Your report is clear that more must be done to enhance the police’s capability to sufficiently manage sex offender in the community, and I agree that is the case. To make sure that the police, prisons, probation service and others have the right systems in place to do this and share pertinent information on registered sex offenders and other dangerous individuals, the Home Office is developing a new” Source location Response from Home Office
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review national expectations for managing the highest-risk offenders.
Verbatim wording from the response “However, I recognise your concerns regarding the lack of sufficient staffing amongst sexual offender management units and the impact that this has in ensuring sex offenders are being effectively managed in communities. I am committed to making our streets safer. As part of our mission to halve violence against women and girls in a decade, we will ask the police to relentlessly pursue those perpetrators who pose the greatest risk to women and use all the tools at their disposal to protect victims and get dangerous offenders off the streets. We are currently working at pace to look at our national expectations on the management of the highest-risk offenders.” Source location Response from 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 Ask police to prioritise and pursue perpetrators posing the greatest risk to women.
Verbatim wording from the response “However, I recognise your concerns regarding the lack of sufficient staffing amongst sexual offender management units and the impact that this has in ensuring sex offenders are being effectively managed in communities. I am committed to making our streets safer. As part of our mission to halve violence against women and girls in a decade, we will ask the police to relentlessly pursue those perpetrators who pose the greatest risk to women and use all the tools at their disposal to protect victims and get dangerous offenders off the streets. We are currently working at pace to look at our national expectations on the management of the highest-risk offenders.” Source location Response from 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 Chief constables and elected police and crime commissioners decide how police funding and resources are utilised.
Verbatim wording from the response “Decisions on how funding and resources are utilised is a matter for chief constables and elected police and crime commissioners (including mayors with Police and Crime Commissioner (PCC) functions). However, it is vitally important that every police force has the specialist officers and other resources necessary to support victims of rape and sexual violence, bring perpetrators to justice and manage the risks they pose.” Source location Response from Home Office
Open published response
20 May 2024 James Furlong and 2 others · Prevention of Future Deaths report Central Criminal Court
View report summary
Concerns raised 6 Failure to maintain and disseminate an adequate intelligence picture View source Failure to provide an adequate and integrated response to identified risk View source Failure to address consequential risks created by inadequate intelligence dissemination View source Failure to provide adequate secondary mental healthcare in prison View source Failure to provide adequate mental healthcare in the community View source Failure to avoid discounting extremist risk because of personality disorder and PTSD symptoms 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
James Furlong 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
James Furlong, Joseph Ritchie-Bennett and David Wails were murdered by Khairi Saadallah in a premeditated attack in Forbury Gardens, Reading, on 20 June 2020. The principal concerns were failures by multiple bodies to assess and share intelligence about Saadallah’s risks, provide an adequate integrated response, and provide adequate mental healthcare in the community and prison; the report states these failures probably or possibly contributed to the three 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 maintain and disseminate an adequate intelligence picture
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 adequate and integrated response to identified risk
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 address consequential risks created by inadequate intelligence dissemination
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 adequate secondary mental healthcare in prison
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 adequate mental healthcare in the community
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 avoid discounting extremist risk because of personality disorder and PTSD symptoms
Wider context from the report “The critical context of this Report is that there were notable failures on the part of multiple bodies which both probably and possibly contributed to the three deaths. These have been explained in extenso in my Factual Findings. In summary form, however, there was a failure to:
a) assess the intelligence in its entirety (there was an extensive intelligence history concerning KS’s extremism and capacity for violence) and then share the intelligence appropriately; instead – certainly on occasion – limited pieces of information only were made available, which were thereby rendered potentially misleading;
b) address the substantial consequential risks created by this lack of dissemination of the overarching intelligence picture (which included KS’s extremist views and associations, military training and violent impulsivity, which were potentiated by his personality disorder);
c) provide an adequate and integrated response to the true risk posed by KS, based on a consideration of the entirety of the relevant material; and
d) offer KS adequate mental healthcare in the community and secondary mental healthcare in prison.
The failures principally involved the Home Office, Counter Terrorism Police South-East (“CTPSE”), HMPPS, BHFT and MPFT. There were concurrent deficiencies in the approach adopted within the Prevent, Pathfinder and MAPPA schemes. A common enduring error during the relevant period was the tendency to downplay or discount KS’s extremist risk on account of his EUPD and symptoms of PTSD.
The failure to maintain and disseminate an adequate intelligence picture (the Secretary of State for the Home Department, the Secretary of State for Justice, the Chief Constable of Thames Valley Police)
The failure to provide KS adequate mental healthcare in the community and to provide KS adequate secondary mental healthcare in prison (the Secretary of State for Justice, Berkshire Healthcare NHS Foundation Trust and Midlands Partnership University NHS Foundation Trust)
” 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 Reinforce to Channel Chairs that mental-health needs do not replace Prevent support and that the Clinical Consultancy Service is available.
Verbatim wording from the response “To further this point, we have written to all Channel Chairs to raise awareness of the concern in the report that KS’s risk assessment was incorrectly focused on his mental health difficulties, and to reinforce that the purpose of Channel is both to safeguard individuals and to manage the potential terrorist risk they may pose. Therefore, the existence of or need for wraparound mental health support for an individual does not negate the need for the person to receive Prevent support. We also reminded Channel Chairs that the CCS is available to provide Prevent officers with advice, guidance and options to help manage the individuals in their casework with mental health needs.” Source location Response from the 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 Use referral and training data to target Prevent outreach and training where referral quality or local risk alignment is weaker.
Verbatim wording from the response “We are using Prevent referral data (from the new case management system) and training data to identify where the quality of referrals is lower, or not in line with the risk in that area or sector. This has enabled us to better target Prevent outreach and training to improve the quality of referrals. Alongside this, a refreshed list of ideology categories has also been created for use in the new case management system, which will be accompanied by updated training and guidance for case officers to ensure accurate recording of data and evidence about ideology. We will review the ideology categories on an annual basis to ensure they are reflective of the wider ideological picture and routinely monitor Prevent data, carrying out dip sampling to provide assurance that there are no disparities in decision-making throughout the Prevent pathway.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing Prevent policy to identify improvements in managing mental-health and neurodiversity issues.
Verbatim wording from the response “We keep our operational policy approach to Prevent under constant review, and we will continue to look at mental health issues and neurodiversity as part of this, to identify areas we can strengthen.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update Prevent and Channel guidance to strengthen risk understanding, training, assessment and progression of referrals meeting the Prevent threshold.
Verbatim wording from the response “In 2023 the Home Office updated the Prevent duty guidance (England and Wales)⁵ and the Channel duty guidance⁶. My understanding is that this is to better enable those sectors subject to the Prevent duty (such as local authorities, police, health, education, and prisons and probation) as well as those working on Channel panels, to be effective at understanding and mitigating terrorism risk, and to have structures in place that identify and support people vulnerable to radicalisation. The new guidance provides clearer advice on how to understand and manage risk, including by ensuring comprehensive training and risk assessments take place. It also introduces new tools for frontline practitioners to ensure that those meeting the Prevent threshold are progressed for Prevent specific support, with a focus on ideology as a determinant of Prevent thresholds.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor and quality-assure Prevent assessment framework use through CT-ARC, CTPHQ and Home Office systems, including longer-term evaluation.
Verbatim wording from the response “I understand that the PAF has been piloted since November 2023 in the South-West and Eastern regions. During this pilot stage, as well as receiving feedback on the PAF, I am told that CT-ARC have been quality assuring the PAF process monthly to assess the quality of use and completion by looking at how integrity to the guidance is upheld. We will continue to monitor the PAF with CT-ARC and CTPHQ to ensure it is robust, efficient, evidence-informed, operationally viable and well-integrated into the current system. Details of how longer-term quality assurance will be conducted will be finalised in August ahead of national PAF rollout later in autumn. However, this will include continuous and regular review of PAF use, as well as a longer-term evaluation.” Source location Response from the 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 Train CTCOs to complete the Prevent assessment framework, using assessed readiness checks and further training where needed.
Verbatim wording from the response “The PAF is being rolled out in Autumn of 2024 to all regions. Prior to using it, CTCOs must attend an assessed training day to become familiar with the PAF, how to complete it, how it fits into current processes, and to practise completing it. During the training day there are three assessment points where attendees will be assessed as either ‘Ready’ or ‘Not Yet Ready’ to complete a PAF for live cases. If awarded ‘Not Ready’, attendees will be provided a further opportunity to complete the task training.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce strengthened Channel quality assurance, including routine panel and case-management assessment and data-led improvement activity.
Verbatim wording from the response “Following the introduction of the Channel Quality Assurance Framework in 2021, we are introducing an improved and strengthened quality assurance process. This includes routine assessment of Channel panel performance and case management. We will also utilise the data trends drawn from the new case management system to identify areas (regional or thematic) to provide additional case assurance and direct improvements where needed. We will use this quality assurance process and performance monitoring to further drive-up standards of delivery. I have been informed that this process started in April 2024 and initial results are expected to be shared with Channel panels in April 2025.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the joint Prevent case management system to flag previous referrals and expose data trends for risk-assessment oversight.
Verbatim wording from the response “I understand that the Home Office and CTPHQ launched a new joint Prevent case management system in May 2024. In developing this system, I am told we have ensured that when a new Prevent referral is registered, any previous referrals are automatically flagged to ensure this information is fully considered during the initial assessment stage and throughout the individual’s Prevent pathway. I am concerned about the specific issue of repeat Prevent referrals falling below the threshold and am committed to look closely at this. This new case management system also provides CTPHQ and the Home Office access to data trends, which allows for consideration of any outliers in decision making. These outliers can be flagged for potential further action.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce refreshed ideology categories with supporting case-officer training and guidance, and review categories annually while monitoring pathway decision-making.
Verbatim wording from the response “We are using Prevent referral data (from the new case management system) and training data to identify where the quality of referrals is lower, or not in line with the risk in that area or sector. This has enabled us to better target Prevent outreach and training to improve the quality of referrals. Alongside this, a refreshed list of ideology categories has also been created for use in the new case management system, which will be accompanied by updated training and guidance for case officers to ensure accurate recording of data and evidence about ideology. We will review the ideology categories on an annual basis to ensure they are reflective of the wider ideological picture and routinely monitor Prevent data, carrying out dip sampling to provide assurance that there are no disparities in decision-making throughout the Prevent pathway.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the independently endorsed Prevent assessment framework nationally to improve referral triage and cumulative-risk assessment.
Verbatim wording from the response “As I understand Chief Constable ████████ will also be addressing in Thames Valley Police’s response to you from the operational perspective, the Home Office and CTPHQ have also worked with the national CT Assessment and Rehabilitation Centre (CT-ARC)⁴ to develop a new Prevent assessment framework (PAF). I understand that this replaces the Vulnerability assessment framework and is designed to ensure that the triaging of referrals into Prevent is consistent, rigorous, and proportionate. I am told the PAF, which has been independently endorsed, will ensure that thresholds and decision-making are implemented consistently across all ideological threats by creating a framework that is easily understood, easily completed, and supports CTCOs in their decision making.” Source location Response from the 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 CTPHQ is responsible for operational Prevent risk management and monitoring, including the operational issues identified in the Report.
Verbatim wording from the response “The Home Office's Prevent directorate provides the strategic direction for Prevent, including Prevent relevant training to non-police Prevent statutory partners within local authorities. The police are responsible for managing the terrorism risk of individuals throughout all stages of the Prevent pathway, as well as the policy, assessment tools, and training of police officers and staff conducting these assessments. As all of KS’s referrals were closed at the initial assessment stage by Counter Terrorism Policing Prevent officers, the Home Office Channel programme did not manage the case. Therefore, effective monitoring of the operational Prevent issues raised in the Report is best addressed by CTPHQ.” Source location Response from the Home Office
Open published response
25 Apr 2024 Dr Jonathan Harvey Shaw · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Inability to retain consignments beyond the 30-day holding period View source Lack of training for joint working on managing overseas consignments of the substance View source Lack of national guidance on joint working for managing overseas consignments of the substance View source Lack of a legal requirement to alert the local police force before releasing consignments View source Lack of a legal requirement to request a welfare check before releasing consignments View source Lack of legal powers to seize consignments of the substance 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
Dr Jonathan Harvey Shaw · 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
Dr Jonathan Harvey Shaw took his own life by intentionally ingesting the contents of a package purchased online from a Malaysian company. The package had been stopped by UK Border Force but was released without consultation with Greater Manchester Police, after which Dr Shaw used its contents to end his life. The report identifies concerns about the 30-day limit on holding the consignment and the absence of national guidance or training for police and UK Border Force on managing such consignments and coordinating welfare checks or safe destruction.
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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 Inability to retain consignments beyond the 30-day holding period
Wider context from the report “The UK Border Force do not have the legal powers to seize a consignment of ████████ because it is not a prohibited poison under the Poisons Act 1972. If there is an ongoing police investigation or police interest in a particular consignment, the UK Border Force can use section 19 of the Police and Criminal Evidence Act 1984 to stop and hold. However the holding power is limited to 30 days, after which the consignment must be 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 Lack of training for joint working on managing overseas consignments of the substance
Wider context from the report “There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 national guidance on joint working for managing overseas consignments of the substance
Wider context from the report “There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 legal requirement to alert the local police force before releasing consignments
Wider context from the report “There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 legal requirement to request a welfare check before releasing consignments
Wider context from the report “There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of legal powers to seize consignments of the substance
Wider context from the report “The UK Border Force do not have the legal powers to seize a consignment of ████████ because it is not a prohibited poison under the Poisons Act 1972. If there is an ongoing police investigation or police interest in a particular consignment, the UK Border Force can use section 19 of the Police and Criminal Evidence Act 1984 to stop and hold. However the holding power is limited to 30 days, after which the consignment must be released.
” 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 Remind frontline Border Force staff of required steps for relevant consignments and provide case-by-case support.
Verbatim wording from the response “Similarly, Border Force are working at pace alongside police colleagues to introduce measures to prevent any similar tragedies occurring. This includes development of specific national guidance for managing suspicious items which is currently lacking and improved sharing of information with police forces, and other relevant agencies where required, to safeguard vulnerable individuals to the full extent possible within the limits of its existing powers. This work is complex and, whilst underway, frontline Border Force staff who may encounter these consignments are actively being reminded of the steps they need to take with additional support available on a case-by-case basis.” Source location Response from Home Office
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop national guidance for Border Force and police on managing suspicious consignments and safeguarding vulnerable individuals.
Verbatim wording from the response “Similarly, Border Force are working at pace alongside police colleagues to introduce measures to prevent any similar tragedies occurring. This includes development of specific national guidance for managing suspicious items which is currently lacking and improved sharing of information with police forces, and other relevant agencies where required, to safeguard vulnerable individuals to the full extent possible within the limits of its existing powers. This work is complex and, whilst underway, frontline Border Force staff who may encounter these consignments are actively being reminded of the steps they need to take with additional support available on a case-by-case basis.” Source location Response from 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 Engage police and legal colleagues to consider whether existing offences could support seizure powers in relevant cases.
Verbatim wording from the response “Border Force, on whom the Regulation 28 Notice is focused, has no control over the extent of the powers granted to it by primary or secondary legislation but is working at pace with Home Office policy leads to understand how it can help to prevent similar tragedies occurring. Furthermore, Border Force will however engage with police and legal colleagues to consider whether powers can be invoked on behalf of police where other relevant offences may apply. For example:” Source location Response from 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 Explore legislative and policy options to control the substance and address ethical frontline responses to welfare concerns.
Verbatim wording from the response “I am determined that we must ensure that all reasonable steps to prevent further loss of life are taken and the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and similar substances) including how to ensure front line officers respond ethically to circumstances where the welfare of individuals is concerned.” Source location Response from 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 Border Force cannot extend its seizure powers because those powers are limited by primary and secondary legislation.
Verbatim wording from the response “As you have summarised, ████████ is not a substance requiring any special authority to import into the UK and so where it has been correctly declared, Border Force have no powers to seize it under the Customs and Excise Management Act 1979, (“CEMA 1979”). You have also highlighted how, Border Force’s CEMA powers are supplemented by the Police and Criminal Evidence Act 1984 (“PACE 1984”) where, in some cases, Border Force officers acting as designated customs officials can exercise powers granted under S19. This does allow for seizure provided that the substance is the consequence of an offence. Suicide/self-harm however are not criminal acts.” Source location Response from Home Office
Open published response
19 Dec 2023 Chloe Elizabeth MACDERMOTT · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Lack of prominent signposting to organisations providing suicide-prevention help View source Internet availability and delivery of an unspecified item to individual users in the UK View source Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide View source Failure of effective border and customs controls for delivery of an unspecified item to UK users View source Lack of age or other access restrictions for children, vulnerable teenagers and vulnerable adults View source Failure to effectively remove posts containing details of suicide methods 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
Chloe Elizabeth MACDERMOTT · 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
Chloe Elizabeth MACDERMOTT died at home in the early hours of 23 May 2021 after ingesting a substance purchased through Amazon US. The report identifies concerns about online forums encouraging, assisting and counselling suicide, inadequate age restrictions and signposting to help, harmful content not being effectively removed, and the availability and delivery of the product to UK users without effective border or customs controls.
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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 prominent signposting to organisations providing suicide-prevention help
Wider context from the report “(6) No prominent signposting is in place to organisations from whom help is available to prevent suicide .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Internet availability and delivery of an unspecified item to individual users in the UK
Wider context from the report “(9) The availability of ████████ through the internet and its delivery to individual users in the UK with a non-commercial or agricultural 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 Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide
Wider context from the report “(3) ████████ is a forum that permits material to be exchanged and reviewed within its open chatrooms whereby suicide is encouraged, assisted, counselled and procured through the provision and exchange of information and methods .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 effective border and customs controls for delivery of an unspecified item to UK users
Wider context from the report “(10) The ability for UK users to purchase ████████ through Amazon in the United States and to take delivery in the United Kingdom without effective border and/or custom controls .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 age or other access restrictions for children, vulnerable teenagers and vulnerable adults
Wider context from the report “(5) No age or other restrictions are in place to prevent access to children, vulnerable teenagers and vulnerable 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 effectively remove posts containing details of suicide methods
Wider context from the report “(7) Posts are made by users containing details of methods of suicide without any effective administration to remove such harmful content .
” Open source report
2 Dec 2023 Steven Bowker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Dangers to patients from prolonged prescription and use of opiate medication 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
Steven Bowker · 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 Bowker fell from garden ladders in 2016 and subsequently developed dependence on prescribed opioid medication. He was found unresponsive at home and pronounced dead on 1 December 2021; the report expressed concern about the dangers of prolonged prescription and use of opiate medication.
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 Dangers to patients from prolonged prescription and use of opiate medication
Wider context from the report “I am concerned by the dangers to patients in respect of the prolonged prescription and use of opiate medication .
” Open source report
27 Nov 2023 Gracie Elizabeth Spinks · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 6 Failure to maintain contemporaneous and sufficiently detailed investigation records View source Failure to deal effectively with reports of potential dangerous weapons found in the community View source Lack of consistent availability of stalking advocates for victims across the UK View source Failure to complete and regularly reassess comprehensive investigation risk assessments View source Failure to investigate stalking complaints fully and in line with available guidance View source Failure to individually record all stalking offence locations View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gracie Elizabeth Spinks · 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
Gracie Elizabeth Spinks was unlawfully killed by a former work colleague on 18 June 2021, dying from a stab wound to the neck. The report describes serious police failings in investigating her stalking complaint and in dealing with a rucksack containing weapons, and raises concerns about stalking investigations, risk assessments, record keeping, dangerous items found in the community, and the availability of independent stalking advocates.
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 maintain contemporaneous and sufficiently detailed investigation records
Wider context from the report “4. Contemporaneous note taking/record keeping – during the inquest I heard that police officers failed to make any contemporaneous notes of important steps in the police investigation including, for example, conversations with an informant/member of the public, words of advice given to a suspect, a telephone call to a potential witness and also an internal police discussion between a police constable and police sergeant discussing the closure of an investigation. The written crime reports reviewed during the inquest also lacked sufficient detail around these important conversations/investigative steps – in other words, the crime reports did not compensate for the lack of contemporaneous notes.
I am concerned that a lack of contemporaneous notes/insufficient detail within a crime report may impact on the ability to make properly informed risk assessments which rely on the existence of a good written record of important conversations/steps taken during an investigation. This may become an issue where, for example, an investigation is re-allocated to another police officer who has had no prior involvement in the investigation such that the newly allocated police officer will be reliant upon the quality of the original police officer’s records/notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 deal effectively with reports of potential dangerous weapons found in the community
Wider context from the report “5. Potential weapons/dangerous items found in the community – during the inquest I heard that police officers attended to a report of a rucksack containing weapons found by a member of the public in May 2021. Despite the rucksack containing weapons, it was treated by the attending police officers as if it were an item of found property . Derbyshire Constabulary accepted that there were serious failings in how the officers dealt with this incident. During the inquest, I heard that there has been another recent incident around 11 August 2023 in which a child found a knife concealed in bushes in a local park. The knife was concealed in a sock and the child’s parent was concerned that the knife had been concealed so that it could be used at a later date. Despite the obvious potential danger, the police call handler advised the member of the public to ‘destroy’ the knife and advised that police would not be attending . Whilst I recognise that further steps have been taken very recently in response to this latest incident, I am concerned that there appears to be an ongoing issue within Derbyshire Constabulary around the ability of some police officers/staff to deal effectively with reports of potential dangerous weapons found 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 consistent availability of stalking advocates for victims across the UK
Wider context from the report “6. Independent Stalking Advocates – during the inquest I heard evidence about the benefits that stalking advocates can provide to those who are victims of stalking. Whilst I was reassured to hear that Derbyshire would have benefits from stalking advocates, I heard evidence that many other areas around the UK do not have stalking advocates . This essentially creates a postcode lottery for victims who report stalking to the police . I am concerned about the lack of consistency and availability of stalking advocates to victims of stalking 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 Failure to complete and regularly reassess comprehensive investigation risk assessments
Wider context from the report “2. Risk assessments – during the inquest I saw a number of good quality risk assessments completed by police call handlers/officers who were involved in the very early stages of Gracie’s stalking complaint in February 2021 and also the rucksack incident in May 2021. However, it became apparent during the inquest that the police officers who were subsequently allocated to deal with the stalking complaint and the rucksack incident failed to record any form of risk assessment or fully assess the potential risks . As was recognised by the Detective Chief Superintendent who gave evidence for the Constabulary at the inquest, the crime report for the stalking investigation in February 2021 lacked any sort of risk assessment or even a recognition of potential risks . I heard evidence from the police officers involved in the stalking investigation and the rucksack incident and I am concerned that there may be an ongoing lack of understanding about the importance of completing comprehensive risk assessments which include the initial identification of risk and also, importantly, a regular re-assessment of risk as the investigation progresses . I consider that further steps should be considered in order to improve understanding and appreciation of the importance of completing comprehensive risk assessments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 investigate stalking complaints fully and in line with available guidance
Wider context from the report “1. Stalking – during the inquest I heard evidence from the police officers who were involved in investigating Gracie’s stalking complaint in February 2021. Derbyshire Constabulary accepted that there were serious failings in how Gracie’s complaint was investigated by these officers . I do recognise that Derbyshire Constabulary has taken some steps following Gracie’s death to improve knowledge around stalking. However, as the Detective Chief Superintendent who gave evidence for the Constabulary accepted, more needs to be done to improve knowledge and understanding around how officers should investigate complaints of stalking . Consideration may be given to:
• Reviewing the current force guidance/training on stalking and considering whether further guidance/training is required in light of the issues identified during the inquest (including consideration of whether there ought to be a force policy on stalking);
• Re-enforcing understanding of the existing training/guidance on stalking including consideration of further training sessions/briefings to emphasise the key issues around investigating complaints of stalking, particularly in relation to the need to investigate the stalking complaint fully in order to identify potential patterns in the suspect’s alleged behaviour ;
• Ensuring officers are aware of the available resources on stalking and, crucially, the importance of actually consulting the available resources on stalking when police officers are investigating stalking cases to ensure that investigations are conducted in line with expected standards.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 individually record all stalking offence locations
Wider context from the report “3. Independent Office for Police Conduct (“IOPC”) – the IOPC carried out an investigation into the conduct of the five officers involved in the stalking investigation and the rucksack incident. The IOPC made a number of recommendations to Derbyshire Constabulary which included:
‘2. To consider how stalking offence locations are recorded on Niche. There does not appear to be any guidance to suggest that all of the locations of the stalking offending are tagged to the incident individually . In this instance it may not have made any difference as the officers who received the bag did not do a search of police systems for the area. However, in future that may well be done, and it could make the difference between linking risk and suspects.’
I heard evidence about this issue from the Detective Chief Superintendent on behalf of the Constabulary and I am concerned that more needs to be done to engage with this specific recommendation from the IOPC. The inquest heard that specific geographical locations can be particularly important in stalking investigations (i.e the horse field in Gracie’s case). As such, it seems to me that the IOPC recommendation is an important one which could assist in future cases with linking suspects and particular locations relevant to the stalking investigation.
” 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 statutory guidance on coercive and controlling behaviour to clarify its differences from stalking.
Verbatim wording from the response “I would also like to respond to some of the wider points made in the report in relation to the police response to stalking. The Home Office regularly works with the National Police Chiefs’ Council to raise awareness among police officers of the available guidance and training on stalking. I have also asked officials to review the Home Office statutory guidance on coercive and controlling behaviour (CCB) so it makes clear what the differences are between CCB and stalking, allowing officers to respond appropriately.” Source location Response from 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 Gather policing best-practice examples on stalking cases and share them with forces to support stalking policies.
Verbatim wording from the response “I have also asked officials to work with the National Police Chiefs’ Council to gather examples of best practice in terms of policing stalking cases, to share with forces and support them with their force policies on stalking.” Source location Response from 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 additional funding to stalking charities supporting victims.
Verbatim wording from the response “In your report, you raise concerns regarding the lack of consistency and availability of Independent Stalking Advocates (ISAs) to victims of stalking across the UK. The Government recognises the value of this support and has provided additional funding to stalking charities for victims. The National Stalking Helpline, run by the Suzy Lamplugh Trust with part-funding from the Home Office provides advice and advocacy services for victims. The Ministry of Justice are also quadrupling funding for victim and witness support services by 2024/25, up from £41m in 2009/10.” Source location Response from 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 Raise police awareness of available stalking guidance and training through regular work with the National Police Chiefs’ Council.
Verbatim wording from the response “I would also like to respond to some of the wider points made in the report in relation to the police response to stalking. The Home Office regularly works with the National Police Chiefs’ Council to raise awareness among police officers of the available guidance and training on stalking. I have also asked officials to review the Home Office statutory guidance on coercive and controlling behaviour (CCB) so it makes clear what the differences are between CCB and stalking, allowing officers to respond appropriately.” Source location Response from Home Office
Open published response
27 Nov 2023 Barbara Jean Rymell · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 1 Insufficient English proficiency among direct care staff to communicate urgent medical needs and summon emergency help View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Barbara Jean Rymell · 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
Barbara Jean Rymell, a frail elderly resident with dementia and mobility limitations, was left unattended on a mechanical stairlift at her care home on 8 August 2022. She left the stairlift, attempted to climb the stairs, fell, and became entrapped with her head under the stairlift chair; she was pronounced deceased when paramedics arrived. The report raises concerns about staff leaving vulnerable residents unattended and about care workers’ English proficiency affecting their ability to communicate the nature of an emergency and obtain appropriate medical assistance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient English proficiency among direct care staff to communicate urgent medical needs and summon emergency help
Wider context from the report “I am concerned that those working with vulnerable people who are in a position of trust and responsibility must be able to demonstrate a sufficient proficiency in English to enable them to summon appropriate emergency medical attention when needed . Vulnerable people, by very definition, are unable to often appreciate the need for help; take steps to keep themselves safe and/or summon help for themselves when they need it.
By being unable to speak the native language of England with any proficiency I am concerned that deaths will continue to arise where those who are young, disabled, suffering from a mental impairment or who are elderly and in need of urgent medical help will not have this summoned for them if those who are engaging with emergency professionals are unable to communicate effectively .
The Court looked at evidence of the B1 English test. Examples from the paper were as follows:
“I ________ that book last year” (options are bought, have bought, had bought)
“The town, ________ is very beautiful, has lots of parks” (options are which, where, what).
This level of comprehension is comparable to a KS2 curriculum being studied by Year 6 students sitting their SATS exam and appears to be wholly insufficient for those working in the direct care and protection of vulnerable people , as demonstrated in this case by carers who were alone (i.e. no English speaking members of staff on duty) being unable to explain to medical professionals the presenting condition of the patient .
” 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 Tighten Health and Care visa sponsorship requirements so only CQC-regulated providers can sponsor care worker and senior care worker applications from Spring 2024.
Verbatim wording from the response “However, the Government has recently announced that it will tighten the requirements for care workers coming to the UK on the Health and Care visa. Most relevant is the fact that only care providers who are regulated by the CQC will be eligible to sponsor care worker and senior care worker applications from Spring 2024. We will keep immigration requirements, including those relating to English language, under review as part of this work.” Source location Response from 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 Keep immigration requirements, including English-language requirements, under review as part of the Health and Care visa changes.
Verbatim wording from the response “However, the Government has recently announced that it will tighten the requirements for care workers coming to the UK on the Health and Care visa. Most relevant is the fact that only care providers who are regulated by the CQC will be eligible to sponsor care worker and senior care worker applications from Spring 2024. We will keep immigration requirements, including those relating to English language, under review as part of this work.” Source location Response from 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 Employers are primarily responsible for ensuring overseas care staff can fulfil their roles and may require higher English standards.
Verbatim wording from the response “I absolutely recognise that ensuring the safety of those who require care is a very important issue, but the responsibility for ensuring that employees can fulfil the requirements of their role primarily rests with employers. An employer should ensure their overseas staff can speak English to an adequate standard. The employer should consider the merits of requiring higher levels of English language than necessitated by immigration requirements – on the basis that it may be required for the settings overseas staff will be working in. In some cases, a higher level of English than required for a visa may be” Source location Response from 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 Imposing English requirements on routes without them could defeat those routes' intended purposes.
Verbatim wording from the response “This creates a mix of immigration routes with different purposes, but where people could end up working in social care. Raising the English language level in those routes which have an English language requirement would be very difficult, and imposing such a requirement on routes which do not have such a requirement would in some cases defeat the purpose of the route as it was intended.” Source location Response from 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 Raising Skilled Worker English requirements is considered inappropriate, impractical, and unlikely to address all concerns.
Verbatim wording from the response “Given the points which I have set out above, we do not believe that raising the level of the English language requirements for Skilled Workers would be appropriate, nor do we think it would be practical to set different levels for different sectors. In any event, it would not fully address the concerns you have raised for all the reasons set out earlier.” Source location Response from 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 Different English language requirements for different sectors would be difficult to assess and manage.
Verbatim wording from the response “I receive representations on a regular basis from sectors who argue that the English language requirements are too high for their sector. Unfortunately, it would prove very difficult, both to assess and also to manage, a system where we had different English language requirements for different occupations.” Source location Response from Home Office
Open published response
3 Oct 2023 Manoel Messias Santos · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 10 Failure to provide timely notification of immigration detention before release View source Delays and failures by the SSHD in progressing FNO cases and obtaining required information View source Delays by probation in allocating community offender managers and providing up-to-date OASYS reports View source Absence of a prison offender manager specialist model for FNO immigration liaison View source Failure to facilitate and signpost access to immigration legal advice View source Failure of communication between immigration and sentence-planning agencies View source Persistent misunderstanding of the policy governing OSG officers opening cell doors at night View source Insufficient communication of entitlement to free immigration legal advice View source Lack of clear systems for obtaining medical information View source Failure to disseminate and action important learning points View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Manoel Messias Santos · 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
Manoel Messias Santos, a Brazilian national detained in prison and facing immigration detention and possible deportation, was found hanging in his cell in the early hours of 2 November 2020 and was declared dead at 3.30am. The jury found that his understanding of his immigration position made a material contribution to his death and identified failures in notifying him about the IS91 notice and communicating his immigration position. The report also raised concerns about delays in notification and case handling, access to legal advice, communication between agencies, dissemination of learning, and staff understanding of the policy on opening cell doors at night.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely notification of immigration detention before release
Wider context from the report “2. The timing of the notification to Mr Santos by the SSHD that he was not to be released at the end of his custodial sentence but was to be held on immigration detention pending a decision on deportation. The SSHD target for notification is 30 days prior to release. In this case it was 8 days late. I heard PFD evidence that this 30-day target is not met in 40% of cases and that 83% of cases are notified within 7 days of the end of the sentence . I am concerned at the potential uncertainty and distress caused to Foreign National Offenders (“FNOs”) by notification at this stage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and failures by the SSHD in progressing FNO cases and obtaining required information
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case , including issue of the Stage 2 letter , failure to obtain medical records and delay in requesting the OASYS report .
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical 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 Delays by probation in allocating community offender managers and providing up-to-date OASYS reports
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report . There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical 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 Absence of a prison offender manager specialist model for FNO immigration liaison
Wider context from the report “6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice for FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 facilitate and signpost access to immigration legal advice
Wider context from the report “4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 communication between immigration and sentence-planning agencies
Wider context from the report “6. Communication issues between the agencies dealing with immigration and sentence planning may lead to confusion and uncertainty for FNOs.
7. I appreciate that any legal advice for FNOs should be from a legal adviser. I am encouraged that the probation service (who employ community offender managers) is seeking to develop a cohort of probation officers specialising in FNOs and immigration. There are now 201 SPOCs across 12 regions and a hub lead developing this model and leading engagement with the SSHD. There is no such model in the prison in respect of “prison offender managers” who also liaise with the SSHD about FNOs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Persistent misunderstanding of the policy governing OSG officers opening cell doors at night
Wider context from the report “13. In evidence there was a continued misunderstanding that the policy did not apply to Operational Support Grade (OSG) officers and it was understood that they should never open cell doors at night . This was despite the PPO report dated December 2021 (at paragraph 73) requesting this be addressed.
14. The prison stated in PFD evidence that all staff will be instructed as to the policy in terms of opening cell doors at night (which requires a dynamic risk assessment).
15. I remain concerned that this appears to be a longstanding belief held by experienced officers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication of entitlement to free immigration legal advice
Wider context from the report “4. I am concerned as to how access to legal advice is facilitated and signposted.
5. In PFD evidence, I was informed that FNOs (in a similar position to Mr Santos) are now entitled to 30 minutes of free legal advice following a High Court decision in February 2021. In HMP Belmarsh, this entitlement is displayed on a notice in each Houseblock. I am concerned that displaying a notice is insufficient to draw this entitlement to the attention of FNOs. I do not know if this is a wider issue in other prisons. Understanding of immigration status, including appeal and bail procedures and is complex. Access to legal advice is vital to prevent confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 systems for obtaining medical information
Wider context from the report “8. I am concerned at the potential impact of delays/failure to obtain information in other cases. In Mr Santos’ case there were delays by probation in allocating a community offender manager and providing an up-to-date OASYS report. There were also delays by the SSHD progressing Mr Santos’ case, including issue of the Stage 2 letter, failure to obtain medical records and delay in requesting the OASYS report.
9. I am encouraged that there is now a centralised system (and form) for the SSHD to request OASYS reports from probation although it is not clear the extent to which requests are going through this system. Consent to obtain medical information is sought from FNOs at an induction meeting by Immigration Prison Teams (“IPTs”). Further IPT officers attend prisons and play a key role in obtaining this type of information. However it is not clear what systems are in place to facilitate the obtaining of medical 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 disseminate and action important learning points
Wider context from the report “10. The SSHD disclosed an Internal report into Mr Santos’ case midway through the Inquest, which was not on his Home Office file. The lawyers representing the SSHD were unaware of this report. The head of FNO Returns Command only became aware of it the preceding week and understood it had been disclosed.
11. The report detailed delays and issues in Mr Santos’ case and the SSHD then made formal admissions of the relevant (non-causative) failures which where recorded by the jury in the Record of Inquest at my direction.
12. This report was dated February 2021 and listed action points for the relevant department. Although I am told that these are now being addressed, I am concerned that important learning points (which could prevent future deaths) were not disseminated and actioned as they should have been.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide awareness sessions in hub prisons on deportation processes, immigration notices and immigration officers’ work.
Verbatim wording from the response “We recognise the benefit of improving a mutual understanding of relevant processes to both departments in our aim to work more cohesively. Therefore, awareness sessions have been provided at our hub prisons providing an overview of the deportation process, the service of immigration notices and the work of our immigration officers.” Source location Response from 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 Continue reviewing potential technological improvements to support timely and secure information exchange with prison officials.
Verbatim wording from the response “Digitalisation improvements have allowed for engagements with FNOs to be raised on internal databases along with any vulnerability concerns promptly after interactions, while IPT Officers have access to a Ministry of Justice system, to ensure immigration contact and records are widely shared. We will continue to review where further technological improvements can be made to ensure the timely and secure exchange of information between itself and prison officials.” Source location Response from 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 Deploy dedicated immigration officers embedded in prisons to engage and induct FNOs, recording interactions and making them accessible on internal databases.
Verbatim wording from the response “meet every month to collaborate on operational issues and feed into the HMPPS/FNORC task force.
The Home Office understands that ‘in person’ contact with individuals subject to deportation action is hugely important. A dedicated team of immigration officers embedded in the prison estate carry out that engagement and endeavour to induct the individual soon after they arrive at a prison. This induction seeks to explain the deportation process, obtain basic person details and any vulnerabilities or medical conditions. The induction process is periodically reviewed, and the interactions are now recorded and accessible to other Home Office officials on internal databases.” Source location Response from 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 Operate the Strategic Improvement Operations team to log, assign, monitor and coordinate recommendations from internal and external investigations and audits.
Verbatim wording from the response “We recognise and regret that this was a significant oversight and have taken immediate steps to address this issue. Following consultation with the PSU we have implemented new commissioning and handling processes to ensure that work commissioned by us from the PSU receives appropriate Director’s attention. Within FNORC a new team, the Strategic Improvement Operations team, has been set up to log, review and track recommendations from all internal and external investigations/audits on our central records. The team is responsible for maintaining a central record of all the recommendations, assigning ownership, monitoring progress and coordinating actions with the central Immigration Enforcement Assurance and Risk team to ensure all FNORC risks are managed through a consistent assurance process and recommendations are implemented in a timely manner.” Source location Response from 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 30-day aspirational target sufficiently balances up-to-date detention decisions with reasonable notice and avoids disproportionate caseworking burdens.
Verbatim wording from the response “deport the individual by the end of their custodial detention, the caseworker will consider whether, at the end of their custodial sentence, the individual should be detained under immigration powers to facilitate their deportation. There is a presumption in favour of liberty for all individuals and decisions to detain are made in line with the published guidance. The published policy requires written reasons to be provided to the individual through the service of form IS 91R, before they are detained under immigration powers. However, under neither statute nor detention policy is there a specified timescale for the service of an IS 91R prior to the actual start of immigration detention. A person detained from the community will usually be served an IS 91R on the day of their initial detention.” Source location Response from 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 Healthcare teams cannot disclose medical records to the Home Office without the detained person's consent because of third-party confidentiality requirements.
Verbatim wording from the response “FNOs can also request to speak with an immigration officer on an individual basis via a wing application that is lodged with the prison’s wing office which is then passed to the embedded Immigration Prison Liaison Teams (IPTs).
Due to third party confidentiality implications, healthcare teams at a prison or an IRC require the FNO’s consent before their medical records are disclosed to the Home Office. Therefore, in order to make informed detention decisions, caseworkers seek the individual’s consent at the earliest possible stage of the process. Once consent is given, the caseworker will directly contact the healthcare team within a prison or an IRC to obtain updated medical information relating to the individual.
At a local level, the Home Office’s IPTs work very closely with prison colleagues, with established lines of communication and regular meetings between the two parties.” Source location Response from Home Office
Open published response
2 Oct 2023 Jack Peter Zarrop · Prevention of Future Deaths report West London
View report summary
Concerns raised 3 Lack of adequate mental health training for Custodial Nurse Practitioners seeing high-risk and complex patients in police custody View source Failure to train agency healthcare staff in the ACCT process and the threshold for opening an ACCT View source Failure of the 2003 Home Office circular to recognise suicide and self-harm risk as a core competency 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
Jack Peter Zarrop · 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
Jack Peter Zarrop, who had a history of mental-health difficulties, alcohol abuse and previous suicide attempts, died by suicide while in custody. The jury identified failures relating to referral to Liaison and Diversion services, opening an ACCT, access to relevant history, and removal of a bedsheet and closure of a hatch as main contributing factors. The report raised concerns about the use and training of Custodial Nurse Practitioners in police custody and the training of agency prison healthcare staff in the ACCT process.
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 adequate mental health training for Custodial Nurse Practitioners seeing high-risk and complex patients in police custody
Wider context from the report “1. The use of Custodial Nurse Practitioners (CNPs) in Police custody instead of doctors. The 2003 Home Office circular appeared to envisage nurses working alongside doctors, when this is not how they are deployed. CNPs are also seeing high risk and complex patients without adequate training in mental health . The deployment in Police custody of CNPs places detained persons at risk of death in the future . The 2003 Home Office circular also does not recognise the risk of suicide and self-harm as being a core competency.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 train agency healthcare staff in the ACCT process and the threshold for opening an ACCT
Wider context from the report “2. The training of agency staff in the ACCT process and recognising the appropriate threshold to open an ACCT . The training of agency staff in ACCT does not appear to be part of the commissioning process by NHS England and individual providers do not appear to provide training to agency staff in the ACCT process . This places residents in prison at risk of death, given the high level of usage of agency healthcare staff in prison.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of the 2003 Home Office circular to recognise suicide and self-harm risk as a core competency
Wider context from the report “1. The use of Custodial Nurse Practitioners (CNPs) in Police custody instead of doctors. The 2003 Home Office circular appeared to envisage nurses working alongside doctors, when this is not how they are deployed. CNPs are also seeing high risk and complex patients without adequate training in mental health. The deployment in Police custody of CNPs places detained persons at risk of death in the future. The 2003 Home Office circular also does not recognise the risk of suicide and self-harm as being a core competency .
” Open source report
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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 Home Office cannot amend the archived and no longer extant 2003 circular, so it formally proposes no action.
Verbatim wording from the response “I believe that the element of the matters of concern identified which was directed to the Home Office was the exclusion from the list of core competencies for Custodial Nurse Practitioners within Home Office Circular 020/2003 (Healthcare Professionals in Custody Suites: Guidance to Supplement Revisions to the Codes of Practice Under the Police and Criminal Evidence Act 1984) of the ability to identify the risk of suicide and self-harm in detainees. Home Office Circular 020/2003 is no longer extant: it was archived in 2013 and does not appear on the Gov.UK website. It is therefore not possible for the Home Office to make amendments to it, which is why, formally, we propose to take no action in response to your report.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responding to concerns about prison healthcare staff training in the ACCT process.
Verbatim wording from the response “I understand too that NHS England is responding to your second matter of concern, relating to the training of prison healthcare staff in the ACCT process.” Source location Response from the Home Office
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NPCC response addresses the remaining content of the first matter of concern.
Verbatim wording from the response “However, this in no way represents a lack of interest in the issues which you have identified. As the response to your report from the Chair of the NPCC sets out, the 2003 Circular has effectively been superseded by the publication of the National Healthcare Specification for police custody, which is written by NHS England on behalf of the NPCC, College of Policing and Home Office, and which Chief Constables may use when tendering for healthcare provision. That document is far more comprehensive than the 2003 Circular. The Home Office has a close interest in the content of the Specification, and in ensuring that highly qualified and capable medical personnel work in police custody. I understand that the NPCC response also represents the response to the remaining content of your first matter of concern.” Source location Response from the Home Office
Open published response
21 Aug 2023 David Joseph Celino · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Lack of authoritative guidance on permitted front-of-house drug testing View source Failure of festival staff and volunteers to proactively identify and assist people showing signs of adverse drug reactions View source Lack of reliable records of drug-related festival casualties View source Lack of governing oversight of music festivals View source Lack of accurate information about the number of under-18 festival attendees 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
David Joseph Celino · 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 Joseph Celino, aged 16, took tablets sold as an illicit drug at Leeds Festival in August 2022, developed an adverse reaction, and died after being treated at the festival field hospital and in hospital. The concerns included inadequate information about the number of under-18 attendees, the absence of national oversight and reliable data on drug-related casualties at music festivals, insufficient action to deter drug supply, and a failure by festival staff to identify and assist David as his condition deteriorated.
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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 authoritative guidance on permitted front-of-house drug testing
Wider context from the report “(6) Various witnesses raised the issue of “Front of House” drug testing, expressing views as to the benefits and disadvantages of this being permitted. It would help all those involved in the management of events similar to the Leeds Festival to have authoritative guidance on this subject, from the Home Office , along with clarification as to exactly what is permitted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 festival staff and volunteers to proactively identify and assist people showing signs of adverse drug reactions
Wider context from the report “(5) Evidence at the inquest indicated David Celino had walked about the Leeds Festival site between approximately 7pm and 8.45pm on the evening of Saturday 27 August 2022. As the signs of his adverse drug reaction developed, he was unable to walk straight, was pale, sweating profusely and agitated. In the latter stages he needed help from two other 16-year-olds to prevent him falling over. In this period, he passed through at least one check point manned by stewards or security staff. It is likely he encountered other festival staff and/or volunteers in this period also. Lamentably, no staff or volunteers spotted the need to intervene to ask about his well-being or offer assistance. This history suggests further instruction or training for festival staff and volunteers is required as to the need to be proactive, particularly in view of the prevalence of illicit drugs and teenagers. As it was, David Celino’s friends only obtained advice as to his condition from the drug dealer they happened to encounter, who reassured them that his reaction as “normal”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 reliable records of drug-related festival casualties
Wider context from the report “(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties , which might reveal the extent of the problem.
(3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 governing oversight of music festivals
Wider context from the report “(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties, which might reveal the extent of the problem.
(3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 accurate information about the number of under-18 festival attendees
Wider context from the report “(1) Neither the organiser of the festival (Festival Republic) nor Leeds City Council which licenced the event had accurate information about the number of people under 18 who were attending the festival. It was estimated to be 20% of the 90,000 attending, so about 18,000. In consequence, the magnitude of the problem of potentially vulnerable, naïve teenagers exposed to possible exploitation by drug dealers, was not appreciated.
” Open source report
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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 Approval of event licences and any additional conditions is a matter for local authorities.
Verbatim wording from the response “Licence reviews play an important role. Reviews give licensing authorities (and others) powers to address problems, and can be triggered by complaints from local residents or businesses – ensuring appropriate local representation in the decision making processes – or by representations from relevant authorities, such as the police or the licensing authority itself. The approval of event licences - including any additional conditions placed on event organisers - is at the discretion of Local Authorities.” Source location Response from Home Office
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employers, rather than the regulator, must provide additional training required for licensed security operatives' particular deployments.
Verbatim wording from the response “With respect to licensed security guards and door supervisors, the SIA sets the minimum training required for each role. This includes training on drug awareness, which covers recognising the signs and symptoms of drug use and identifying drug dealing. Beyond the minimum standards set by the regulator, it is for the employer of licensed security operatives to supply any additional training required for the particular situation in which the licence holder is to be deployed. I would encourage event coordinators to consider any enhanced skills needed for the provision of robust security services and public protection during Leeds Festival, and then to communicate those needs with partners (including security contractors and, separately, volunteers and stewards who do not fall within SIA regulation).” Source location Response from Home Office
Open published response
25 Jul 2023 Paul Keating · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Lack of statutory power to enter private dwellings to install sprinkler systems View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paul Keating · 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 Keating, aged 59, died on 15 April 2023 in a fire at the flat where he lived alone, from the combined effects of carbon monoxide toxicity and pre-existing heart disease. His flat was the only one in the tower block not connected to the sprinkler system because contractors could not enter without his consent, and smoke detectors had been disabled. The report raised concerns about the absence of statutory power for the local authority to enter the flat to install the sprinkler system.
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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 Lack of statutory power to enter private dwellings to install sprinkler systems
Wider context from the report “(2) Being a single private dwelling, albeit in a tower block, Mr Keating’s flat was not covered by the provisions of The Regulatory Reform (Fire Safety) Order 2005. The local authority had no statutory power to enter Mr Keating’s flat for the purposes of installing a sprinkler system without his consent.
(3) Over a period of six months during which the sprinkler system was installed in the tower block where Mr Keating lived, he did not respond to letters informing him of the planned installation of the sprinkler system and inviting his agreement to contractors entering his flat as part of that work. He additionally refused to open his door to the tenant liaison officer. (Further, it was discovered after his death that Mr Keating had disabled the hard-wired smoke detector and a battery-operated smoke detector within his flat.)
(4) The necessary work was done in the common parts of the building to connect Mr Keating’s flat to the sprinkler system, but the work done could not cross the threshold of his flat without his consent. Of the 98 flats in the building, Mr Keating’s was the only flat not connected to the sprinkler system.
(5) If the local authority had had the statutory power to enter Mr Keating’s flat for the purposes of installing the sprinkler system, it would have exercised that power and Mr Keating’s flat would have been connected to that system.
” Open source report
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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 housing, fire-service and tenancy arrangements provide a basis for action to improve domestic fire safety.
Verbatim wording from the response “The Decent Homes Standard sets the minimum standards that social homes are required to meet. To meet it, the standard that all social housing (including local authority-owned stock) must achieve, a dwelling must be free from hazards at the most dangerous ‘category 1’ level that is assessed using the aforementioned HHSRS. In addition, where a dwelling is privately rented or rented from a housing association, local authorities have a duty to enforce if they identify category 1 hazards, and a discretionary power to enforce where less serious category 2 hazards are assessed. The decision whether to enforce in respect of a category 2 hazard should be taken in accordance with the local authority’s enforcement policy. The actions available to the local authority include powers to require remedial works, prohibit the use of part or all of a building or carry out emergency works themselves.” Source location Response from Home Office
Open published response
30 Jun 2023 Victoria STOREY · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Uncertainty about the contents of illicit potent synthetic opiates View source Illicit marketing of potent synthetic opiates as common pharmaceutical opiates View source Failure to control potent synthetic opiates under Class A and Schedule 1 View source
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AI-generated summary
Victoria STOREY · 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
Victoria Storey was found deceased in her bedroom on 3 September 2022 after taking an accidental overdose of a potent synthetic opioid that was not licensed for medicinal use. The report raised concerns that the substance was illicitly traded and marketed as common pharmaceutical opiates, that its contents were unknown to users, and that it was not then controlled under the relevant drug legislation despite its high risk of fatal overdose.
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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 Uncertainty about the contents of illicit potent synthetic opiates
Wider context from the report “- Due to the nature of the drug in potent synthetic opiates, there is no way for the end user to know what the illicit substance contains.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Illicit marketing of potent synthetic opiates as common pharmaceutical opiates
Wider context from the report “- ████████ is illicitly traded and marketed as common pharmaceutical opiates. It has potent analgesic effects but is not approved for medicinal use due to the increased risk of adverse events.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 potent synthetic opiates under Class A and Schedule 1
Wider context from the report “- The Home Office requested advice from the Advisory Council on the Misuse of Drugs (ACMD) on the appropriate domestic control of ████████, and was advised by the ACMD on 18th July 2022 that ████████ (and other similar compounds) should be placed in schedule 1 of the Misuse of Drugs Regulations 2001 and listed as Class A drugs under the Misuse of Drugs Act 1971. However, at present the Act and Regulations have not been amended to include ████████ and it is unclear if and when this will take place. ████████ is not therefore currently controlled under Class A, Schedule 1, Misuse of Drugs Act 1971 despite its heroin-like effects with a high risk of fatal overdose.
” 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 Bring forward legislation to control 11 synthetic opioids under the Misuse of Drugs Act and associated Regulations.
Verbatim wording from the response “The Government accepted these recommendations in February, committing to control 11 synthetic opioids, including ████████, under the 1971 Act and associated Regulations. In light of ongoing drug-related deaths and non-fatal overdoses associated with synthetic opioids in the UK, we intend to bring forward this legislation by the end of the year to come into force in early 2024. This letter can be found on GOV.UK here: Government response to the ACMD’s advice on 2-benzyl benzimidazole and piperidine benzimidazole opioids (publishing.service.gov.uk)” Source location Response from 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 and planned measures are considered appropriate to reduce the risk of deaths involving synthetic opioids.
Verbatim wording from the response “Given we are already in the process of controlling ████████, and the other measures which I have outlined above, I consider that appropriate measures to reduce the risk of deaths like this from happening are already coming into place. I hope that you agree with my assessment, and I would like to thank you for bringing this matter to my attention.” Source location Response from Home Office
Open published response
12 Jun 2023 Heather FINDLAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 15 Omissions from serious incident investigations View source Failure to communicate the appropriate level of suicide risk to police View source Lack of ward assistance and contingency planning for retrieval of an absconded patient View source Lack of instructions for staff following an absconded patient View source Failure to prepare clinical staff to maintain line of sight when a patient absconds View source Failure to recognise imminent suicide risk after a patient absconds View source Failure to volunteer the trust's risk grading when reporting a patient to police View source Confusion about police contact when a patient is missing View source Lack of training for doctors and nurses in street restraint and patient transport View source Unavailability of police assistance for clinicians responding to an absconded patient View source Failure of police and health-trust partnership working to allocate responsibility for patient retrieval View source Lack of learning culture at ELFT View source Inconsistent terminology and definitions between police and mental-health services View source Failure of police reporting information to align with local policies View source Failure to routinely record all useful risk information in police reports View source See 12 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
Heather 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
Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.
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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 Omissions from serious incident investigations
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation .
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the appropriate level of suicide risk to police
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide . Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection .
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 ward assistance and contingency planning for retrieval of an absconded patient
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task . I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward.
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 instructions for staff following an absconded patient
Wider context from the report “2. By the time the HCA rang the duty senior nurse for advice Ms Findlay was out of sight, and so the HCA was instructed to return to the ward.
I heard evidence that an email is to be sent out shortly to explain that a new ELFT absent without leave policy will be in place by the end of June 2023. The new policy will confirm that, if it is safe to do so an escort may follow a patient who has absconded, keeping them in line of sight whilst ringing the duty senior nurse for instructions.
However, there is no ELFT policy for what those instructions should be or even what they could include . No member of ELFT gave evidence of any organisational thought having gone into how then to progress such a situation, other than the ward calling the police to report a missing person. No member of ELFT giving evidence was able to set out what the staff member following should do .
This appears to be a significant omission.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prepare clinical staff to maintain line of sight when a patient absconds
Wider context from the report “1. When Ms Findlay ran off, the HCA escorting her was so panicked that she did not even think of following. Ms Findlay had run across a road and so chasing her at speed did present safety considerations. However, the ELFT policy, training, culture and expectation was such, that there the HCA did not at any point consider attempting to walk after her to keep her in sight . Clinical staff must be adequately prepared for such an eventuality .
That means more than simply a change in policy wording.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise imminent suicide risk after a patient absconds
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff .
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 volunteer the trust's risk grading when reporting a patient to police
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it .
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Confusion about police contact when a patient is missing
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves ; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing .
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 doctors and nurses in street restraint and patient transport
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task. I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward .
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 police assistance for clinicians responding to an absconded patient
Wider context from the report “3. Moreover, one of the MPS policy leads in this area gave evidence that in such a situation the police would not necessarily attend , even if called direct by a hospital staff member in the street following a patient about whom they are worried.
I spent some time examining the police regarding this point, and I was left with the impression that a clinician calling the police in what the clinician perceived to be an emergency situation might not be assisted by the police .
That concerned me.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 and health-trust partnership working to allocate responsibility for patient retrieval
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task. I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward.
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility , whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 learning culture at ELFT
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 terminology and definitions between police and mental-health services
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions .
It seems that this would benefit from consideration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 reporting information to align with local policies
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies , whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 record all useful risk information in police reports
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine , and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” Open source report
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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 operational missing-person decisions rests with individual police forces and their Chief Officers.
Verbatim wording from the response “With regards to the response to the missing person report made by the East London Foundation Trust (ELFT) to the Metropolitan Police Service (MPS), the police investigation of a missing person report is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned. However, my officials have consulted the MPS to gain assurance that the correct protocols are in place in order to prevent future incidents of this nature.” Source location Response from 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 Operational decisions about missing-person investigations are outside the Home Office’s authority.
Verbatim wording from the response “With regards to the response to the missing person report made by the East London Foundation Trust (ELFT) to the Metropolitan Police Service (MPS), the police investigation of a missing person report is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned. However, my officials have consulted the MPS to gain assurance that the correct protocols are in place in order to prevent future incidents of this nature.” Source location Response from 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 MPS Affinity Protocol is considered sufficient because it reflects the NPCC framework for missing persons from healthcare settings.
Verbatim wording from the response “The MPS response will set out details of its Affinity Protocol, a joint agreement between the MPS and ELFT, which aligns with the NPCC’s framework, published in October 2020, and accessible at https://www.gov.uk/government/publications/the-multi-agency-response-for-adults-missing-from-health-and-care-settings-a-national-framework-for-england.” Source location Response from Home Office
Open published response
13 Mar 2023 Jane Walker · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 1 Unavailability of rapid analgesics to paramedics for immediate pre-hospital pain relief 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 Walker · 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 Walker was a passenger on a rigid inflatable boat involved in a collision with a jet ski on the Menai Straits. She suffered significant internal injuries, was treated by paramedics and later died in hospital. The principal concern was that paramedics could not administer faster-acting alternative analgesics, such as mucosal fentanyl, because of controlled drug legislation, potentially affecting patients requiring immediate pain relief.
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 rapid analgesics to paramedics for immediate pre-hospital pain relief
Wider context from the report “Evidence was heard at the Inquest that there are alternative analgesics which can be administered much more quickly, have a much quicker impact and can be easier to remove when required. Example of such is mucosal fentanyl lozenge. This can be administered by placing the lozenge (on a stick) into the patient’s mouth, which takes effect very quickly and which can be removed quickly if required. It can be considered a safe and rapid method of delivering pre-hospital analgesia and is used by the military. It is not, however, available to paramedics.
I am concerned that the unavailability of such analgesics to paramedics (in England as well as Wales) to assist patients who require immediate pain relief in the context of it reducing stress on the body, providing easier and potentially faster extrication and patient handling, and improving breathing, where time is of the essence for medical treatment, to reflect a risk of deaths into the future.
Pursuant to controlled drug legislation paramedics are not currently permitted to administer such analgesics. Whilst matters of health are devolved to Wales, controlled drug legislation in this context is not a devolved matter to Wales, hence this Report to the Home Secretary. I am aware that The Medicines Act 1968 and/or other controlled drug legislation would require amendment to allow paramedics to administer such analgesia.
” 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