Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Maxine Betty Davison and 4 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to condition firearms licensing delegation on adequate training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training .
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training .
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Absence of a mandatory requirement for role-specific firearms licensing training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training . I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular .
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff ;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
×
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 £500,000 funding to the College of Policing to support development and adoption of firearms licensing training.
Verbatim wording from the response “We have noted your concerns about the lack of accredited training for firearms licensing staff and a mandatory requirement to undertake necessary training. The provision of police training is primarily a matter for the College of Policing and police forces, and a programme of work is already being taken forward since 2022 by the College and the National Police Chiefs Council to develop the required training package. The Government accepts the need for such a training package, and today I was pleased to announce that funding of £500,000 to the College of Policing has been made by the Home Office specifically to ensure this training is taken forward and adopted by police forces. The training will be reinforced and supported by the refresh of the relevant Authorised Professional Practice by the College of Policing, which was the subject of a consultation from January to March 2023.” 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 Determine with policing bodies how to mandate firearms licensing staff completion of the national accredited training programme once finalised.
Verbatim wording from the response “We have noted your concerns about the lack of accredited training for firearms licensing staff and a mandatory requirement to undertake necessary training. The provision of police training is primarily a matter for the College of Policing and police forces, and a programme of work is already being taken forward since 2022 by the College and the National Police Chiefs Council to develop the required training package. The Government accepts the need for such a training package, and today I was pleased to announce that funding of £500,000 to the College of Policing has been made by the Home Office specifically to ensure this training is taken forward and adopted by police forces. The training will be reinforced and supported by the refresh of the relevant Authorised Professional Practice by the College of Policing, which was the subject of a consultation from January to March 2023.” 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 Police training provision is primarily the responsibility of the College of Policing and police forces, rather than central government.
Verbatim wording from the response “We have noted your concerns about the lack of accredited training for firearms licensing staff and a mandatory requirement to undertake necessary training. The provision of police training is primarily a matter for the College of Policing and police forces, and a programme of work is already being taken forward since 2022 by the College and the National Police Chiefs Council to develop the required training package. The Government accepts the need for such a training package, and today I was pleased to announce that funding of £500,000 to the College of Policing has been made by the Home Office specifically to ensure this training is taken forward and adopted by police forces. The training will be reinforced and supported by the refresh of the relevant Authorised Professional Practice by the College of Policing, which was the subject of a consultation from January to March 2023.” Source location Response from Home Office
Open published response
Concerns raised 1 Disconnect between police guidance and available legal powers in domestic violence cases involving former cohabitants View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sharon Elaine Harman · 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
Elaine Harman was assaulted by her husband, who breached police bail conditions by attending their home and stabbing her to death on 6 August 2021. The principal concern was an apparent disconnect between policing guidance and available legal powers, including the absence of a power to retain a house key during bail conditions in domestic violence cases.
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 Disconnect between police guidance and available legal powers in domestic violence cases involving former cohabitants
Wider context from the report “There appears an obvious disconnect in the guidance issued by the College of Policing and the laws provided to police under s19 PACE or otherwise. This appears of particular concern in cases of domestic violence where, previously, the parties have lived together.
” 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 Consult stakeholders and review legislation and Codes of Practice to assess whether police powers remain proportionate, necessary and appropriately safeguarded.
Verbatim wording from the response “Thank you for bringing to our attention the disconnect between the College of Policing guidance and the powers provided to the police under s19 PACE. We will look to raise these discrepancies with the College of Policing. In terms of the recommendation to consider an additional power for police to retain house keys (for the duration of bail conditions only), we regularly consult with stakeholders, review existing legislation and associated Codes of Practice including any requirements for legislative reform, to ensure that the powers available to the police and law enforcement bodies are reasonable, proportionate and necessary in the circumstances, with the requisite safeguards to protect the rights of individuals and victims.” Source location Response from Home Office
Open published response
Concerns raised 2 Lack of formal guidance, training, and protocols for correlating COMPACT risk assessments with ACT stop priority instructions View source Mismatch between COMPACT risk assessments and ACT stop priority instructions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
HANNAH WARREN · 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 Warren was reported missing on 3 February 2016 after leaving London by car while expressing delusional thoughts, and her body was found in Port Talbot harbour the following morning. The inquest concluded that she died from drowning and a head injury. Concerns included shortcomings in the missing-person investigation, including delayed or insufficient use of the ANPR Bureau, communication failures, failure to contact family, and the use of a low-priority vehicle stop despite a medium risk assessment; the report also identified a lack of formal guidance, training, or protocols linking these systems.
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 formal guidance, training, and protocols for correlating COMPACT risk assessments with ACT stop priority instructions
Wider context from the report “(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling;
(2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle.
(3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems ; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all.
(4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT.
(5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.
(6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Mismatch between COMPACT risk assessments and ACT stop priority instructions
Wider context from the report “(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling;
(2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle.
(3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all.
(4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT.
(5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.
(6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically.
” 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 Current police guidance is readily available and clearly sets out the actions officers should take in equivalent circumstances.
Verbatim wording from the response “I am satisfied by the College that there is current police guidance on this matter which is readily available to forces; and clearly sets out the actions police officers should take were these circumstances to arise again. Specifically, the guidance states that missing persons fall into the category of ‘serious incidents’ and as such, at a minimum, a medium priority ACT report should have been put in place. The response from the College will set out further detail on the use of the ACT guidance.” 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 policing matters fall outside the Home Office’s authority, so it cannot intervene in police officers’ operational decisions.
Verbatim wording from the response “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, for the purposes of this response, my officials have consulted the College, the Metropolitan Police and the National Police Chiefs Council (NPCC) to seek assurance that the appropriate guidance is in place which addresses the concerns that you have raised.” 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 Individual police forces are responsible for operational missing-person investigations, while the College of Policing sets applicable standards and guidance.
Verbatim wording from the response “The police investigation of a missing person report is an operational decision for individual police forces. The standards for these investigations for all forces in England and Wales are set by the College of Policing (henceforth ‘the College’) through their Authorised Professional Practice (APP). The College also issues guidance for police forces, including instructions on the use of ACT and REACT reports on PNC, the most recent version was published in November 2022.” Source location Response from Home Office
Open published response
30 Dec 2022 Gavin Peter Pedleham · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Lack of requirements for safe community storage of Oramorph and prevention of access by others View source Lack of regulations governing Oramorph use in community settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gavin Peter Pedleham · 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
Gavin Peter Pedleham inadvertently drank a dose of Oramorph left in a glass at a family Christmas party after consuming a significant quantity of alcohol. He was found dead the following morning, and the inquest recorded morphine and ethanol toxicity, concluding that his death was accidental. The substantive concern was that community use of Oramorph is not subject to similar safe-storage requirements as its use in institutional settings, allowing access by others.
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 requirements for safe community storage of Oramorph and prevention of access by others
Wider context from the report “1. Oramorph is a controlled drug the storage, handling and administration of which in institutional settings is highly regulated. However, there are no similar regulations which govern its use in a community setting. There is no requirement for the recipient of the drug in the community to keep it in a safe place and ensure that it cannot be accessed by 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 Lack of regulations governing Oramorph use in community settings
Wider context from the report “1. Oramorph is a controlled drug the storage, handling and administration of which in institutional settings is highly regulated. However, there are no similar regulations which govern its use in a community setting . There is no requirement for the recipient of the drug in the community to keep it in a safe place and ensure that it cannot be accessed by others.
” 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 reviewing drugs controls for evidence indicating a need for additional controls.
Verbatim wording from the response “However, drugs controls are kept under review, and should further evidence emerge indicating the need for additional controls I will consider whether it is appropriate to seek advice from the ACMD.” 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 Additional patient controls are not pursued because extending healthcare safeguards could criminalise patients and obstruct timely access to pain relief.
Verbatim wording from the response “As the report mentions, the 2001 Regulations make controlled drugs available in healthcare, and impose administrative obligations and requirements to mitigate risks of harm, misuse and diversion of controlled drugs. Before making decisions on the appropriate safeguards under the 2001 Regulations, Ministers take expert advice from the Advisory Council on the Misuse of Drugs (ACMD). Liquid morphine in this form is placed in Schedule 5 to the 2001 Regulations. Extending the legal requirements applicable in healthcare, for example, those requiring safe custody, to patients would risk criminalising patients lawfully prescribed a controlled drug, and potentially put in place barriers to legitimate and timely access to pain relief. Therefore, I have no plans at present to consider additional controls on oral morphine.” 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 Existing advice, patient information and controlled-drug safeguards are considered sufficient to reduce risks from oral morphine.
Verbatim wording from the response “I consider that appropriate measures to reduce the risk of accidents like this from happening are already in place. Prescribers and dispensing pharmacists are obligated to provide advice to patients or carers on what the medicines are and how they should be taken, including any risks and information on drug interactions. This advice is also a statutory requirement in the patient information leaflet provided with licensed medicines, which for oramorph includes that alcohol should be avoided whilst taking this medicine.” Source location Response from Home Office
Open published response
Concerns raised 2 Lack of clarity over responsibility for monitoring, investigating and enforcing DNP sales for human consumption View source Risk of fatal harm from DNP remaining available for human consumption View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jack Kn apman · 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 Kn apman died shortly after 1am on 23 March 2018 after taking a substantial quantity of dinitrophenol (DNP) for weight loss and body-building, suffering severe cardiotoxicity and a cardiac arrest. The principal concern was that, after DNP is categorised as a poison, unclear responsibility for monitoring and preventing its sale could delay an effective response and put lives at risk.
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 clarity over responsibility for monitoring, investigating and enforcing DNP sales for human consumption
Wider context from the report “However, after DNP is categorised as a poison it seems that it is not clear which organisation or Department of Government should have responsibility for monitoring and preventing its sale for human consumption . This would include identification of sites offering it for sale, investigation and enforcement.
My concern is that a lack of clarity on this issue might delay an effective response to any site advertising DNP . This would clearly put lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Risk of fatal harm from DNP remaining available for human consumption
Wider context from the report “DNP is a highly toxic substance. It should never be used for human consumption. Nevertheless some people do use it to assist with weight loss and body-building. There have been many deaths associated with the use of DNP and it has been the subject of previous Prevention of Future Death Reports from coroners. The inquest heard that the number of deaths associated with the use of DNP has fallen but that the risk of further deaths remains for as long as it continues to be available and used for human consumption .
” 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 Lay legislation regulating DNP as a poison, restricting lawful public sales to registered pharmacists and licensed purchasers.
Verbatim wording from the response “As you note in your report, the Home Office has now laid legislation to regulate DNP as a poison under the Poisons Act 1972. This will mean that, from 1 October 2023, DNP can only legally be sold to a member of the public by a registered pharmacist, and then only to a member of the public with a valid explosives precursors and poisons (EPP) licence issued by the Home Office. We are not aware of any legitimate uses of DNP by the general public, and therefore this would act as an effective ban on sales to that group.” 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 cross-government work to consider all aspects of DNP and tackle unlawful sales and use.
Verbatim wording from the response “The police are responsible for enforcing the Poisons Act 1972, and therefore will be responsible for investigating unlawful sales of DNP from 1 October 2023. However, we recognise that some sellers, including those overseas, will do everything they can to flout regulations. To this end, work will remain ongoing in the Home Office and across Government to do everything we can to crack down on the unlawful sale and use of DNP by working holistically to consider all aspects of the problem.” 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 Police are responsible for enforcing the Poisons Act 1972 and investigating unlawful DNP sales from 1 October 2023.
Verbatim wording from the response “The police are responsible for enforcing the Poisons Act 1972, and therefore will be responsible for investigating unlawful sales of DNP from 1 October 2023. However, we recognise that some sellers, including those overseas, will do everything they can to flout regulations. To this end, work will remain ongoing in the Home Office and across Government to do everything we can to crack down on the unlawful sale and use of DNP by working holistically to consider all aspects of the problem.” Source location Response from Home Office
Open published response
14 Dec 2022 Fatima Abukar · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Reduced legal enforcement of unlawful e-scooter use View source Failure to provide prominent written warnings about the illegal use of e-scooters View source Failure to require head protection for riders of legally authorised scooters 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
Fatima Abukar · 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
Fatima Abukar, a 14-year-old girl, died from catastrophic head injuries after the privately owned e-scooter she was riding entered the carriageway and struck a mini-bus. The concerns included e-scooter fatalities and enforcement, the absence of a requirement for riders of legally authorised scooters to wear head protection, and inconsistent or insufficiently prominent warnings about illegal e-scooter 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 Reduced legal enforcement of unlawful e-scooter use
Wider context from the report “1. Evidence in this inquest confirmed that since 2019 here have been 8 recorded fatalities involving e-scooters in London and 31 in the country at large. At the time of her death Ms Abukar was riding a privately owned e-scooter on a public highway. Despite the ubiquity of such devices on London’s streets, riding them on public roads is unlawful.
Whereas approximately 4000 unlawfully used scooters were seized by the Metropolitan Police Service in 2021, only 1100 were confiscated in 2022 . The reduction is attributable to a change in policy introduced in November 2021.
An inverse correlation exists between the rate of legal enforcement and the rate of deaths caused by e-scooters. The number of deaths in Q1 & 2 of 2022 is more than double that of Q1 & 2 of 2021.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 prominent written warnings about the illegal use of e-scooters
Wider context from the report “3. Some manufacturers and retailers of e-scooters in England and Wales provide consumers with written warnings about the illegal use of e-scooters, others do not. Where such warnings are present, often they are not prominent.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 head protection for riders of legally authorised scooters
Wider context from the report “2. Ms Abukar died due to traumatic head injuries. Riders of legally authorised scooters (those hired from licenced operators) are not required to wear head protection.
” Open source report
Concerns raised 1 Insufficient staffing and resources for domestic abuse investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Raneem Oudeh and Khaola Saleem · 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
Raneem Oudeh and her mother, Khaola Saleem, were murdered outside Khaola’s home address just after midnight following an incident at a Birmingham shisha lounge. Both women died from multiple stab wounds. The report raises a concern that serious staff shortages in the domestic abuse team led to cases not being effectively investigated, placing repeat victims of domestic abuse and coercive control at serious risk.
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 staffing and resources for domestic abuse investigations
Wider context from the report “1. The inquest heard evidence that the domestic abuse team within the Public Protection Unit were seriously short staffed . The inquest was told that in Raneem's case the officer reviewing her case on 28/04/18 understood that more needed to be done however he filed the report due to having no staff to investigate the case . The officer stated that this problem continues . The inquest was told that cases are not being investigated due to lack of resources in the department . This leaves a very real and immediate concern that women like Raneem, who was a repeat victim of domestic violence and controlling and coercive control from a man who had made threats to kill her, are at serious risk due to a lack of effective investigation by the department responsible for investigating domestic abuse .
” 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 Recruit an additional 20,000 police officers through the Police Uplift Programme by March 2023.
Verbatim wording from the response “Alongside implementing the commitments set out in the Tackling Domestic Abuse Plan, the Government are providing policing and law enforcement agencies with everything they need to bring murderers to justice. The Government is on track to deliver its commitment of recruiting an additional 20,000 police officers by March 2023. As of 30th September 2022, 15,343 additional uplift officers have been recruited in England and Wales through the Police Uplift Programme, 77% of the target of 20,000 additional officers by March 2023. As part of this commitment, West Midlands Police have benefitted from up to £40m of additional funding this year alone. As at the end of September, the force has recruited an additional 944 officers towards its overall Uplift allocation of 1,218.” 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 Officer deployment, including staffing decisions, is a local responsibility for Chief Constables because police forces are operationally independent.
Verbatim wording from the response “It is important to note, however, that forces are operationally independent, and the deployment of officers remains a local decision for Chief Constables.” Source location Response from Home Office
Open published response
4 Oct 2022 Reginald Cauthery · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to review telecare services in light of increased fire risk and deteriorating mobility View source Failure to answer telecare fire calls as a priority View source Dependence on other people recognising smoke alarms and calling the Fire Brigade for urgent fire assistance View source Smoke alarms not connected to telecare systems View source Delays in calling 999 while seeking confirmation of smoke alarm activation View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Reginald Cauthery · 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
Reginald Cauthery was a frail man with limited mobility who lived alone and died in hospital after sustaining extensive burns in a smouldering fire at his flat. The report raised concerns that his telecare service was not reviewed despite his increased fire risk and deteriorating mobility, and that his smoke alarms were not connected to the telecare system, delaying contact with the Fire Brigade.
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 review telecare services in light of increased fire risk and deteriorating mobility
Wider context from the report “(1) There was no review of the telecare service provided to Mr Cauthery despite the agencies working with him being aware of his increased fire risk and deteriorating mobility .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 answer telecare fire calls as a priority
Wider context from the report “(3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority . In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Dependence on other people recognising smoke alarms and calling the Fire Brigade for urgent fire assistance
Wider context from the report “(2) The ability of frail and vulnerable people to get urgent help in a fire situation will often depend upon other people recognising that a smoke alarm has triggered and calling the Fire Brigade . This raises particular problems if the person lives alone and their smoke alarm is not connected to their telecare system.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Smoke alarms not connected to telecare systems
Wider context from the report “(2) The ability of frail and vulnerable people to get urgent help in a fire situation will often depend upon other people recognising that a smoke alarm has triggered and calling the Fire Brigade. This raises particular problems if the person lives alone and their smoke alarm is not connected to their telecare system .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Delays in calling 999 while seeking confirmation of smoke alarm activation
Wider context from the report “(3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority. In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call .
” 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 Encourage dissemination of the report’s findings and continued highlighting of telecare links to smoke alarms during fire safety checks.
Verbatim wording from the response “To ensure that lessons from this case are learned, the Home Office will be sharing information from this case with the National Fire Chiefs Council (NFCC), which drives improvement and development throughout the UK FRSs. We will encourage it to disseminate the findings from your Regulation 28 report and ask FRSs (as part of their fire safety checks) to continue highlighting the importance of linking telecare systems to smoke alarms to help inform local agencies and carers about using them effectively.” 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 Local agencies are best placed to determine vulnerable people's required care packages and telecare equipment.
Verbatim wording from the response “Local agencies are best placed to consider the care packages and equipment, including telecare systems, that are required to support vulnerable people. Officials from my Department have sought information from London Fire Brigade (LFB) on its policy regarding telecare systems. LFB confirmed that where telecare systems are installed it advises all care providers and support workers that the systems should be linked to smoke alarms as standard.” 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 Fire Safety Order does not apply to individual homes, and fire and rescue services lack statutory powers to enforce telecare system changes.
Verbatim wording from the response “The Home Office is responsible for the Regulatory Reform (Fire Safety) Order 2005, which applies to existing non-domestic premises and the common parts of multi-occupied residential buildings. It does not apply to individual homes. The Fire Safety Order places certain duties on the person responsible for the premises (usually the owner, landlord or employer) to ensure their fire safety. It is Local authorities that have a duty under the Housing Act 2004 to take enforcement action if they identify seriously hazardous conditions - including fire - in residential accommodation. This is assessed using the Housing Health and Safety Rating System risk assessment tool.” 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 Telecare installation, maintenance and linking to smoke alarms must be undertaken by telecare engineers, not fire and rescue services.
Verbatim wording from the response “Under the FSO, Fire and rescue services do not have statutory powers to enforce changes to telecare systems. Further, fire and rescue services (FRSs) do not install or maintain telecare systems and have no capability to link them to smoke alarms. Such work must be undertaken by telecare engineers.” Source location Response from Home Office
Open published response
15 Sep 2022 Harper DENTON · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Lack of an offender register or equivalent protection for children from people convicted of cruelty against a child View source Failure to require Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children View source Failure to adopt MOSOVO guidance for managing sexual and violent offenders, particularly PDPs View source Lack of proactive police information sharing to protect children from people convicted of violence or cruelty against a child 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
Harper DENTON · 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
Harper DENTON, aged one month, was unlawfully killed by her father, who had previously been convicted of violent offences against a two-year-old child. The inquest found that failures by state agencies to manage the continuing risk he posed contributed to her death. Concerns included police information-sharing and risk-management practices, the absence of an offender register for people convicted of cruelty offences against children, and the non-mandatory nature of full safeguarding assessments by health visitors.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of an offender register or equivalent protection for children from people convicted of cruelty against a child
Wider context from the report “3. There is nothing today, such as form of Offender Register, to protect children from an individual who has already been convicted of a cruelty offence against a child and served their sentence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children
Wider context from the report “4.The need for a Health Visitor to carry out a full safeguarding assessment of a father’s/co-parent's potential risks to a child is currently only ‘best practice’ and not mandatory .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 adopt MOSOVO guidance for managing sexual and violent offenders, particularly PDPs
Wider context from the report “1.The MPS does not appear to have adopted ACPO Guidance on Protecting the Public: Managing Sexual Offenders and Violent Offenders 2010 and subsequent APP College of Policing MOSOVO Guidance , particularly with respect to PDPs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 proactive police information sharing to protect children from people convicted of violence or cruelty against a child
Wider context from the report “2. There appears to be a lacuna in pro-active information sharing practices by Police (similar to those found under Clare’s Law and Sarah’s Law) in order to protect children from those who may present a threat to them as a result of having previous convictions for violence/cruelty offences against a child - this concern is directed to the CEO College of Policing and the Chair of the NPCC.
” 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 Share the independent review findings and consider the Government’s response, including implications for offence-based registers.
Verbatim wording from the response “It is now for Ministers to decide how the findings of the review will be shared and consider any response to the recommendations; including potential implications for work on the development of offence-based ‘registers’.” 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 Continue considering options for implementing a domestic abuse offender register.
Verbatim wording from the response “HM Government is continuing to consider options for better management of domestic abuse offenders. The Tackling Domestic Abuse Plan, published in April, committed to consider the implementation of a domestic abuse ‘register’ to deal with, and effectively manage, the most harmful perpetrators of such offences and reduce the risk they pose. It is anticipated that there will be overlap between those offenders who commit domestic” 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 Continue considering the case for a child cruelty register within wider safeguarding policy discussions.
Verbatim wording from the response “In May, we welcomed the publication of the Independent Review of Children’s Social Care, and the Child Safeguarding Practice Review Panel’s national review ‘Child Protection in England’; while October saw the final report of the Independent Inquiry into Child Sexual Abuse in England and Wales. All three of those reviews make recommendations to Government on how to improve multi-agency working to strengthen child protection, and taken together provide us with an opportunity to consider how safeguarding can be improved in the round. The Government will be responding to the recommendations in those reviews in due course, and we will continue to consider the case for a child cruelty register in context of all ongoing policy discussions in this space.” 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 Lay a report before Parliament setting out policy on safeguarding information sharing by public authorities, including the feasibility of a consistent child identifier.
Verbatim wording from the response “We know information and data sharing between agencies is a challenge, and across Government we are actively considering how to improve relevant processes for operational partners. The Health and Social Care Act 2022 commits the Government to laying a report before Parliament in Summer 2023 setting out its policy on information sharing by public authorities for the purposes of safeguarding and promoting the welfare of children; including the feasibility of using a consistent child identifier.” 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 Continue supporting domestic violence and child sex offender disclosure schemes through national guidance.
Verbatim wording from the response “We are also continuing to support disclosure schemes through the provision of national guidance. The Domestic Violence Disclosure Scheme and the Child Sex Offender Disclosure Scheme both provide members of the public with a clear process to seek information from the police on individuals who may pose a risk of harm to children.” 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 Consider improvements to information-sharing processes among agencies safeguarding children.
Verbatim wording from the response “We know information and data sharing between agencies is a challenge, and across Government we are actively considering how to improve relevant processes for operational partners. The Health and Social Care Act 2022 commits the Government to laying a report before Parliament in Summer 2023 setting out its policy on information sharing by public authorities for the purposes of safeguarding and promoting the welfare of children; including the feasibility of using a consistent child identifier.” Source location Response from Home Office
Open published response
30 Aug 2022 David Honnor · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of colour coding of gas cylinders for emergency-service identification View source Lack of licensing controls for public purchase or acquisition of gas canisters View source Insufficient clarity and adequacy of gas canister safety information 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
David Honnor · 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 Honnor had oesophageal cancer and underwent radiotherapy and stent placement before his condition worsened in 2022. He obtained a gas canister and died from asphyxia; the inquest recorded suicide. Concerns included public access to these products, whether they should be licensed, the lack of colour coding to help emergency services identify gas cylinders, and whether safety information was clear and sufficient.
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 colour coding of gas cylinders for emergency-service identification
Wider context from the report “2. I have concerns with regard to the following:
i. I have concerns that members of the public are able to purchase or acquire ████████.
ii. I have concerns that these products should be licensed.
iii. I have concerns that there is no colour coding of gas cylinders to assist first response emergency services .
iv. I have concerns as to whether the safety information on these gas cannisters is clear and sufficient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 licensing controls for public purchase or acquisition of gas canisters
Wider context from the report “2. I have concerns with regard to the following:
i. I have concerns that members of the public are able to purchase or acquire ████████ .
ii. I have concerns that these products should be licensed .
iii. I have concerns that there is no colour coding of gas cylinders to assist first response emergency services.
iv. I have concerns as to whether the safety information on these gas cannisters is clear and sufficient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Insufficient clarity and adequacy of gas canister safety information
Wider context from the report “2. I have concerns with regard to the following:
i. I have concerns that members of the public are able to purchase or acquire ████████.
ii. I have concerns that these products should be licensed.
iii. I have concerns that there is no colour coding of gas cylinders to assist first response emergency services.
iv. I have concerns as to whether the safety information on these gas cannisters is clear and sufficient .
” Open source report
27 Jun 2022 Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 11 Lack of national recognition of proactive collative vulnerability processes View source DASH form not adequately updated View source Lack of information sharing between agencies View source Lack of national-level complex case forums View source Lack of a single point of contact for information collation, assessment and coordinated proactive action View source Lack of a system to identify and care for vulnerable people outside the “high risk” criteria View source Failure of processes and policies to recognise the link between domestic abuse and suicide View source Insufficient information sharing about sleep deprivation risks and impacts on mental health and suicide View source Lack of a robust information-sharing policy for suicidal ideation, self-harm and vulnerable people View source Unavailability of a shared database for agencies to input common concerns View source Insufficient training and awareness of domestic abuse and suicide risk among front line police officers View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jessica Louise LAVERACK “Jessie” · 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
Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.
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 national recognition of proactive collative vulnerability processes
Wider context from the report “(8) The processes of Humber police’s vulnerability hub and DARA forms which show a more proactive, collative approach, are not currently a nationally recognised method of working .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation DASH form not adequately updated
Wider context from the report “(7) Evidence was heard that the DASH form may benefit from updating .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of information sharing between agencies
Wider context from the report “(3) There was a lack of information sharing between all agencies , even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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-level complex case forums
Wider context from the report “(9) If not already in place, to consider complex case forums on a national level .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 single point of contact for information collation, assessment and coordinated proactive action
Wider context from the report “(4) There is no single point of contact to oversee the collation of all information, to appropriate assess it and to coordinate a structured proactive approach to people with dual or multi diagnosis. This is in both MARAC and for those who are vulnerable but do not meet the “high risk” criteria.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 system to identify and care for vulnerable people outside the “high risk” criteria
Wider context from the report “(2) There is no system to appropriately identify and care for the vulnerable who do not meet the criteria of “high risk” which is covered by MARAC, evidence was heard that a large number of domestic homicide reviews cover victims who have not been rated as “high 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 processes and policies to recognise the link between domestic abuse and suicide
Wider context from the report “(1) The is a need for the recognition of the link between domestic abuse and suicide. Processes and policies do not seem to include this serious area to the extent that is required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 information sharing about sleep deprivation risks and impacts on mental health and suicide
Wider context from the report “(11) To consider better information sharing about the risks of sleep deprivation and its impact on mental health and 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 Lack of a robust information-sharing policy for suicidal ideation, self-harm and vulnerable people
Wider context from the report “(3) There was a lack of information sharing between all agencies, even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a shared database for agencies to input common concerns
Wider context from the report “(3) There was a lack of information sharing between all agencies, even those tasked with domestic abuse.
a. There is no one database which is accessible for all agencies to input their common concerns.
b. There is lack of robust policy of information sharing regarding both suicidal ideation, self harm as well as identification of the vulnerable.
It is noted that the Health and Care Act is due to commence on 1st July 2022, which outlines need for interagency working. This may be an ideal opportunity to address these issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 training and awareness of domestic abuse and suicide risk among front line police officers
Wider context from the report “(5) There is a need to consider better training and awareness of both domestic abuse and risk of suicide for front line police officers.
” 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 police suicide guidance to reference domestic abuse and prompt consideration of domestic abuse in unexplained deaths and suspected suicides.
Verbatim wording from the response “The commitments in the Tackling Domestic Abuse Plan include measures to update police guidance on suicide so that it explicitly includes references to domestic abuse and for the police to consider whether domestic abuse was a contributing factor in cases of unexplained deaths and suspected suicides. We also committed to continue to fund the Domestic Homicide and Suspected Victim Suicides Project, led by the National Police Chiefs’ Council, College of Policing (NPCC) and the National Policing Vulnerability Knowledge and Practice Programme (VKPP).” Source location Response from Home Office (2)
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 up to £3.3 million to support further rollout of domestic abuse and related policing training.
Verbatim wording from the response “In terms of training, the College of Policing has developed the Policing Education Qualifications Framework which is an important step in raising standards in policing, including in tackling violence against women and girls. Additionally, the College have developed a range of other training products, including the Domestic Abuse Matters programme. We committed up to £3.3m to support further rollout of the training.” Source location Response from Home Office (2)
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 Strengthen statutory guidance for Domestic Homicide Reviews involving suicide to clarify referral criteria and review processes.
Verbatim wording from the response “We will also be strengthening the Domestic Homicide Review statutory guidance for suicide cases to improve clarity for cases which should be referred for a Domestic Homicide Review and how to review these complex cases.” Source location Response from Home Office (2)
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 funding the Domestic Homicide and Suspected Victim Suicides Project.
Verbatim wording from the response “The commitments in the Tackling Domestic Abuse Plan include measures to update police guidance on suicide so that it explicitly includes references to domestic abuse and for the police to consider whether domestic abuse was a contributing factor in cases of unexplained deaths and suspected suicides. We also committed to continue to fund the Domestic Homicide and Suspected Victim Suicides Project, led by the National Police Chiefs’ Council, College of Policing (NPCC) and the National Policing Vulnerability Knowledge and Practice Programme (VKPP).” Source location Response from Home Office (2)
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 Use of DASH risk assessments and vulnerability hubs is an operational policing matter rather than a government matter.
Verbatim wording from the response “Whilst the use of Domestic Abuse, Stalking and Harassment (DASH) risk assessment form and vulnerability hubs are an operational issue for policing, the Government is committed to ensuring that police are equipped to tackle domestic abuse effectively. The Home Secretary commissioned Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Services (HMICFRS) to help police forces to keep strengthening their responses, and to further support the action we set out in our cross-Government Violence Against Women and Girls Strategy, which we published in summer 2021, and Tackling Domestic Abuse Plan. The Government has committed to ensuring all HMICFRS actions are implemented and we have taken decisive action. This will include, for example adding violence against” Source location Response from Home Office (2)
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 Department for Health and Social Care will respond separately on information sharing about sleep deprivation, mental health and suicide risks.
Verbatim wording from the response “The Department for Health and Social Care will respond separately on better information sharing about the risks of sleep deprivation and its impact on mental health and suicide.” Source location Response from Home Office (2)
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 current MARAC model provides an effective, flexible forum for agencies to manage domestic abuse safeguarding risks without statutory duties.
Verbatim wording from the response “The MARAC model is designed to provide an effective multi-agency response to manage the risks to victims of domestic abuse. There is a concern that statutory duties can be a blunt tool and that making MARACs statutory risks fostering a culture of minimum compliance rather than genuine local ownership and accountability. More importantly, placing MARACs on a statutory basis also risks locking down a particular model of multi-agency working and may stifle the development of local, innovative models to manage safeguarding risks, such as those with complex needs. The Government believes the current MARAC model gives agencies flexibility in the actions they put forward to protect those at risk of harm from domestic abuse. The cases discussed at MARAC are, by their very nature, demanding and complex. We believe the MARAC process can provide an effective forum for managing those risks.” Source location Response from Home Office (2)
Open published response
23 Jun 2022 Khalid Seneen Yousef · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Insufficient understanding of the L&D police custody suite model’s role and limitations View source Inadequate training of L&D practitioners View source Lack of clarity about responsibility for mentally unwell persons in custody View source Failure to learn sufficient lessons from the incident View source Inadequate experience of L&D practitioners View source Lack of commissioned psychiatrists within the L&D police custody suite model View source Inadequate supervision of L&D practitioners 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
Khalid Seneen Yousef · 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
Khalid Seneen Yousef was decapitated during a sustained knife assault at a premises in Birmingham on 4 January 2018. The report identifies concerns that a Liaison and Diversion clinician failed to recognise the perpetrator’s psychosis and refer him for mental health assessment, and that the custody-suite model lacked commissioned psychiatrists, with wider concerns about responsibility, training and supervision.
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 understanding of the L&D police custody suite model’s role and limitations
Wider context from the report “3. West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 clarity about responsibility for mentally unwell persons in custody
Wider context from the report “2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D services on who has responsibility for mentally unwell persons in custody .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 learn sufficient lessons from the incident
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 experience of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience , training and supervision of L&D practitioners .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 commissioned psychiatrists within the L&D police custody suite model
Wider context from the report “1. The L&D police custody suite model has not commissioned psychiatrists .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 supervision of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with policing and health partners to improve escalation processes between police and NHS services.
Verbatim wording from the response “I can also confirm that Home Office officials work very closely with the NPCC, NHS England, the Department for Health and Social Care on a range of different issues relating to mental health and how healthcare partners and the police can work together most effectively. Currently, they are collectively working on how to improve escalation processes between the police and NHS and how mental health is managed in the custody environment with a view to the NPCC issuing guidance on effectively managing these referral pathways.” 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 is responsible for commissioning Liaison and Diversion Services, so the Home Office will not comment or intervene.
Verbatim wording from the response “The commissioning of Liaison and Diversion Services is a matter for NHS England. The tendering and commissioning of all police custody healthcare services is the responsibility of Police and Crime Commissioners and their forces and it is for them to take decisions on how to allocate resources based on their local knowledge and experience. Therefore, it would not be appropriate for the Home Office to comment or intervene in either of these two services.” Source location Response from Home Office
Open published response
Concerns raised 3 Lack of legal powers to require appointment of an Event Organiser View source Lack of legal powers to grant or refuse permission for events with significant public safety concerns View source Failure to appoint an Event Organiser responsible for whole-event public safety coordination View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Laura Amy Smallwood · 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 1 May 2019, Laura Amy Smallwood was unintentionally struck on the back of her neck by an Oss during the May Day festival in Padstow. She deteriorated at the scene, suffered a respiratory arrest, and died from her injuries in hospital on 4 May 2019. The principal concern was the absence of a single Event Organiser for the festival, with resulting gaps in engagement with safety agencies and in legislative oversight of public safety.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of legal powers to require appointment of an Event Organiser
Wider context from the report “Those who attend May Day from the Oss organisations, however, represent only a small fraction of the total number of attendees. At inquest, I heard that there is still no one willing to act as an ‘Event Organiser’ for the May Day event as a whole despite repeated requests from the police for this to happen. As a consequence, there is no single point of contact for the police or others and no one who is engaged with the LSAG to look at public safety.
I heard in evidence that the current legislative framework does not provide the police or any other agency with powers in law to insist on the appointment of an Event Organiser . Further, neither the police nor any other agency have powers in law to grant or refuse permission to hold an event where there are significant concerns around public safety. I enclose statements from:
- Inspector ████████;
- PS ████████
- ████████ with counsel’s advice.
If these submissions are correct, this gap in legislative oversight is relevant not simply for the May Day festival in Padstow but for events nationally. What is the expectation of government, in terms of the management of public safety, where there is no Event Organiser to engage with a LSAG and other agencies like the police?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 grant or refuse permission for events with significant public safety concerns
Wider context from the report “Those who attend May Day from the Oss organisations, however, represent only a small fraction of the total number of attendees. At inquest, I heard that there is still no one willing to act as an ‘Event Organiser’ for the May Day event as a whole despite repeated requests from the police for this to happen. As a consequence, there is no single point of contact for the police or others and no one who is engaged with the LSAG to look at public safety.
I heard in evidence that the current legislative framework does not provide the police or any other agency with powers in law to insist on the appointment of an Event Organiser. Further, neither the police nor any other agency have powers in law to grant or refuse permission to hold an event where there are significant concerns around public safety . I enclose statements from:
- Inspector ████████;
- PS ████████
- ████████ with counsel’s advice.
If these submissions are correct, this gap in legislative oversight is relevant not simply for the May Day festival in Padstow but for events nationally. What is the expectation of government, in terms of the management of public safety, where there is no Event Organiser to engage with a LSAG and other agencies like the police?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 appoint an Event Organiser responsible for whole-event public safety coordination
Wider context from the report “Those who attend May Day from the Oss organisations, however, represent only a small fraction of the total number of attendees. At inquest, I heard that there is still no one willing to act as an ‘Event Organiser’ for the May Day event as a whole despite repeated requests from the police for this to happen. As a consequence, there is no single point of contact for the police or others and no one who is engaged with the LSAG to look at public safety .
I heard in evidence that the current legislative framework does not provide the police or any other agency with powers in law to insist on the appointment of an Event Organiser. Further, neither the police nor any other agency have powers in law to grant or refuse permission to hold an event where there are significant concerns around public safety. I enclose statements from:
- Inspector ████████;
- PS ████████
- ████████ with counsel’s advice.
If these submissions are correct, this gap in legislative oversight is relevant not simply for the May Day festival in Padstow but for events nationally. What is the expectation of government, in terms of the management of public safety, where there is no Event Organiser to engage with a LSAG and other agencies like the police?
” 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 Amending the law would not necessarily prevent rare event tragedies, so further legislation is not considered necessary.
Verbatim wording from the response “For that reason, we have taken the view that it is better to support and encourage sensible planning and preparation, rather than to mandate every element of it through legislation. The latest public guidance from the Cabinet Office (Organising a voluntary event: a 'can do' guide - GOV.UK (www.gov.uk)) is intended to help people planning voluntary events, with advice on the steps that organisers should take.” Source location Response from Home Office
Open published response
26 Jan 2022 Ketheeswaran KUNARATHNAM · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Failure of communication arrangements between prison and immigration staff View source Lack of recording and audit trails for attempted communications View source Lack of accessible information and advice for detained prisoners facing deportation View source Delays and failures in dealing with prisoners' requests 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
Ketheeswaran KUNARATHNAM · 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
Ketheeswaran KUNARATHNAM, a refugee detained at HMP Wormwood Scrubs after completing a prison sentence, was found hanging in his cell on 23 February 2018; the inquest concluded suicide. The report identified shortcomings in communication, record keeping, risk assessment, healthcare checks, prison procedures and the timeliness of immigration responses. It also raised concerns about detained prisoners receiving insufficient accessible information and support regarding their immigration and legal matters.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of communication arrangements between prison and immigration staff
Wider context from the report “Communication between the prison officers and home office officials and immigration staff was ineffective and frequently not evidenced at all. Pieces of paper were lost, phones were unanswered with no answer phone facility, email addresses were unavailable due to incompatible systems and there was no audit trail of attempted communications or the reason why these were unsuccessful. Many requests made by or on behalf of the prisoner were not dealt with in a timely manner or at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of recording and audit trails for attempted communications
Wider context from the report “Communication between the prison officers and home office officials and immigration staff was ineffective and frequently not evidenced at all . Pieces of paper were lost, phones were unanswered with no answer phone facility, email addresses were unavailable due to incompatible systems and there was no audit trail of attempted communications or the reason why these were unsuccessful . Many requests made by or on behalf of the prisoner were not dealt with in a timely manner or at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 accessible information and advice for detained prisoners facing deportation
Wider context from the report “During the inquest it became apparent that a certain number of prisoners in HMP Wormwood Scrubs were detained for deportation reasons after the conclusion of their prison sentence. There seemed to be a marked disparity between the information and advice available to a detained prisoner, compared with a free individual or one in a deportation centre. There was a paucity of available information and the letters sent out by the Home Office were written in legal English with no offer of translation or “plain English” assistance. Individuals in the community could access the internet, Law centres, citizens advice or any other sources of assistance that were not available to detained prisoners due to the restrictive regime , putting them at a disadvantage.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 in dealing with prisoners' requests
Wider context from the report “Communication between the prison officers and home office officials and immigration staff was ineffective and frequently not evidenced at all. Pieces of paper were lost, phones were unanswered with no answer phone facility, email addresses were unavailable due to incompatible systems and there was no audit trail of attempted communications or the reason why these were unsuccessful. Many requests made by or on behalf of the prisoner were not dealt with in a timely manner or at all.
” 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 Ensure immigration officers attend prison ACCT reviews to exchange case-progression information.
Verbatim wording from the response “At a local level, the Home Office’s Immigration Prison Team (IPT) embedded at HMP Wormwood Scrubs now works very closely with prison colleagues, with established lines of communication and regular meetings between the two parties around vulnerable persons. Since 2018, IPT have also been working with individual prisons across the country to ensure the attendance of Home Office officials at all Assessment Care in Custody and Teamwork (ACCT) reviews so that updates on case progression can be provided and information effectively exchanged.” Source location 2022-0030-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 Maintain dedicated immigration officers embedded in prisons to induct foreign national offenders and record accessible interaction information.
Verbatim wording from the response “We have considered the concerns you have raised as to the effectiveness of in person engagement with immigration officials in Mr Kunarathnam’s case. 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 an FNO 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 2022-0030-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 Continue reviewing technological improvements for timely and secure information exchange with prison officials.
Verbatim wording from the response “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 2022-0030-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 Notify prison units about vulnerabilities when serving immigration notices, record relevant information, and review vulnerable cases through monthly senior-officer meetings.
Verbatim wording from the response “You concluded that an individualised assessment of Mr Kunarathnam’s needs did not take place when relying immigration matters. I would like to assure you that officials recognise it is paramount to consider the individual circumstances of a FNO and their vulnerabilities when serving immigration notices. This routinely takes place in prisons across the country where FNOs are serving their sentences. Immigration Officers will make the relevant Officer Manager Unit and Wing Offices aware when serving immigration notices to ensure the FNO can access support if required. This will also be recorded on Home Office databases for other officials to view. A further line of assurance is provided by monthly meetings with senior immigration officers to discuss vulnerable cases and take forward actions in our hub prisons.” Source location 2022-0030-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 Launch an FNO Information Hub to provide shared signposting resources supporting preparation for release or removal.
Verbatim wording from the response “Communications are also more appropriately documented. Immigration officers embedded in prisons now ensure all conversations are recorded and where appropriate signed by the FNO. Digitalisation improvements have allowed for engagements with FNOs to be raised on internal databases along with any vulnerability concerns promptly after interactions, while Immigration Officers have access to a Ministry of Justice system, to ensure immigration contact and records are widely shared. At HMP Wormwood Scrubs, immigration officers now have access to the HMPPS database where relevant information is also accessible. To further strengthen collaborative working an FNO Information Hub has been launched which will pave the way for a digital platform and sharing forum for both Home Office and HMPPS users which aims to provide signposting resources to prepare FNOs for their release or removal.” Source location 2022-0030-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 Explain and signpost deportation processes, possible claims, evidence sources and legal assistance throughout the deportation process.
Verbatim wording from the response “In your report, you specifically highlighted an inability to access the internet, Law Centres, Citizens Advice or any other sources of assistance for those detained in a prison. We recognise that not all FNOs will be legally represented and therefore throughout the deportation process we will seek to explain and signpost appropriately whether through written documents or direct engagement. The deportation notice informs the FNO why deportation is being considered and invites the person to provide any reasons why they consider it should not be pursued. A statement of reasons accompanies this decision, clearly setting out examples of possible claims, including those protection and human rights based, which could be raised alongside possible sources of supportive evidence.” Source location 2022-0030-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 Record immigration-officer conversations and vulnerability concerns in shared digital systems accessible to relevant Home Office and prison officials.
Verbatim wording from the response “Communications are also more appropriately documented. Immigration officers embedded in prisons now ensure all conversations are recorded and where appropriate signed by the FNO. Digitalisation improvements have allowed for engagements with FNOs to be raised on internal databases along with any vulnerability concerns promptly after interactions, while Immigration Officers have access to a Ministry of Justice system, to ensure immigration contact and records are widely shared. At HMP Wormwood Scrubs, immigration officers now have access to the HMPPS database where relevant information is also accessible. To further strengthen collaborative working an FNO Information Hub has been launched which will pave the way for a digital platform and sharing forum for both Home Office and HMPPS users which aims to provide signposting resources to prepare FNOs for their release or removal.” Source location 2022-0030-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 Prison access to 30 minutes of legally aided immigration advice provides a functional equivalent to the service available in immigration removal centres.
Verbatim wording from the response “These notices signpost Civil Legal Advice (and Scottish and Northern Ireland equivalents); an organisation which can provide information on legal aid if a person is unable to pay for a legal representative. A published list of legal aid providers is available from the Legal Services Commission. Removal paperwork reminds the person of the same. Additionally, in November 2021, HM Prisons and Probation Service (HMPPS) issued an instruction which allows all individuals held under immigration powers in a prison, access to 30 minutes of legally aided immigration legal advice. This provides a functional equivalent to the service currently available in IRCs.” Source location 2022-0030-Response-from-Home-Office
Open published response
Concerns raised 2 Failure to apply regulated-poison controls to the substance View source Easy purchase of relatively small quantities of the substance 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 Michael Lacey · 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 Michael Lacey, otherwise known and living as Victoria Lacey, died by suicide on 13 June 2020 after taking a fatal dose of a readily available chemical together with other preparations. The report raised concerns about the ease of purchasing the substance and the less rigorous controls applied to reportable poisons compared with regulated poisons.
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 apply regulated-poison controls to the substance
Wider context from the report “(2) a ████████ is currently a “reportable substance” or “reportable poison” under Part 4 of Schedule 1 to the Poisons Act 1972 . As a result, under certain circumstances, sellers are under an obligation to report suspicious transactions, disappearances, and thefts of the substance, in a manner prescribed by the Secretary of State (s.3C Poisons Act 1972).
a. However, this is a much less rigorous degree of control than is exercised over “regulated poisons” under the terms of the legislation . Those substances, which are listed in Part 2 of Schedule 1 of the Act, are subject to requirements including licensing, record-keeping of sales, and other restrictions in relation to the general public .
c. Both the regulated poisons and reportable poison lists can specify “concentration limits” which restrict the obligations imposed by the legislation to chemicals in concentrations at or above that limit. For example, ammonia is “reportable” in concentrations at or above 10% weight in weight (w/w) and phenols are “regulated” at or above 60% w/w. The power to specify a concentration can ensure that low concentrations of substances are not subject to the regime but higher (and therefore more dangerous levels) are subject to scrutiny.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Easy purchase of relatively small quantities of the substance
Wider context from the report “(1) relatively small quantities of ████████ can easily be purchased .
” Open source report
26 Nov 2021 Felicity Jane Clough · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of accessibility to records held by different healthcare trusts View source Failure of Emergency Department staff to access vital pre-admission and paramedic records View source Lack of access by other police forces to information held on individual police force systems View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Felicity Jane Clough · 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
Felicity Jane Clough was taken to hospital on 24 November 2019 after being prescribed Tramadol, discharged during the early morning, and later found collapsed and unresponsive in a field. The concerns included limited information-sharing between healthcare trusts and police forces, and the failure to consistently review paramedic records containing potentially critical information at Yeovil District Hospital.
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 accessibility to records held by different healthcare trusts
Wider context from the report “i. There could be future deaths nationally due to the lack of accessibility to records held by different healthcare trusts . I would request consideration is given to the sharing of records between healthcare trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Department staff to access vital pre-admission and paramedic records
Wider context from the report “iii. I have concerns that future deaths could occur at Yeovil District hospital due to the missing of vital information within the pre admission documentation due to the fact that the staff within the Emergency Department at Yeovil District Hospital are not always accessing admission documentation, especially the paramedic records when a person is brought into the Accident and Emergency department. I request that consideration is given to issuing further guidance to remind staff of the need to review this documentation or amending the current policy in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of access by other police forces to information held on individual police force systems
Wider context from the report “ii. I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces , especially neighbouring forces who may both have contact with individuals. Whilst I understand there is some work being done on a regional basis to address this, I would request that the issue is considered nationally as to how information held on all Police systems, not just the Police National Database, can be shared to assist in the management and assessment of individuals and the risk they pose to themselves or others.
” Open source report
22 Nov 2021 BERENICE NADIKA BELL · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 The single largest cause of death among people under 35 in the UK View source Access to various family and mental health professionals View source Access to services before death among children who subsequently died from the same cause 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
BERENICE NADIKA BELL · 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
Berenice had booked into an Airbnb and was found dead there on 20 May 2021 after failing to check out, having left a note. Evidence indicated that she had sought psychotherapy in April 2021 and had been feeling anxious and depressed; she had also lost her life savings after being scammed. Concerns included the role of ████████ in deaths among people under 35 and evidence that Berenice had accessed various ████████ family and mental health professionals, alongside reports of similar post-death findings by other families.
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 The single largest cause of death among people under 35 in the UK
Wider context from the report “(1) ████████ is the single largest cause of death in the UK for people under 35.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Access to various family and mental health professionals
Wider context from the report “(2) Evidence was provided by the family that Berenice had accessed various ████████ family and mental health professionals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Access to services before death among children who subsequently died from the same cause
Wider context from the report “(3) The family have discovered through a support group that other parents who have lost their children to ████████ have also discovered, after the deaths of their children, that their own children were also accessing ████████ before they died.
” Open source report
19 Nov 2021 Mustafa Dawood Bakht ABDELKARIM (Mustafa Dawood) · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1 Lack of training in pursuit and decision-making during stressful situations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mustafa Dawood Bakht ABDELKARIM (Mustafa Dawood) · 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 30 June 2018, Mustafa Dawood was pursued by Immigration Officers at a car wash in Newport, climbed onto a roof, fell through plastic roofing, and died in hospital from severe head injuries. The jury identified concerns that officers remained close after the pursuit was to be abandoned, that this decision was not effectively communicated, that a baton was kept racked, and that officers lacked appropriate pursuit training; these factors could have contributed to his death.
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 training in pursuit and decision-making during stressful situations
Wider context from the report “1. Training in Pursuit for Immigration Officers.
The jury heard that during the induction process all Immigration Officers are introduced to the Pursuit Policy. However none of the Officers had undergone training in pursuit or in how to make decisions in those stressful situations. The jury determined that the lack of training could have contributed to Mustafa Dawood’s death as has been reflected in their conclusion.
” Open source report
3 Nov 2021 Saskia Jones and 2 others · Prevention of Future Deaths report London City
View report summary
Concerns raised 24 Failure to inform MAPPA panels about regularity and form of overt offender-management contact View source Insufficient consideration of extremist offenders’ dishonest self-presentation View source Failure to share and consider counter-terrorism police intelligence in MAPPA management View source Failure to properly reason and record offender-manager licence-condition approvals View source Failure to provide MAPPA panels important prison-history information View source Failure to provide MAPPA panels direct input from the preparing forensic psychologist View source Failure to communicate between offender managers and event organisers before extremist offenders attend events View source Insufficient risk assessment and management for prison higher education programmes involving post-release offender contact View source Sudden disruption of DDP mentoring arrangements View source Sudden loss of supervised internet access for employment searches View source Failure to complete the full structured assessment before changing an OASys risk rating View source Failure to properly consider security-sensitive information in MAPPA decisions View source Lack of precautionary search capability for terrorist offenders on licence View source Failure to detect Class A drug use by terrorist offenders on licence View source Unavailability of offender risk-profile information to prison-based higher education providers View source Failure to ensure all MAPPA meeting attendees receive meeting minutes View source Failure to ensure direct forensic psychologist involvement in ERG 22+ assessment reports View source Failure to assess risks of continuing close contact between serious offenders and young students View source Excessive reliance on compliance in management of extremist offenders View source Failure to communicate high-risk event attendance to host venues View source Failure to directly address risks when approving licence-condition changes View source Lack of formal risk assessment for higher education events held outside university premises View source Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes View source Failure to record proper rationale for changes to OASys risk ratings View source See 21 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
Saskia Jones and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 29 November 2019, Usman Khan carried out a terrorist attack at Fishmongers’ Hall, fatally stabbing Saskia Jones and Jack Merritt before being fatally shot by firearms officers on London Bridge. The report raised concerns about risk assessment and communication for events involving high-risk offenders, and about the assessment, information-sharing, supervision and management of terrorist offenders released into the community.
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 inform MAPPA panels about regularity and form of overt offender-management contact
Wider context from the report “The facts of this case give cause for concern that MAPPA panels responsible for managing terrorist offenders may be unaware of the regularity and form of contact with police officers responsible for overt offender management .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 consideration of extremist offenders’ dishonest self-presentation
Wider context from the report “The facts of this case give rise to concern that probation officers may give insufficient regard to instances of dishonesty in self-presentation by extremist offenders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to share and consider counter-terrorism police intelligence in MAPPA management
Wider context from the report “This case gives cause for concern that counter-terrorism police may be in possession of intelligence or information which may be useful to the management of an offender by the MAPPA panel, but that such intelligence or information may not be brought to the knowledge of or taken into account by MAPPA agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to properly reason and record offender-manager licence-condition approvals
Wider context from the report “This case gives rise to concern that offender managers may take significant decisions to give approvals under licence conditions without those decisions being properly reasoned and recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MAPPA panels important prison-history information
Wider context from the report “The facts of this case give cause for concern that some members of MAPPA panels responsible for managing extremist offenders may not be aware of important information from the offender’s time 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 to provide MAPPA panels direct input from the preparing forensic psychologist
Wider context from the report “It is a matter for concern that MAPPA panels managing even the most serious offenders may not have the benefit of hearing directly from a forensic psychologist who has prepared an ERG report shortly prior to the offender’s release .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate between offender managers and event organisers before extremist offenders attend events
Wider context from the report “This case gives rise to concern that an extremist offender may be permitted to attend an event or venue without there having been proper communication between the probation and police officers responsible for managing the offender and the event organisers and/or venue hosts .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 risk assessment and management for prison higher education programmes involving post-release offender contact
Wider context from the report “Consideration should be given to whether further measures of risk assessment and management can be introduced for any higher education programmes running in prisons which involve continued contact with offenders after their release into 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 Sudden disruption of DDP mentoring arrangements
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Sudden loss of supervised internet access for employment searches
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 the full structured assessment before changing an OASys risk rating
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 properly consider security-sensitive information in MAPPA decisions
Wider context from the report “The facts of this case give cause for concern that security sensitive information may not be properly taken into account in decision-making by MAPPA panels concerning the management of terrorist offenders.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of precautionary search capability for terrorist offenders on licence
Wider context from the report “The facts of this case gave cause for concern that those involved in managing terrorist offenders on licence may lack a valuable means of addressing risks they pose, namely an ability to carry out a search on a precautionary basis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 detect Class A drug use by terrorist offenders on licence
Wider context from the report “The facts of this case give cause for concern that a terrorist offender on licence, who was subject both to strict licence conditions and to a priority investigation, could obtain and use Class A drugs without that being detected .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 offender risk-profile information to prison-based higher education providers
Wider context from the report “It is a matter of concern that Learning Together could operate courses in prisons in the way it did without being given information about the risk profiles of offenders joining courses .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 all MAPPA meeting attendees receive meeting minutes
Wider context from the report “Based on the evidence in this case, there is cause for concern that effective procedures are not in place to ensure that all MAPPA meeting attendees receive meeting minutes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 direct forensic psychologist involvement in ERG 22+ assessment reports
Wider context from the report “Notwithstanding the measures which the NPS has put in place since the attack, there remains cause for concern that ERG 22+ assessment reports may be prepared by a CTPO without the direct involvement of a forensic psychologist .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 risks of continuing close contact between serious offenders and young students
Wider context from the report “It is a matter of concern that focussed consideration was not given to the risks of serious offenders being placed in close and continuing contact with young students .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Excessive reliance on compliance in management of extremist offenders
Wider context from the report “Based on the facts of this case, there is cause for concern that probation officers may attach excessive weight in their management of extremist offenders to “compliance” (i.e. absence of evidence of breach of licence conditions and police 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 Failure to communicate high-risk event attendance to host venues
Wider context from the report “It is a matter of concern that a major event could be held by a University at a livery company hall in London without clear communication of the fact that it would be attended by serving and recently released serious offenders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to directly address risks when approving licence-condition changes
Wider context from the report “This case gives cause for concern that an offender manager and/or MAPPA panel participants could approve a permission, variation or relaxation in relation to a licence condition without directly addressing the potential risks involved .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 risk assessment for higher education events held outside university premises
Wider context from the report “It is a matter of concern that there was no such risk assessment for Learning Together events as set out above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes
Wider context from the report “The facts of this case give rise to concern that important decisions on approvals, variations and relaxations in relation to licence conditions may be taken without clearly reasoned discussion and decision-making in MAPPA panels .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to record proper rationale for changes to OASys risk ratings
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale .
” 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 Expand DDP access to prisoners so offenders can begin engagement before release.
Verbatim wording from the response “The Government accepts these recommendations and can confirm that there have been significant changes in the way that the Desistance and Disengagement Programme (DDP) operates as the programme has matured. These include:” Source location 2021-0362-Response-from-Home-Office_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with relevant case-management forums to coordinate covert and overt risk management and share proportionate intelligence with HMPPS from prison entry.
Verbatim wording from the response “The JCTPPH is also working with other forums in the case management of those of counter-terrorism interest in the Prisons and Probation sector to enable further co-ordination of covert and covert risk management, such as Pathfinder, the Parole Board and the Prison Separation Centre Management Committee. This will provide us with the ability to share intelligence, where assessed to be necessary and proportionate, with HMPPS from the moment an individual enters the Prison estate, meaning that case management decisions will be able to take into account the entirety of what is known about the individual rather than a part of the picture. Once in place, this means that towards the end of a prisoner’s sentence, when the individual is managed by MAPPA, there will be a full and detailed narrative that draws on all sources of information and intelligence to inform decision-making.” Source location 2021-0362-Response-from-Home-Office_Published
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 Create and use the Covert/Overt Bridge to share sensitive intelligence directly with appropriately cleared MAPPA participants.
Verbatim wording from the response “through multi-agency partnerships and engagement with the appropriate statutory bodies. The JCTPPH composes staff from the Security Service, CTP and HMPPS. The key piece of work that is being undertaken to achieve this aim is the JCTPPH-owned “Covert / Overt Bridge”. The Bridge will facilitate the sharing of sensitive intelligence into the MAPPA process and, importantly, other key forums. The JCTPPH has created a mechanism for directly sharing sensitive intelligence with those within the MAPPA process, most notably the MAPPA Chair(s), as well as others who hold appropriate clearances, regarding individuals subject to MAPPA. Use of the Bridge will support MAPPA in making informed decisions but will also ensure that the intelligence is shared in a way which ensures that the Security Service complies with the requirements as set out in the Security Service Act 1989.” Source location 2021-0362-Response-from-Home-Office_Published
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 Strengthen DDP supplier performance management through monthly reviews and enhanced performance indicators.
Verbatim wording from the response “The Government accepts these recommendations and can confirm that there have been significant changes in the way that the Desistance and Disengagement Programme (DDP) operates as the programme has matured. These include:” Source location 2021-0362-Response-from-Home-Office_Published
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 Legislate for a personal-search power applicable to terrorist offenders whose licence conditions require such searches.
Verbatim wording from the response “Following the Fishmongers’ Hall terror attack, Jonathan Hall QC, the Independent Reviewer of Terrorism Legislation (IRTL), was asked by the Home Secretary and then Lord Chancellor to conduct an independent review of MAPPA used to supervise terrorist and terrorism-risk offenders. Mr Hall QC’s recommendations included the creation of new police powers, including the consideration of whether a new power of personal search is required.” Source location 2021-0362-Response-from-Home-Office_Published
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 Establish the Joint Counter Terrorism Prisons and Probation Hub to coordinate multi-agency risk management and intelligence sharing.
Verbatim wording from the response “At the time of the attack perpetrated by Usman Khan at Fishmongers’ Hall in 2019, the Security Service relied on counter-terrorism police (“CTP”) to pass intelligence to and represent the Security Service’s interest in MAPPA. As indicated to the inquest, CTP were the bridge between the Security Service and MAPPA. This is no longer the case. In direct response to Jonathan Hall QC’s MAPPA review, the Joint Counter Terrorism Prisons and Probation Hub (“JCTPPH”) was set up with the aim of ensuring that there is a shared understanding of who poses a risk, and why, and to enable management of those individuals” Source location 2021-0362-Response-from-Home-Office_Published
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 Diversify and increase the number of DDP suppliers to strengthen service resilience.
Verbatim wording from the response “The Government accepts these recommendations and can confirm that there have been significant changes in the way that the Desistance and Disengagement Programme (DDP) operates as the programme has matured. These include:” Source location 2021-0362-Response-from-Home-Office_Published
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 relevant licence condition was not a blanket internet ban; access remained available with supervising officer approval for specific purposes.
Verbatim wording from the response “It is important to note that the relevant licence condition to which Usman Khan was subject was not a blanket ban on internet access; it permitted access with prior approval of a” Source location 2021-0362-Response-from-Home-Office_Published
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 Matters concerning MAPPA intelligence sharing, security-sensitive information and police contact reporting are predominantly operational and assigned to other named bodies.
Verbatim wording from the response “The Home Office has liaised closely with operational partners and other Government Departments regarding the collective Matters of Concern (MCs). Three MCs - 19, 20 and 21 - will be addressed by the Chief Constables of West Midlands Police and Staffordshire Police and the Secretary of State for Justice. The Home Office has reviewed these responses and agrees with their content.” Source location 2021-0362-Response-from-Home-Office_Published
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 probation arrangements provide alternative supervised internet access when DDP mentoring is unavailable.
Verbatim wording from the response “Probation staff, through partner agencies, support offenders in seeking employment. Processes are in place to avoid service users being left without access to the internet if that would impact on their ability to find work. In Usman Khan’s case (which would be true of other terrorist offenders), there were numerous avenues for him to seek permission to use the internet for legitimate purposes and the mentor was just one of these: he had access to Ixion (an employment agency which was authorised to supervise his internet use), and the Approved Premises key worker and Offender Manager who could also have accessed the internet with him to search for employment. Not having a mentor does not equate to having no internet access. Probation are able to facilitate searches for employment in the absence of a mentor, as they did in Usman Khan’s case.” Source location 2021-0362-Response-from-Home-Office_Published
Open published response
19 Oct 2021 Donna Constantine · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Unavailability of verbatim recording for calls received by officers View source Lack of a clear escalation policy for calls received by officers from members of the community View source Failure to monitor officers’ work mobile phones when they are off duty or on annual leave View source Lack of a clear policy for creating an audit trail of actions taken on received calls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Donna Constantine · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Donna Ann Constantine, a vulnerable adult known to multiple agencies, was found severely decomposed at her home on 21 September 2019 after neighbours raised concerns. The post-mortem examination could not establish a cause of death, and the inquest conclusion was open. Concerns included the use of unmonitored police work mobile phones for contact from vulnerable people, alongside the absence of clear escalation, audit-trail, and verbatim call-recording policies.
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 verbatim recording for calls received by officers
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately.
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling 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 Lack of a clear escalation policy for calls received by officers from members of the community
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately.
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling 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 to monitor officers’ work mobile phones when they are off duty or on annual leave
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave . This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately .
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling 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 Lack of a clear policy for creating an audit trail of actions taken on received calls
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately.
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team.
” 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 Specific policing issues are for Greater Manchester Police, the National Police Chiefs’ Council and the College of Policing to address.
Verbatim wording from the response “I acknowledge your concerns detailed in your report, and should stress that police forces are operationally independent and, as such, it is for the Greater Manchester Police, the National Police Chiefs Council and the College of Policing to address the specific issues raised about their ways of working as they relate to the inquest into the death of Ms Constantine. However, I can reassure you that the NPCC and CoP, who you have named in the report and have operational responsibilities, are aware of the recommendations and are working together to address them and respond within the requisite 56-day period.” Source location Response from Home Office
Open published response
23 Sep 2021 Hamish John Cameron HOWITT · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Absence of directives in police training material and national policy on referral of apparently intoxicated injured people View source Alcohol-appearing effects masking serious underlying medical conditions View source Insufficient police training to identify and refer apparently intoxicated people complaining of injury View source Failure to recommend hospital or ambulance assessment for apparently intoxicated people complaining of injury View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Hamish John Cameron HOWITT · 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
Hamish John Cameron HOWITT, a 20-year-old university student, died unexpectedly overnight in Frome on 1 July 2016 after an evening involving alcohol, a traumatic brain injury and self-administered ketamine. The concerns were that police did not recommend hospital assessment after he reported being injured, and that police training and national policy should address the risk of serious underlying conditions being masked by apparent intoxication.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Absence of directives in police training material and national policy on referral of apparently intoxicated injured people
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Alcohol-appearing effects masking serious underlying medical conditions
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 police training to identify and refer apparently intoxicated people complaining of injury
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 recommend hospital or ambulance assessment for apparently intoxicated people complaining of injury
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” 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 Existing first-aid training and formal governance routes will address the concerns about police responses to injured or vulnerable people.
Verbatim wording from the response “My officials have consulted College of Policing and National Police Chiefs Council (NPCC) on their response to your report. As mentioned in their joint letter, front line response police officers receive training at least equivalent to HSE Emergency First Aider level. Our police are required to deal with a wide range of situations on a daily basis and this includes working closely with ambulance services and other medical colleagues when responding to certain medical incidents, where appropriate.” Source location 2021-0320-Response-from-Home-Office_Published
Open published response
3 Aug 2021 Emma Day · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 11 Failure to identify all children when sharing risk information View source Failure to record the duration and conditions of protective orders View source Failure to require escalation of domestic-violence concerns beyond immediate risk View source Failure to include the Non-Molestation Order in the Merlin Report View source Lack of safety netting for escalation of risk View source Inadequate caseworker training on the wider domestic-violence risk context View source Lack of guidance on accepting a caller’s assessment of domestic-violence risk View source Lack of a procedure for responding to threats and passing information to other authorities View source Lack of a system for direct entry of protective orders on the Police National Computer View source Failure of case-record access and handover of key domestic-violence risk information View source Failure to hold or know protective-order conditions and arrest powers View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Emma Day · 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
Emma Day died in the street on 26 May 2017 from multiple stab wounds and was found to have been unlawfully killed. The report describes a history of domestic violence, coercive and controlling behaviour, threats to her life and protective orders that had expired shortly before her murder. Principal concerns included failures to share and record risk information, inadequate domestic-violence training and guidance, and a system failure in handling reports of domestic violence within the Child Maintenance Service.
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 identify all children when sharing risk information
Wider context from the report “3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report, and when shared with Lambeth CSC only one of the children was mentioned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to record the duration and conditions of protective orders
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order , nor did there appear to be any safety netting if the situation escalated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 escalation of domestic-violence concerns beyond immediate risk
Wider context from the report “d) A caseworker who learnt from a caller of domestic violence was only required to escalate for consideration of signposting or reporting to police if there was an immediate risk of violence , not necessarily if the worker was concerned or an immediate risk was likely to eventuate in the future , in particular on reapplying for maintenance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 include the Non-Molestation Order in the Merlin Report
Wider context from the report “3. The Metropolitan Police Service did not mention the Non-Molestation Order in the Merlin Report , and when shared with Lambeth CSC only one of the children was mentioned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 safety netting for escalation of risk
Wider context from the report “1. The Gaia Centre did not record the length or conditions of either the Non-Molestation Order or the Prohibited Steps Order, nor did there appear to be any safety netting if the situation escalated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 caseworker training on the wider domestic-violence risk context
Wider context from the report “b) Training of caseworkers at the time on domestic violence was focused on domestic violence as a criterion to grant waiver of the fee and did not provide information about the wider definition, the reluctance to self-declare or the available services to be signposted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on accepting a caller’s assessment of domestic-violence risk
Wider context from the report “e) Nevertheless in relation to 16th May, Ms Lilley expected case workers to pick up the degree of risk from a report of past threat to kill and escalate and Mr Gilchrist thought the response of the case worker inadequate, as there was a specific request to continue the maintenance claim in the knowledge of a specific threat. But the guidance at the time was silent as to whether to accept the caller’s assessment of risk . I concluded that staff would likely be uncertain of their duties .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 procedure for responding to threats and passing information to other authorities
Wider context from the report “f) Asked about the Domestic Homicide Report’s reference to systemic issues, Mr Gilchrist’s own words were that in May 2017 is where the system fell down. There should be a threat procedure and how to initiate it and pass information to other authorities
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 system for direct entry of protective orders on the Police National Computer
Wider context from the report “4. The Domestic Homicide Review recommended (R24) that the Home Office work with the Ministry of Justice to implement a system whereby protective orders can be input directly to the Police National Computer . It was not clear whether all State bodies that needed to were able to make entries themselves on the Police National Computer Conflicting evidence was heard, but one police officer stated that R24 had not been adopted , and to do so would be welcomed by other agencies and that without this change there might be missed opportunities to save lives .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 case-record access and handover of key domestic-violence risk information
Wider context from the report “The Coroner concluded that there was a system failure in Child Maintenance Service of Department of Work and Pensions in handling reports of domestic violence.
a) There was no mutual access of case records or system of handing on key risk information between CMO and CMS and so the eliciting of domestic violence risks relies upon repeated self-reporting by a victim .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 hold or know protective-order conditions and arrest powers
Wider context from the report “2. Lambeth Children’s Social Care (CSC) had no copy nor knew conditions of either Order, nor that there was a power of arrest . There seem to be steps taken by the CSC to consider action to mitigate the risk posed by the perpetrator in light of these Orders.
” Open source report
2 Jul 2021 Henry Boddy · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Gap in enforcement powers for addressing fire risks from hoarding-related fire loads in residential properties View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Henry Boddy · 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
Henry Boddy was found collapsed during a significant fire at his home on 4 November 2020 and died later that day from the consequences of the fire. The fire was later found to have been caused by either unsafe use of candles for lighting or unsafe use or disposal of smoking materials, in the context of longstanding hoarding and an accumulated fire load. The principal concern was a gap in enforcement powers for addressing fire risks in residential properties arising from hoarding 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 Gap in enforcement powers for addressing fire risks from hoarding-related fire loads in residential properties
Wider context from the report “I am aware that the Government has recently consultant on and responded to potential additional fire safety measures. However, from the evidence I heard at this inquest and from my review of the Government’s response, I am concerned that there is a gap in enforcement powers, as they relate to addressing fire risks in residential properties; specifically in this circumstance, the risks of a fire load arising from hoarding behaviour .
” 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 The Fire Safety Order provides enforcement powers for serious hoarding-related fire risks, including prohibition notices in certain residential circumstances.
Verbatim wording from the response “I must offer my sincerest condolences to the family and friends of Mr Boddy. I understand that the inquest concluded that Mr Boddy died from a fire at his own home, which was later found to have been caused by either unsafe use of candles for lighting or unsafe use or disposal of smoking materials. Your report also raises concerns regarding the fire risks as a consequence of hoarding in Mr Boddy’s home and about a potential gap in enforcement powers with regards to the risks of a fire load arising from hoarding behaviour” Source location 2021-0227-Response-from-Home-Office_Published
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 Local Fire and Rescue Authorities, which are operationally independent of Government, decide compliance and enforcement under the Fire Safety Order.
Verbatim wording from the response “Local Fire and Rescue Authorities (FRAs) are the enforcing authority for the majority of buildings to which the FSO applies, including for the common parts of residential buildings. FRAs are operationally independent to Government and decisions on compliance and enforcement of the FSO rests with them.” Source location 2021-0227-Response-from-Home-Office_Published
Open published response
10 Jun 2021 Emiel Ariel Malinski · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of minimum regulation of miniature rifle ranges View source Failure to require users to sign a prohibited person declaration on every visit View source Failure to provide continuous competent range officer supervision of shooters View source Failure to control weapon loading and account for ammunition View source Failure to provide first-aid-trained staff and a first-aid kit View source Failure to keep weapons and ammunition secure, controlled and supervised at all times View source Failure to securely tether weapons to restrict projectiles to down-range discharge 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
Emiel Ariel Malinski · 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
Emiel Ariel Malinski attended a miniature rifle range on 2 November 2020, where he fired a rifle in the direction of his right temple and later died in hospital. The report recorded that he died as a consequence of suicide and raised concerns about the limited regulation of miniature rifle ranges, including the absence of requirements for supervision, secure weapons, ammunition control and first-aid provision.
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 minimum regulation of miniature rifle ranges
Wider context from the report “It is a matter of concern that the continued existence and operation of s11 (4) Firearms Act 1968 enables miniature rifle ranges to operate with no minimal regulation , with attendees able to fire miniature rifles and ammunition not exceeding .23 calibre and air weapons in a largely unregulated environment .
In addition, it is a matter of particular concern that the following specific requirements do not currently apply to miniature rifle ranges:
1) Requirement for the user to sign a prohibited person (Section 21) declaration on each and every visit;
2) Requirement for the weapon to be securely tethered so that any projectile discharged from it can only be ‘down range’;
3) Requirement for a competent Range Conducting Officer (“RCO”) to be present on the range at all times to enable effective supervision of the shooter;
4) Requirement for the weapon to be loaded for the customer by the RCO or other member of staff so ammunition may be accounted for;
5) Requirement for the RCO or other member of staff present to be first aid trained with a first aid kit present;
6) Requirement for any weapon or ammunition used on the range to be kept secure, controlled and supervised by a member of staff at all times.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to require users to sign a prohibited person declaration on every visit
Wider context from the report “It is a matter of concern that the continued existence and operation of s11 (4) Firearms Act 1968 enables miniature rifle ranges to operate with no minimal regulation, with attendees able to fire miniature rifles and ammunition not exceeding .23 calibre and air weapons in a largely unregulated environment.
In addition, it is a matter of particular concern that the following specific requirements do not currently apply to miniature rifle ranges:
1) Requirement for the user to sign a prohibited person (Section 21) declaration on each and every visit ;
2) Requirement for the weapon to be securely tethered so that any projectile discharged from it can only be ‘down range’;
3) Requirement for a competent Range Conducting Officer (“RCO”) to be present on the range at all times to enable effective supervision of the shooter;
4) Requirement for the weapon to be loaded for the customer by the RCO or other member of staff so ammunition may be accounted for;
5) Requirement for the RCO or other member of staff present to be first aid trained with a first aid kit present;
6) Requirement for any weapon or ammunition used on the range to be kept secure, controlled and supervised by a member of staff at all times.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuous competent range officer supervision of shooters
Wider context from the report “It is a matter of concern that the continued existence and operation of s11 (4) Firearms Act 1968 enables miniature rifle ranges to operate with no minimal regulation, with attendees able to fire miniature rifles and ammunition not exceeding .23 calibre and air weapons in a largely unregulated environment.
In addition, it is a matter of particular concern that the following specific requirements do not currently apply to miniature rifle ranges:
1) Requirement for the user to sign a prohibited person (Section 21) declaration on each and every visit;
2) Requirement for the weapon to be securely tethered so that any projectile discharged from it can only be ‘down range’;
3) Requirement for a competent Range Conducting Officer (“RCO”) to be present on the range at all times to enable effective supervision of the shooter ;
4) Requirement for the weapon to be loaded for the customer by the RCO or other member of staff so ammunition may be accounted for;
5) Requirement for the RCO or other member of staff present to be first aid trained with a first aid kit present;
6) Requirement for any weapon or ammunition used on the range to be kept secure, controlled and supervised by a member of staff at all times.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to control weapon loading and account for ammunition
Wider context from the report “It is a matter of concern that the continued existence and operation of s11 (4) Firearms Act 1968 enables miniature rifle ranges to operate with no minimal regulation, with attendees able to fire miniature rifles and ammunition not exceeding .23 calibre and air weapons in a largely unregulated environment.
In addition, it is a matter of particular concern that the following specific requirements do not currently apply to miniature rifle ranges:
1) Requirement for the user to sign a prohibited person (Section 21) declaration on each and every visit;
2) Requirement for the weapon to be securely tethered so that any projectile discharged from it can only be ‘down range’;
3) Requirement for a competent Range Conducting Officer (“RCO”) to be present on the range at all times to enable effective supervision of the shooter;
4) Requirement for the weapon to be loaded for the customer by the RCO or other member of staff so ammunition may be accounted for ;
5) Requirement for the RCO or other member of staff present to be first aid trained with a first aid kit present;
6) Requirement for any weapon or ammunition used on the range to be kept secure, controlled and supervised by a member of staff at all times.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to provide first-aid-trained staff and a first-aid kit
Wider context from the report “It is a matter of concern that the continued existence and operation of s11 (4) Firearms Act 1968 enables miniature rifle ranges to operate with no minimal regulation, with attendees able to fire miniature rifles and ammunition not exceeding .23 calibre and air weapons in a largely unregulated environment.
In addition, it is a matter of particular concern that the following specific requirements do not currently apply to miniature rifle ranges:
1) Requirement for the user to sign a prohibited person (Section 21) declaration on each and every visit;
2) Requirement for the weapon to be securely tethered so that any projectile discharged from it can only be ‘down range’;
3) Requirement for a competent Range Conducting Officer (“RCO”) to be present on the range at all times to enable effective supervision of the shooter;
4) Requirement for the weapon to be loaded for the customer by the RCO or other member of staff so ammunition may be accounted for;
5) Requirement for the RCO or other member of staff present to be first aid trained with a first aid kit present ;
6) Requirement for any weapon or ammunition used on the range to be kept secure, controlled and supervised by a member of staff at all times.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to keep weapons and ammunition secure, controlled and supervised at all times
Wider context from the report “It is a matter of concern that the continued existence and operation of s11 (4) Firearms Act 1968 enables miniature rifle ranges to operate with no minimal regulation, with attendees able to fire miniature rifles and ammunition not exceeding .23 calibre and air weapons in a largely unregulated environment.
In addition, it is a matter of particular concern that the following specific requirements do not currently apply to miniature rifle ranges:
1) Requirement for the user to sign a prohibited person (Section 21) declaration on each and every visit;
2) Requirement for the weapon to be securely tethered so that any projectile discharged from it can only be ‘down range’;
3) Requirement for a competent Range Conducting Officer (“RCO”) to be present on the range at all times to enable effective supervision of the shooter;
4) Requirement for the weapon to be loaded for the customer by the RCO or other member of staff so ammunition may be accounted for;
5) Requirement for the RCO or other member of staff present to be first aid trained with a first aid kit present;
6) Requirement for any weapon or ammunition used on the range to be kept secure, controlled and supervised by a member of staff at all times .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Home Office; that does not assign responsibility.
PFD Monitor interpretation Failure to securely tether weapons to restrict projectiles to down-range discharge
Wider context from the report “It is a matter of concern that the continued existence and operation of s11 (4) Firearms Act 1968 enables miniature rifle ranges to operate with no minimal regulation, with attendees able to fire miniature rifles and ammunition not exceeding .23 calibre and air weapons in a largely unregulated environment.
In addition, it is a matter of particular concern that the following specific requirements do not currently apply to miniature rifle ranges:
1) Requirement for the user to sign a prohibited person (Section 21) declaration on each and every visit;
2) Requirement for the weapon to be securely tethered so that any projectile discharged from it can only be ‘down range’ ;
3) Requirement for a competent Range Conducting Officer (“RCO”) to be present on the range at all times to enable effective supervision of the shooter;
4) Requirement for the weapon to be loaded for the customer by the RCO or other member of staff so ammunition may be accounted for;
5) Requirement for the RCO or other member of staff present to be first aid trained with a first aid kit present;
6) Requirement for any weapon or ammunition used on the range to be kept secure, controlled and supervised by a member of staff at all times.
” 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 consultation responses and decide what further measures are needed to tighten controls on miniature rifle ranges.
Verbatim wording from the response “The consultation attracted more than 12,000 responses which the Government is now carefully considering before deciding what further measures may be needed to tighten the controls on miniature rifle ranges, as well as in relation to the other issues considered in the consultation. We will use the outcomes of the consultation to explore the scope for restricting the use of licensing exemptions contained within the existing firearms legislation to prevent further deaths or injuries, while retaining some of the benefits of that arise from the exemption.” Source location 2021-0198-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 Explore restricting firearms-licensing exemptions to prevent further deaths or injuries while retaining their benefits.
Verbatim wording from the response “The consultation attracted more than 12,000 responses which the Government is now carefully considering before deciding what further measures may be needed to tighten the controls on miniature rifle ranges, as well as in relation to the other issues considered in the consultation. We will use the outcomes of the consultation to explore the scope for restricting the use of licensing exemptions contained within the existing firearms legislation to prevent further deaths or injuries, while retaining some of the benefits of that arise from the exemption.” Source location 2021-0198-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 firearms-licensing exemption for miniature rifle ranges in light of public-safety risks.
Verbatim wording from the response “The shooting range used by Mr Malinski at Weir Mill, Tameside, operates under the exemption from the firearms licensing legislation afforded by section 11(4) of the Firearms Act 1968, which applies to miniature rifle ranges and shooting galleries. While this exemption is widely used to introduce people to target shooting, we are already reviewing the exemption, because of the risks that it can pose to public safety, which this sad case demonstrates all too clearly.” Source location 2021-0198-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 Consult on tighter controls for miniature rifle ranges, including police-licensed operators subject to safety and suitability checks.
Verbatim wording from the response “We included proposals on tightening the controls that apply to miniature rifle ranges as part of a public consultation that we ran on a range of issues relating to the safety of firearms between 24 November 2020 and 16 February 2021. Although the consultation is now closed, it can still be accessed through the following link: Firearms safety - GOV.UK (www.gov.uk). As you will see, the consultation sought views on introducing new controls on this type of rifle range, including specifying that the operator of the range must have a firearms licence which has been granted by police following safety and suitability checks.” Source location 2021-0198-Response-from-Home-Office
Open published response
Concerns raised 2 Lack of police records of crossbow ownership, storage and circulation View source Lack of ongoing regulatory control or licensing requirements for crossbows 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
Shane Adrian GILMER · 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
Shane Adrian GILMER was shot with a crossbow on 12 January 2018 and died shortly after midnight on 13 January 2018 from injuries causing catastrophic blood loss. The principal concern was that crossbows were not subject to the same ongoing ownership controls, records, storage requirements or licensing as firearms and shotguns, despite their lethal capabilities.
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 police records of crossbow ownership, storage and circulation
Wider context from the report “Evidence was heard from all police witnesses who were called, that unlike shotguns and firearms, which are subject to regulation and a record of ownership, no such provision applies to crossbows. The Crossbows Act 1987, as amended, controls the possession of crossbows by persons under 18 years throughout the United Kingdom. Once sold there is no on-going control, record or licensing requirement for these weapons, unlike those in place for firearms and shotguns, pursuant to the Firearms Act 1968 as amended. The police have no record of who owns crossbows, how they are stored, the number that are in circulation in the community and so forth , yet evidence was heard about the power and lethal capabilities of these weapons, as well as the fact that they are essentially silent. Over the last few years, there have been some high profile incidents and killings that have involved the use of these weapons and the present case is unfortunately another example.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a 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 ongoing regulatory control or licensing requirements for crossbows
Wider context from the report “Evidence was heard from all police witnesses who were called, that unlike shotguns and firearms, which are subject to regulation and a record of ownership, no such provision applies to crossbows. The Crossbows Act 1987, as amended, controls the possession of crossbows by persons under 18 years throughout the United Kingdom. Once sold there is no on-going control, record or licensing requirement for these weapons, unlike those in place for firearms and shotguns, pursuant to the Firearms Act 1968 as amended. The police have no record of who owns crossbows, how they are stored, the number that are in circulation in the community and so forth, yet evidence was heard about the power and lethal capabilities of these weapons, as well as the fact that they are essentially silent. Over the last few years, there have been some high profile incidents and killings that have involved the use of these weapons and the present case is unfortunately another example.
” 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