19 Sep 2025 Rebekah Arter · Prevention of Future Deaths report South London
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Concerns raised 2 Failure to consider domestic abuse risk at police dismissal View source Failure of investigations to identify victims of domestic abuse and coercive control View source
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AI-generated summary
Rebekah Arter · 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
Rebekah Arter, aged 47, died in a hotel room in Barbados on 28 June 2024 in circumstances involving likely intoxication; the medical cause of death was unascertained and the inquest conclusion was open. The principal concern was that missed opportunities by the IOPC and Metropolitan Police Service may have prevented identification of Rebekah as a victim of domestic abuse and coercive control, and prevented protective action.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to consider domestic abuse risk at police dismissal
Wider context from the report “That there may have been missed opportunities for the IOPC and Metropolitan Police Service from their investigations to identify that Rebekah was a victim of domestic abuse and coercive control, which would have enabled her to be protected. This is illustrated by these facts:
• That Rebekah had met her husband initially as a victim of a crime.
• That police investigations uncovered a large number of women with whom he had inappropriate relationships and that he misused his police powers.
• That he was dismissed from the police for drug offences in May 2023, but the risk to Rebekah was not apparently considered at that time .
• A witness has alleged that a video was sent by him of Rebekah ████████ which the family allege was used to shame and enforce control over her, allegedly in 2023.
• A history of her having unexplained repeated bruises and injuries was available in 2024 to anyone who enquired about the risk of domestic abuse.
• ████████
• That in retrospect it is recognised by a Detective Chief Inspector that he was an exceptionally persistent and damaging offender against women, but no charges in relation to that had ever been brought.
The coroner did not accept submissions from the family that the inquest engaged Article 2 of the European Convention on Human Rights and ruled that details of the seven years of conduct investigations were beyond the scope of the inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to identify victims of domestic abuse and coercive control
Wider context from the report “That there may have been missed opportunities for the IOPC and Metropolitan Police Service from their investigations to identify that Rebekah was a victim of domestic abuse and coercive control , which would have enabled her to be protected. This is illustrated by these facts:
• That Rebekah had met her husband initially as a victim of a crime.
• That police investigations uncovered a large number of women with whom he had inappropriate relationships and that he misused his police powers.
• That he was dismissed from the police for drug offences in May 2023, but the risk to Rebekah was not apparently considered at that time.
• A witness has alleged that a video was sent by him of Rebekah ████████ which the family allege was used to shame and enforce control over her, allegedly in 2023.
• A history of her having unexplained repeated bruises and injuries was available in 2024 to anyone who enquired about the risk of domestic abuse .
• ████████
• That in retrospect it is recognised by a Detective Chief Inspector that he was an exceptionally persistent and damaging offender against women, but no charges in relation to that had ever been brought.
The coroner did not accept submissions from the family that the inquest engaged Article 2 of the European Convention on Human Rights and ruled that details of the seven years of conduct investigations were beyond the scope of the inquest.
” 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 Update and strengthen safeguarding procedures.
Verbatim wording from the response “While we do not think a specific risk to Rebekah was apparent from the information available to the IOPC, we wish to reassure you that the IOPC has robust safeguarding procedures in place, which were updated and strengthened in 2024. We will take this opportunity to review whether any additional content to this guidance would be appropriate in respect of risk assessments for spouses and intimate partners.” Source location Response from Independent Office for Police Complaints
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review whether guidance needs additional content on risk assessments for spouses and intimate partners.
Verbatim wording from the response “While we do not think a specific risk to Rebekah was apparent from the information available to the IOPC, we wish to reassure you that the IOPC has robust safeguarding procedures in place, which were updated and strengthened in 2024. We will take this opportunity to review whether any additional content to this guidance would be appropriate in respect of risk assessments for spouses and intimate partners.” Source location Response from Independent Office for Police Complaints
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 No specific risk to Rebekah was apparent because no domestic abuse allegations or concerning evidence had been reported to or identified by the IOPC.
Verbatim wording from the response “Prior to Rebekah’s death, the IOPC was not on notice of any allegations of controlling or coercive behaviour or any other domestic abuse allegation in respect of Mr ████████. When in” Source location Response from Independent Office for Police Complaints
Open published response
25 Jun 2025 Muhammad QASIM · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 4 Inconsistent training of standard police drivers on spontaneous pursuits View source Failure to obtain full forensic collision investigation reports in fatal incidents View source Lack of consistent APP guidance on when a spontaneous pursuit can occur View source Unclear investigative responsibilities during conduct investigations in fatal incidents View source See 1 more concern
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AI-generated summary
Muhammad QASIM · 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
Muhammad QASIM died on 2 October 2023 after a high-speed BMW collision in which the vehicle left the road and struck two trees; he suffered unsurvivable traumatic head injuries. The report raises concerns about differing interpretations and training regarding spontaneous police pursuits, and about investigative responsibilities and the absence of a full forensic collision investigation report in fatal incidents involving a conduct investigation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Inconsistent training of standard police drivers on spontaneous pursuits
Wider context from the report “1. For the college of policing: The inquest heard evidence from 2 specialist police driving instructors in different police forces. Both had a different interpretation of when a spontaneous pursuit could occur as set out in the APP guidance. One force did not train officers who were standard drivers in relation to spontaneous pursuits as these were thought to be a type of pursuit and dependent on first satisfying the main definition of a pursuit under the APP guidance. The other force considered spontaneous pursuit to be a stand alone type of pursuit and trained standard driving officers in relation to it. The confusion around what amounts to a spontaneous pursuit and when one can occur, and the difference in training of police standard drivers , creates a risk of future deaths and action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain full forensic collision investigation reports in fatal incidents
Wider context from the report “2. For the IOPC: The IOPC were investigating the conduct of the police driver in this case. As a result of their investigation no full forensic collision investigation report was obtained. The IOPC need to confirm where investigative responsibilities lie when a conduct investigation is being conducted in all fatal incidents to ensure lessons are learnt from the death and adequate evidence is obtained. The lack of a full forensic collision investigation report in this case creates a risk of future deaths and action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent APP guidance on when a spontaneous pursuit can occur
Wider context from the report “1. For the college of policing: The inquest heard evidence from 2 specialist police driving instructors in different police forces. Both had a different interpretation of when a spontaneous pursuit could occur as set out in the APP guidance. One force did not train officers who were standard drivers in relation to spontaneous pursuits as these were thought to be a type of pursuit and dependent on first satisfying the main definition of a pursuit under the APP guidance. The other force considered spontaneous pursuit to be a stand alone type of pursuit and trained standard driving officers in relation to it. The confusion around what amounts to a spontaneous pursuit and when one can occur , and the difference in training of police standard drivers, creates a risk of future deaths and action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Unclear investigative responsibilities during conduct investigations in fatal incidents
Wider context from the report “2. For the IOPC: The IOPC were investigating the conduct of the police driver in this case. As a result of their investigation no full forensic collision investigation report was obtained. The IOPC need to confirm where investigative responsibilities lie when a conduct investigation is being conducted in all fatal incidents to ensure lessons are learnt from the death and adequate evidence is obtained. The lack of a full forensic collision investigation report in this case creates a risk of future deaths and action should be taken.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require lead investigators to assess each fatal road traffic incident and consult the Coroner early about whether a full forensic collision investigation report is needed.
Verbatim wording from the response “Going forward, all lead investigators will need to assess the circumstances of an incident and have early contact with the Coroner to determine whether a full Forensic Collision Investigation Report is required. If one is required, we will either request this from a police force or source an independent report if necessary.” Source location Response from the IOPC
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update internal guidance for lead investigators to address securing full forensic collision reports and consulting the Coroner about the investigative approach.
Verbatim wording from the response “We will update the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Our internal guidance will be updated within the next six weeks but in the meantime, our internal technical leads will liaise with investigators in the early stages of any investigations involving a road traffic fatality to ensure the correct considerations are made.” Source location Response from the IOPC
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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 Have internal technical leads liaise with investigators early in road traffic fatality investigations to support appropriate evidence considerations.
Verbatim wording from the response “We will update the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Our internal guidance will be updated within the next six weeks but in the meantime, our internal technical leads will liaise with investigators in the early stages of any investigations involving a road traffic fatality to ensure the correct considerations are made.” Source location Response from the IOPC
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 Policing partners are responsible for providing independent collision investigation assistance within their technical expertise.
Verbatim wording from the response “With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of” Source location Response from the IOPC
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 respondent lacks the technical skills and expertise to undertake collision investigation work itself.
Verbatim wording from the response “With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of” Source location Response from the IOPC
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 streamlined collision investigation report was considered sufficient because evidence indicated the police vehicle had not caused the collision through physical contact.
Verbatim wording from the response “The IOPC lead investigator was advised that a full forensic collision report into the crash would not ordinarily be produced because Mr Qasim’s vehicle had not collided with another vehicle– it had left the road and impacted with a tree.” Source location Response from the IOPC
Open published response
23 May 2025 Lewis Dean JOHNSON · Prevention of Future Deaths report Inner North London
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Concerns raised 1 Failure to include measurement of the distance between pursuing and subject vehicles in forensic collision investigation terms of reference View source
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AI-generated summary
Lewis Dean JOHNSON · 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
Lewis Johnson died aged 18 as a consequence of a road traffic collision while riding a motorcycle during a police pursuit in London on 9 February 2016. The inquest identified that the forensic collision investigation had not been instructed to measure the distance between the pursuing police vehicle and the motorcycle, leaving the jury without clear objective evidence on that issue.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to include measurement of the distance between pursuing and subject vehicles in forensic collision investigation terms of reference
Wider context from the report “At inquest I heard that the terms of reference set out for the forensic collision investigator by the IOPC (then IPCC) at the outset of the investigation, did not include an instruction to attempt to measure the distance between the pursuing vehicle and the subject vehicle at points when the two appeared to be closer together .
Obviously this omission did not have an impact upon Lewis Johnson’s death, but it did have an impact upon the inquest. It meant that the jury had no clear objective evidence about the distance between his motor cycle and the police car behind. Given that learning and at times policy are informed by such findings, it appears that this would be helpful to include in future investigations when death follows a police pursuit.
” 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 Update internal guidance to require investigators to consider distance calculations in collision-investigator terms of reference and consult the Coroner about the investigative approach.
Verbatim wording from the response “We are in the process of updating the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Following your Preventing Future Deaths Report, our guidance will now also require investigators to consider if a distance calculation should form part of the terms of reference for the Forensic Collision Investigator. This guidance will be available to IOPC lead investigators within the next fortnight.” Source location Response from Independent Office for Police Conduct
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 Collision investigation, including measuring vehicle distances, is assigned to specialist Forensic Collision Investigators rather than undertaken by the IOPC.
Verbatim wording from the response “We work to ensure we gather all relevant and available evidence and seek expert advice where it is necessary and proportionate to the circumstances of the case. Collectively, this helps to inform the investigation and our ability to reach evidence-based decisions. With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of objective and unbiased opinion in relation to matters within their expertise. The reports produced by Forensic Collision Investigators are provided to the IOPC and the salient points are then included in the IOPC investigation report.” Source location Response from Independent Office for Police Conduct
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 Distance measurement may not be possible or proportionate in every road traffic collision investigation because the process can be complicated and time-consuming.
Verbatim wording from the response “The Forensic Collision Investigator would be the expert responsible for measuring distance between two vehicles. However, it is our understanding that this process is not always possible or straightforward and can, on occasion, be particularly complicated and take a significant amount of time. In light of this it may not be possible, or proportionate, in every road traffic collision investigation to pursue this line of enquiry.” Source location Response from Independent Office for Police Conduct
Open published response
25 Oct 2024 Martin Ian Stubbs · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1 Delays in concluding internal disciplinary proceedings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Martin Ian Stubbs · 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
Martin Ian Stubbs was a serving police officer who was arrested, suspended from duty and remained on bail until his death. He died by suicide by hanging at his home on 26 August 2024. The principal concern was the prolonged delay in concluding the internal disciplinary process, which the family believed contributed to his death and might reflect wider resource or management issues.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Delays in concluding internal disciplinary proceedings
Wider context from the report “Mr Stubbs’ father (a former officer himself and still a civilian police employee) expressed his firm belief that the length of time he had been suspended from duty had played a significant part in his son’s decision to take his life. It is a concern that someone subject to an internal disciplinary process has a legitimate expectation that that process will be dealt with expeditiously in the interests of all parties, and that legitimate expectation was not met in Mr Stubbs’ case . Mr Stubbs’ family do not understand whether the delay in concluding the process reflects resource issues or an institutionalised practice of allowing such matters to drift without proactive management to bring them to a conclusion . Anecdotally, Mr Stubbs’ family are aware of other long outstanding internal disciplinary proceedings and fear other families may have to go through an experience similar to theirs.
” Open source report
23 Apr 2024 Ashley Crews · Prevention of Future Deaths report Manchester City
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Concerns raised 1 Lack of a local policy for handcuff use when executing arrest warrants View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Ashley Crews · 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
Ashley Crews died on 20 February 2024 from injuries sustained in a fall from height after police officers attended his ninth-floor flat to execute an arrest warrant. The principal concern was that there was no local policy governing the use of handcuffs when executing an arrest warrant.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of a local policy for handcuff use when executing arrest warrants
Wider context from the report “1. There is no local policy for the use of handcuffs when executing an arrest warrant.
” Open source report
8 Jun 2022 Mr Ian McDonald Taylor · Prevention of Future Deaths report Inner South London
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Concerns raised 5 Failure to provide access to prescribed emergency inhaler medication during public-place police detention View source Failure to identify and address officer training or attitudinal deficits through supervision View source Failure to conduct and record an adequate ongoing risk assessment View source Failure to communicate detainee medical distress with appropriate urgency View source Unavailability of timely paramedic response during exceptional ambulance-service demand View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Ian McDonald Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Ian McDonald Taylor suffered a cardiac arrest after a physical altercation while in police detention and died in hospital. Concerns included the police officer’s assessment and communication of Mr Taylor’s breathing difficulties, access to his inhaler while awaiting an ambulance, and the exceptionally delayed ambulance response.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to provide access to prescribed emergency inhaler medication during public-place police detention
Wider context from the report “Mr Taylor was in police detention in a public place and was known to be a sufferer of both COPD and asthma, required to take a regular combination of inhalers and had a history of emergency admission to hospital with life threatening asthma. He repeatedly asked urgently for his inhaler, which he said was in his pocket, and that he needed it and that he felt he was going to die. Police did not find it (although a broken inhaler found later at the scene might have been his). If he had been in a custody suite he would have had access to a custody nurse or medical practitioner who could have prescribed it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and address officer training or attitudinal deficits through supervision
Wider context from the report “In court he was asked if he had learnt any lessons from the incident and he did not acknowledge he had. He was asked if he would do anything different in future, he made excuses for his comments and he said that he would be more sensitive in future. He was not able to answer a question about what considerations should be made to form the view somebody did not need hospital. He did not accept that he had made an inadequate risk assessment. He did not accept that such comments could have or might in future contribute to death by indicating a lack of urgency to a sergeant not at the scene. He was given an opportunity to make any other comment and could not bring himself to apologize to the family.
There was no evidence heard in court of the content or effect of supervision of the officer after the incident or whether training or attitudinal deficits had been identified and addressed. The family are concerned as to whether the officer should be suspended pending further investigations, and I disclose that merely as a measure of their level of concern about public safety, as it is inappropriate for me to make any such recommendation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct and record an adequate ongoing risk assessment
Wider context from the report “Whilst PC ████████ was away from Mr ████████ he accepts that he is heard shortly after 18.14 stating to his sergeant on the radio “He’s currently on the floor playing the whole poor me poor me; he’s going to have to go to hospital though as a matter of course.” And at 18.24: “He’s saying he has chest pains he cant breathe blah blah; it’s a load of nonsense but there we go”
He said in court that he formed these views as Mr Taylor seemed iller than he would expect from the nature of the previous altercation. He denied he thought Mr Taylor was faking. He claims to have made a continual risk assessment, but there is no record or evidence of that. He said that his views were influenced by a previous incident in which a man sprang to violence from previous calmness. They were not his final conclusion. There was no evidence as to his forming a different conclusion in the following 8 minutes before the cardiac arrest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate detainee medical distress with appropriate urgency
Wider context from the report “Whilst PC ████████ was away from Mr ████████ he accepts that he is heard shortly after 18.14 stating to his sergeant on the radio “He’s currently on the floor playing the whole poor me poor me; he’s going to have to go to hospital though as a matter of course.” And at 18.24: “He’s saying he has chest pains he cant breathe blah blah; it’s a load of nonsense but there we go”
He said in court that he formed these views as Mr Taylor seemed iller than he would expect from the nature of the previous altercation. He denied he thought Mr Taylor was faking. He claims to have made a continual risk assessment, but there is no record or evidence of that. He said that his views were influenced by a previous incident in which a man sprang to violence from previous calmness. They were not his final conclusion. There was no evidence as to his forming a different conclusion in the following 8 minutes before the cardiac arrest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely paramedic response during exceptional ambulance-service demand
Wider context from the report “Because of wholly exceptional demands on the ambulance service, a paramedic was not available until after he had suffered a cardio-respiratory arrest , from which he did not survive. A consultant paramedic and London Ambulance Service Director was asked about the feasibility of an inhaler device being available to police to offer to known asthmatics in exceptional circumstances when medical help was not available, such as is now in place in schools. He said that there were many difficulties: The difficulties included the adequacy of assessment of need by non medically trained persons on the scene, the difficulties of remote assessment, the threshold for confirmation of the person in distress being an established asthmatic, avoiding giving it to those with non asthmatic causes of breathlessness, and police training. Nevertheless he said that lives might be saved and it should be looked at. Advice was given to the court that such a proposal would need legislative change.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The officer’s behaviour did not meet the statutory threshold for disciplinary proceedings and therefore did not require treatment as a conduct matter.
Verbatim wording from the response “The distress that ████████ comments to his Sergeant, and the lack of insight and reflection shown in his evidence to the inquest, will have caused to Mr Taylor’s family, is a harm resulting from his behaviour which will also be capable of harming public confidence in the police service more widely. I agree that this behaviour does need appropriate intervention. Balanced against this, this appears to be a one off incident rather than a pattern of behaviour and while the inquest jury concluded that the dynamic risk assessment of the officers present was not adequate, the evidence did not suggest that ████████ comments to his Sergeant delayed or otherwise affected the treatment of Mr Taylor.” Source location Response from IOPC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A further investigation was unnecessary because existing body-worn video and inquest evidence established the officer’s behaviour, while reflective practice provided appropriate intervention.
Verbatim wording from the response “I agree that this is an appropriate intervention. ████████ behaviour is evidenced in the BWV capturing his comments at the time, and the record of his evidence to the inquest. A further investigation therefore does not appear to be necessary in order to establish the extent of his behaviour or test the evidence. Under the Police (Conduct) Regulations 2020, the appropriate authority has the power to refer an officer to the reflective practice review process without an investigation. The Home Office Guidance on Conduct, Efficiency and Effectiveness 2020 states that the reflective practice review process is intended to:” Source location Response from IOPC
Open published response
13 Apr 2022 Hannah Grace Beardshaw · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to make method of entry kits readily available to trained users View source Delays in escalating incidents 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
Hannah Grace Beardshaw · 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 Grace Beardshaw was found hanging at her home on 20 April 2021 after contacting a friend, leaving a note of intent, and researching methods of taking her own life. The concerns identified were delays in escalating and responding to the incident, limited availability of method-of-entry kits, and document-management issues within Greater Manchester Police.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to make method of entry kits readily available to trained users
Wider context from the report “The IOPC highlighted a number of learning recommendations on how GMP handled the incident which to date have not been implemented:
• A delay in escalating the incident, resulting in almost a 4 hour delay to respond to the incident.
• A failure to make method of entry kits more readily available to those trained in their use .
• Improvement in document 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 Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Delays in escalating incidents
Wider context from the report “The IOPC highlighted a number of learning recommendations on how GMP handled the incident which to date have not been implemented:
• A delay in escalating the incident , resulting in almost a 4 hour delay to respond to the incident.
• A failure to make method of entry kits more readily available to those trained in their use.
• Improvement in document management
” Open source report
25 May 2021 Matthew MACKELL · Prevention of Future Deaths report North West Kent
View report summary
Concerns raised 4 Failure to cascade operational information View source Failure to identify, schedule, monitor and record individual training and updating View source Inadequate training on the use of location-detection software View source Gaps in knowledge of suicide policy, call downgrading and patrol-checking procedures View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Matthew MACKELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew MACKELL was found dead on 7 May 2020 in Dunorlan Park after suspending himself from a tree using a bedsheet as a ligature. The previous evening, he had telephoned Kent Police stating that he intended to kill himself, but the call was not accurately located or treated as a suicide call. The concerns included inadequate training and procedures for using the enhanced mobile-phone location system, grading suicide calls, and recording and monitoring staff training.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to cascade operational information
Wider context from the report “(1) In December 2019 a software update had been installed to a system in the Kent Force Control room which, if used, produced a much greater accuracy in detecting the location of mobile phone calls. There had been inadequate or no training on the use of the update which resulted in the system not being deployed to locate the deceased. The call from the deceased at 22.18 was therefore incorrectly downgraded as the area to search was regarded as too wide to be effective. The downgrade was incorrect because (a) the use of the software would have provided an accurate location and (b) the call should have been treated as a suicide call and not an abandoned 999 call. It is accepted that as a direct result of this incident the software system is now the default setting to detect locations. However, the evidence of those witnesses who were required to use the system raised a more general enquiry which identified gaps in or absence of effective training and the cascading of information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to identify, schedule, monitor and record individual training and updating
Wider context from the report “(2) The totality of the evidence from several experienced operatives in the Force Control Room revealed gaps in their knowledge as to operating procedure in respect of the suicide policy, appropriate downgrading of calls, checking available patrols. Whilst it is accepted that following an IOPC report steps have been taken to review and improve procedures, it was apparent that there was an absence of an effective system to identify those that required training/updating and the keeping a record of specific training/updating received by individual operatives and the date it was undertaken . There did not appear to be a structured system in place to produce a regular training rotation which monitored and recorded individual satisfactory progress . Such a system would clearly identify what training/updating had been received thus identifying those who might otherwise be missed and when training/updating was scheduled to take 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 Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Inadequate training on the use of location-detection software
Wider context from the report “(1) In December 2019 a software update had been installed to a system in the Kent Force Control room which, if used, produced a much greater accuracy in detecting the location of mobile phone calls. There had been inadequate or no training on the use of the update which resulted in the system not being deployed to locate the deceased. The call from the deceased at 22.18 was therefore incorrectly downgraded as the area to search was regarded as too wide to be effective. The downgrade was incorrect because (a) the use of the software would have provided an accurate location and (b) the call should have been treated as a suicide call and not an abandoned 999 call. It is accepted that as a direct result of this incident the software system is now the default setting to detect locations. However, the evidence of those witnesses who were required to use the system raised a more general enquiry which identified gaps in or absence of effective training and the cascading of information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Gaps in knowledge of suicide policy, call downgrading and patrol-checking procedures
Wider context from the report “(2) The totality of the evidence from several experienced operatives in the Force Control Room revealed gaps in their knowledge as to operating procedure in respect of the suicide policy, appropriate downgrading of calls, checking available patrols . Whilst it is accepted that following an IOPC report steps have been taken to review and improve procedures, it was apparent that there was an absence of an effective system to identify those that required training/updating and the keeping a record of specific training/updating received by individual operatives and the date it was undertaken. There did not appear to be a structured system in place to produce a regular training rotation which monitored and recorded individual satisfactory progress. Such a system would clearly identify what training/updating had been received thus identifying those who might otherwise be missed and when training/updating was scheduled to take place.
” Open source report
Concerns raised 4 Lack of dialogue between police and local A&E departments about treatment misunderstandings View source Lack of memorandum of understanding or guideline for taking aggressive detainees to A&E departments View source Insufficient A&E consultant understanding of which detainees will be accepted for treatment View source Insufficient police understanding of A&E treatment for detainees View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kirk William Williams · 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
Kirk William Williams ingested several drugs and displayed highly agitated and aberrant behaviour before being restrained by police. Although one officer considered that he should be taken to hospital, he was taken to a police station and later suffered cardiac arrest and died in hospital. The concerns included differing understandings between police and A&E staff about treating aggressive detainees, and the absence of clear dialogue or guidance for managing such medical emergencies.
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 Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of dialogue between police and local A&E departments about treatment misunderstandings
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to 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 Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of memorandum of understanding or guideline for taking aggressive detainees to A&E departments
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to 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 Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Insufficient A&E consultant understanding of which detainees will be accepted for treatment
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to 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 Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Insufficient police understanding of A&E treatment for detainees
Wider context from the report “(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients.
(3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff.
(4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff.
(5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments.
(6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments.
(7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions.
(8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments.
(9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others.
” Open source report
Concerns raised 10 Lack of fully independent control over fatal shooting scenes during investigation View source Failure to video record fatal police shooting scenes View source Failure to consider pursuing a planned weapons-seizure operation after a fatal shooting View source Failure to record armed police operations after State Red View source Lack of access to all relevant intelligence for fatal-operation investigations View source Failure to review operational strategy in response to developing events View source Failure to devise a coordinated strategy capable of seizing guns before collection View source Failure to develop and share operational intelligence between the MPS and SOCA View source Failure to obtain prompt comprehensive statements from all police witnesses to fatal shootings View source Lack of an agreed protocol between the IPCC, coronial and prosecution bodies View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Duggan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 4 August 2011, Mark Duggan was shot by an armed police officer during an enforced vehicle stop in London and was pronounced dead at the scene. The report raises concerns about intelligence sharing and operational decisions before the shooting, the investigation and preservation of evidence at the scene, the recording of the operation, and the coordination and access to intelligence during the investigation and inquest.
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 Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of fully independent control over fatal shooting scenes during investigation
Wider context from the report “Concern 3: The IPCC had primacy at the scene but did not have the resources to conduct all relevant activities there
I am concerned that no scene of a fatal shooting should be the subject of any confusion about the purpose of the investigation, or about what should be done to further that investigation. There is a tension, in a case such as this, between the duty of the MPS to obtain and secure evidence at the scene, its position as being under investigation, and the IPCC’s obligation to investigate independently. The pragmatic approach adopted of the MPS consulting the IPCC about what should happen may not always resolve that tension. My primary concern is whether that position should persist. If it does then I am concerned that the police service has the practical control of many aspects of the scene and what happens there despite being under investigation , without the public realising that the investigation does not have full independence which the IPCC’s role appears to safeguard . This concern is addressed to the IPCC, the Home Secretary and the MPS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to video record fatal police shooting scenes
Wider context from the report “Concern 4: The scene of the fatal police shooting was not video recorded
I believe that it is important to minimise distrust in the police in connection with fatal shootings, as that distrust can then permeate the entire investigation which follows and may mean that civilian witnesses will not come forward. That plainly has the capacity to prevent lessons being learned which could prevent deaths in the future. This concern is addressed to the MPS, the IPCC and ACPO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to consider pursuing a planned weapons-seizure operation after a fatal shooting
Wider context from the report “Concern 5: The planned operation to seize weapons was not pursued after the fatal shot was fired
My concern is that no consideration appears to have been given to the prospect . A starting point should have been that one of the Trident officers saw the minicab turn into Burchell Road for the handover, and that was a short cul-de-sac. This concern is addressed to the MPS, the IPCC and ACPO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to record armed police operations after State Red
Wider context from the report “Concern 6: The armed police operation was not recorded after State Red was called
I am therefore concerned that the cars involved in stopping the minicab containing Mr Duggan had data available to be downloaded or that the technology was not as effective in 2011 as it was in 2005. I expect to be told the actual position. In the circumstances I address these concerns to the MPS and ACPO.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of access to all relevant intelligence for fatal-operation investigations
Wider context from the report “Concern 8: The IPCC and Counsel to an inquest do not have access to all intelligence
These limitations not only give rise to understandable suspicions in the minds of those not party to the intelligence but also plainly create a risk that an intelligence-led operation which results in death will not be fully investigated so that lessons may be learned. This concern is addressed to the Home Secretary.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to review operational strategy in response to developing events
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA, and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so, in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him . The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan. This concern is directed to the MPS and NCA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to devise a coordinated strategy capable of seizing guns before collection
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA, and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so, in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him. The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan . This concern is directed to the MPS and NCA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to develop and share operational intelligence between the MPS and SOCA
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA , and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so , in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him. The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan. This concern is directed to the MPS and NCA.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain prompt comprehensive statements from all police witnesses to fatal shootings
Wider context from the report “Concern 2: Comprehensive accounts were not taken from police witnesses at the first possible opportunity
I am concerned that fatal police shootings are not as rigorously examined as they could be and that doubts about the accuracy of police accounts are not minimised. Lessons learned after a death should be as complete as possible. My concern is that not all witnesses to a fatal shooting are asked to give full statements as soon as possible after the event, giving a detailed account of what they saw . I am also concerned about whether there is any purpose in seeking to distinguish between “principal officers” and other police officers save that, where there is any reason to caution an officer, then of course that must be done. I am concerned that witnesses who perceived a threat from the person who was shot did not set that out in their statements . I therefore invite ACPO and the MPS to deal with what I have said when they respond to the IPCC consultation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed protocol between the IPCC, coronial and prosecution bodies
Wider context from the report “Concern 7: The IPCC does not have a protocol agreed with the Chief Coroner, ACP and the CPS
With a view to coroners holding effective inquests as soon as practicable I address this concern to the IPCC and ask it to consider approaching the Crown Prosecution Service, the Association of Chief Police Officers, the Chief Coroner and the Coroner’s Society with a view to integrating its memorandum with theirs.
” Open source report
×
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 consultation responses and produce a revised statutory guidance document for submission to the Secretary of State.
Verbatim wording from the response “8. The consultation period for the draft statutory guidance closed on 27 May 2014 and the IPCC is reviewing the many consultation responses received. The IPCC will then, taking account of the consultation responses, produce a revised document that will require the approval of the Secretary of State before being issued. Police officers will then be under a duty to have regard to” Source location 2014-0182-Response-by-IPPC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue draft statutory guidance on obtaining best evidence in death or serious injury matters for consultation.
Verbatim wording from the response “7. The Coroner makes reference to the IPCC consultation on post incident procedures. On 5 March 2014 the IPCC issued for consultation draft statutory guidance to the police service on achieving best evidence in death or serious injury matters (the draft statutory guidance is enclosed with this response). Paragraphs 21–24 of the draft statutory guidance set out the IPCC’s preliminary position on acquiring ‘detailed individual factual accounts’ and addresses a number of the concerns raised by the Coroner in his Report.” Source location 2014-0182-Response-by-IPPC
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 including scene video recording requirements in the statutory guidance.
Verbatim wording from the response “21. The IPCC can see the benefit of early video recording a scene as part of the process of evidencing where items have been found. Therefore, the IPCC will be considering whether reference to video recording scenes should be included in the statutory guidance. The IPCC anticipates being able to submit finalised statutory guidance to the Secretary of State for her approval by the end of March 2015.” Source location 2014-0182-Response-by-IPPC
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 approaching relevant prosecutorial, policing and coronial bodies to integrate the memoranda of understanding governing investigations and inquests.
Verbatim wording from the response “25. The Coroner addressed this concern to the IPCC. He explained that with the objective of coroners holding effective inquests as soon as practicable, the Coroner asked the IPCC to consider approaching the CPS, ACPO, the Chief Coroner and the Coroner’s Society with a view to integrating their memorandum with the Memorandum of Understanding that already exists between the IPCC and the Coroners’ Society.” Source location 2014-0182-Response-by-IPPC
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 IPCC could not deploy all necessary scene-management and forensic staff because it lacked resources and additional funding was restricted.
Verbatim wording from the response “13. In relation to resources, the Report correctly identifies that the IPCC is heavily reliant on the local police force to provide sufficiently experienced specialist scene managers, forensic staff, exhibits officers, search officers etc, to conduct the majority of the work at the scene, because the IPCC does not have these resources itself. The IPCC does not have the resources to deploy a significant number of investigators and specialist staff to a scene soon after an incident is referred to it for investigation. While the Home Office has given the IPCC additional funding in 2014/5, this is specifically to conduct a number of additional independent investigations. The Home Office has asked that the money be separately accounted for and not used to provide additional resources for its existing caseload which includes death and serious injury matters such as police shootings.” Source location 2014-0182-Response-by-IPPC
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 A formal transfer of scene responsibility was not considered practical because police involvement remained necessary for other investigations and evidence preservation.
Verbatim wording from the response “17. Therefore, taking into account the practical issues identified above¹ and that the evidence acquired from a scene may well be relevant to both the IPCC investigation and also on-going criminal investigations, the IPCC is not of the view that the Coroner’s suggestion of a formal transfer of responsibility from the police to the IPCC at the scene of a death once the police duty to obtain and preserve evidence has been discharged, is entirely practical or the best overall solution in the current circumstances.” Source location 2014-0182-Response-by-IPPC
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 Further comment on police witness accounts was deferred because statutory guidance had not been finalised and consultation responses were still under review.
Verbatim wording from the response “9. However, bearing in mind that the IPCC has not issued the final version of this statutory guidance, the IPCC does not consider it appropriate to comment further on this issue until it has completed the consultation exercise and submitted its final position to the Secretary of State.” Source location 2014-0182-Response-by-IPPC
Open published response
Concerns raised 10 Lack of effective Police Service practice for transparent internal review of incidents View source Failure to provide integrated electronic aids for location, route planning and safe passage View source Failure to communicate continuing caller contact to incident managers View source Failure to plan and evaluate resource allocation for critical incidents View source Lack of clear protocols, communication lines and incident command identification View source Failure to define incident management roles View source Failure to review incident grading and allocate resources using essential information View source Lack of co-ordinated management, monitoring and control of serious incidents View source Lack of clear training and understanding of graded-incident response times View source Over-reliance on presumed training and experience instead of individual incident control View source See 7 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
Vincent Gibson · 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
Vincent Gibson was fatally injured while crossing Whiteleas Way, South Shields, when he was struck by a police vehicle travelling at speed in response to a Grade 1 emergency call. The principal concerns related to inadequate coordination, management, monitoring and control of the incident, including the failure to communicate that the caller remained in contact with the call taker, unclear roles, insufficiently informed risk assessment, resource allocation, route planning and uncertainty about response speed.
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 Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of effective Police Service practice for transparent internal review of incidents
Wider context from the report “It is a matter of some concern that this is not an apparent practice of the Police Service even though they have a Professional Standards Department, which is clearly designed to address and respond to issues around Professional Standards and that not only in an objective but effective way .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to provide integrated electronic aids for location, route planning and safe passage
Wider context from the report “Electronic aids are a benefit not only to Central Control but also to responders and such electronic aids should eliminate any issue or debate around the fact as to route and leave the crew speculating as to the position, route or speed.
10. Electronic aids should (a) readily identify the location (b) pre-plan the route (c) determine a safe and where appropriate speedy passage . In any event, any electronic aids and/or systems must be fully integrated being identified for the purpose they are intended to serve.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate continuing caller contact to incident managers
Wider context from the report “Much more significant than all the other facts which appeared on this log directly was the omission of the fact at any stage before the incident of the collision that ████████ was in continued conversation with the caller .
7. ████████ was in the same room as ████████ and it had known of the continuing conversation one assumes, she could have planned accordingly. ████████ clearly appreciated that contact with the caller was an essential way of trying to find out more positive information about him and effectively plan for his help and support.
8. As the Resource Controller and the recipient of the initial log and graded incident she is the obvious point of direct contact for such essential detail. She is also the obvious conduit for not only the fact that the caller is still talking to the Call Taker but to understand the tone and content of that conversation and analyse the level of distress if any, the caller is continuing to demonstrate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to plan and evaluate resource allocation for critical incidents
Wider context from the report “Identifying an allocation of resource should not be a spontaneous response to a demand but a reasoned and considered response to effective planning and to positive resource evaluation.
a. Self-selection borne of enthusiasm and worse, boredom does not make for a balanced plan and safe approach to a critical incident . Officers in this case were able simply to call in, identify themselves as available and willing.
b. The resource controller although she had an electronic map which could identify the whereabouts of resource did not use that map it falling out of favour and being judged not fit for purpose. Accordingly, at no stage was any resource identified even if it was available at a closer proximity .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of clear protocols, communication lines and incident command identification
Wider context from the report “Rules of practice, ie protocols need to be clear and unequivocal identifying robust rules of procedure identifiable lines of communication where appropriate but at all stages in the identifying of the individual in the management, monitoring and control of an incident who can be properly identified as in charge of the incident in hand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to define incident management roles
Wider context from the report “It is not clear that either ████████ or Acting Sergeant Robinson was :-
a) Aware of his or her role
b) Nor does it appear others were clear as to the role of the Sergeant or the resource controller.
c) It is not clear that either of these individuals had a clearly defined role prior to this night in the managing, monitoring or controlling of this incident.
Whatever the roles of these individuals was - whether they were joint or mutually exclusive, that role - their roles - was an essential to the discharge of this grade 1 incident safely and effectively.
As far as Sergeant Robinson was concerned, I am of a view that he was not the manager of this matter. He was not in a position to control or effectively monitor events.
14. That failure to clearly define an identifiable role and consequential confusion over roles , add to a lack of clarity and lead to a lack of effective co-ordination of the essential tasks set within this matter.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Failure to review incident grading and allocate resources using essential information
Wider context from the report “It is of primary importance to keep the grading of the incident under review and that with the benefit of essential and relevant information. Similarly the allocation of resource and the tasking of that resource again demands relevant and essential information sufficient to ensure the effective and safe discharge of and completion of, the task in hand.
11. The two crews were ignorant of both source and content of such essential and relevant information and were being asked to risk assess a task in the absence of such essential relevant and critical information . With that critical information available to them they would be in a better position to determine more safely the speed of approach to the task - which they essentially perceived was to visit a house where the caller was believed to be but was not.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of co-ordinated management, monitoring and control of serious incidents
Wider context from the report “The matters of concern identified by this history centre on an all too apparent lack of co-ordination of the essential elements of management, monitoring and control needed to effectively respond as one would reasonably expect to a properly identified and graded serious incident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Lack of clear training and understanding of graded-incident response times
Wider context from the report “Such an apparent conflict of understanding of what that time response meant or means when attached to a grade 1 incident or indeed a grade 2, or any of the other five graded responses underlines an essential need for this process to be taken into some effective control and to be the subject of particular training and clear understanding on the part of both management and staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Office for Police Conduct; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on presumed training and experience instead of individual incident control
Wider context from the report “What is not good practice and gives rise to concern is the apparent over-reliance on presumed skill sets from periods of training and years of experience and dare one say, a successful completion of a number of incidents without any apparent failing. Each incident merits appropriate levels of individual management, monitoring and control .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations