20 May 2026 [PM] · Prevention of Future Deaths report Kent & Medway
View report summary
Concerns raised 2 Lack of face-to-face update or refresher training for officers undertaking community welfare checks View source Lack of an organisational policy or procedure for risk assessing and safety-netting persons arrested for this type of offence 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
[PM] · 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
The deceased was arrested on 18 June 2025, released on bail, and found deceased at his home on 19 June 2025. The inquest concluded that he died by suicide. Concerns included the absence of a Kent Police policy or standard operating procedure for risk assessing and safety-netting people arrested for this type of offence, and the lack of required face-to-face refresher training for officers conducting welfare checks.
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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 Kent Police; that does not assign responsibility.
PFD Monitor interpretation Lack of face-to-face update or refresher training for officers undertaking community welfare checks
Wider context from the report “2. I heard evidence that, following initial basic training, officers at Kent Police are not required to undertake any face-to-face update or refresher training regarding welfare checks that they undertake regularly in the community . For the avoidance of doubt, I found that relevant officer undertaking the welfare check on the evening of 18 June 2025 was 'kind and compassionate' and did 'her best to conduct the welfare check'; however, it is not difficult to see that a lack of ongoing training raises risk in the future .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Kent Police; that does not assign responsibility.
PFD Monitor interpretation Lack of an organisational policy or procedure for risk assessing and safety-netting persons arrested for this type of offence
Wider context from the report “1. Part of the evidence in this inquest was that Kent Police does not have its own policy or standard operating procedure regarding the risk assessing and safety-netting of those arrested for this type of offence . I was directed to Operational Advice from the College of Policing (June 2019) entitled “Managing the risk of suicide for persons under investigation for online child sexual abuse and exploitation” (the Advice). It was confirmed that the Advice is available to officers on the Kent Police intranet. However, the nature of the Advice is such that some of it's content is not suitable for individual officers to make case-by-case assessments and decisions without there being an organisational level policy or procedure in place . While it is accepted, in the particular circumstances of this case, that parts of the Advice (e.g. paragraph 3.9) would not have altered the outcome, the concern remains regarding future risks to others.
” 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 Amend the policy to require consideration of providing suspects with key contact numbers and offering access to a telephone before leaving the police station.
Verbatim wording from the response “Instead, the policy will be amended to require QIC’s to consider providing suspects with key contact numbers to support their welfare and enable them to maintain contact with their support network. This information can be incorporated into the notes section of the Suspect Information Pack. In addition, officers should consider offering suspects the opportunity to use a telephone at the police station prior to departure to contact family members, friends, or other appropriate support services where necessary.” Source location Response from Kent Police
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 Review and update the Suspect Welfare and Suicide Strategy SOP to make it more comprehensive and incorporate relevant APP guidance.
Verbatim wording from the response “Kent Police does have a Suspect Welfare and Suicide Strategy standard operating procedure (SOP N11e) in place. However, we have identified that staff awareness and familiarity with the guidance is not as strong as it should be. In response, we have reviewed and updated the policy to make it more comprehensive and to incorporate relevant elements of the Authorised Professional Practice (APP) that were not previously included.” Source location Response from Kent Police
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 Circulate and promote the revised policy through staff communications and incorporate it into force-wide and POLIT continuing professional development.
Verbatim wording from the response “To improve awareness, the revised policy will be circulated to staff and promoted through a Spotlight communication. In addition, it will be incorporated into continuing professional development (CPD) activity, including a Public Protection CPD event scheduled for September/October, which will be open to the wider force. The policy will also be specifically covered within CPD for POLIT officers. These actions will be completed within the next fortnight.” Source location Response from Kent Police
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 Amend the SOP to explicitly cover the existing pre-allocation suicide risk assessment and its transfer to the officer in the case.
Verbatim wording from the response “As part of the initial intelligence work a suicide risk assessment is completed prior to allocation to the Officer in the case (OIC) and immediately when a suspect is identified. This is included on the Intel package and is passed to the OIC - Before the suspect is aware of the investigation. Whilst this is standard practice, this is not explicitly covered in our policy N11e - the policy will be updated accordingly to ensure a more cohesive bond to APP exists in the new wording.” Source location Response from Kent Police
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 Deliver refresher training on welfare checks, highlighting suicide risk and consideration of mental health and other agency support for suspects under investigation for child sexual abuse offences.
Verbatim wording from the response “We also utilise a comprehensive Suspect Information Pack, which is currently being refreshed. In support of the above measures, the Detective Chief Inspector in (POLIT) has met with the Chief Inspector, who leads the Medway district where [PM] died. The Chief Inspector will oversee the delivery of refresher training on welfare checks, aligned with the force-wide Right Care, Right Person (RCRP) refresher programme.” Source location Response from Kent Police
Open published response
16 Apr 2025 Freddie SLATER · Prevention of Future Deaths report North West Kent
View report summary
Concerns raised 1 Lack of physical barriers on the grass verge between the M20 and M25/M20 slip road 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
Freddie SLATER · 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 16 October 2024, Freddie Slater died at the scene after his Smart car collided with two other vehicles on the M20 and an adjoining slip road in Kent. The report raised concerns that the grass verge separating the roads had no physical barriers, allowing an uncontrolled vehicle to cross into traffic travelling in the opposite carriageway and creating a risk of high-speed collisions and fatalities.
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 Kent Police; that does not assign responsibility.
PFD Monitor interpretation Lack of physical barriers on the grass verge between the M20 and M25/M20 slip road
Wider context from the report “(1) The grass verge which separates the M20 and M25/ M20 slip road does not have erected upon it any physical barriers to prevent traffic crossing the verge from either of the 2 roads referred to and entering a parallel lane the opposite side of the verge.
(2) The evidence received from National Highways confirmed that under the present policy guidance, barriers would not normally be required as there are no features such as an incline on the slip road, bridge supports or trees requiring physical protection between the two merging roads of traffic travelling at similar speeds in the same direction.
(3) The facts of the present case illustrate that in the event of a loss of control of a vehicle travelling on either the M20 or in the slip road there is the potential for that vehicle, without any warning to drivers travelling at or about the same area in the coastbound direction, cross the grass verge to their side and enter their lane of travel. As both the material roads are subject to the same national speed limit of 70MPH, the risk of a high speed collision and fatality arises.
” Open source report
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 Kent Police; 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 Kent Police; 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 Kent Police; 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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide bespoke training and competence portfolios for new firearms licensing team members, retaining completion records for staff and supervisors.
Verbatim wording from the response “The programme, which also includes practical inputs on firearms dealerships, ranges and antiques, features delivery from academics, Kent Police Legal Services and subject matter experts including the force armourer. Detailed records are retained of completion of modules for all members of staff and supervisors, and new firearms licensing team members are provided bespoke training and required to complete a portfolio outlining occupational and operational competence. Work is ongoing to develop lesson plans for joint training with Essex Police, with whom Kent Police collaborates on Learning and Development, and to explore wider opportunities for peer review.” Source location Response from Kent Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver a modular local training and continuous professional development programme for firearms licensing staff and supervisors.
Verbatim wording from the response “2. Steps I am taking to ensure that (i) adequate local training, of a satisfactory standard, has been universally delivered to all firearms licensing staff and supervisors in applying the Home Office Guidance on Firearms Licensing Law and the revised Statutory Guidance for Chief Officers of Police, and (ii) decision making authority is delegated only to persons who have undergone adequate training in firearms licensing and in applying that guidance.” Source location Response from Kent Police
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 Adequate local firearms licensing training is considered sufficient while nationally accredited training is unavailable.
Verbatim wording from the response “I am sighted on the work being undertaken by the NPCC lead and College of Policing to develop a national training package and my team is engaged with its development. However, in the absence at this time of nationally accredited training for firearms licensing staff, Kent Police has taken steps to ensure that all staff and supervisors receive suitable training and continuous professional development. This has focussed on the development of a modular programme covering: the application of Statutory Guidance, APP and relevant legislation; managing risk and use of the national decision model; investigation techniques and interviewing; domestic abuse (including stalking and harassment), vulnerability and child protection; terrorism and extremism; and modern slavery and human trafficking.” Source location Response from Kent Police
Open published response
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.
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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.
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 Kent Police; 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 Kent Police; 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 Kent Police; 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 Kent Police; 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
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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 Record individual training attendance, identify non-attenders and schedule missed training within the five-week rotation.
Verbatim wording from the response “2. A database is held to record which members of staff have attended the training and those that have not, with a view to capturing non-attenders through subsequent sessions within the 5-week rotation period. The Command duties teams schedule the training and identify those who miss their allotted sessions.” Source location 2021-0177-Response-from-Kent-Police_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 Deliver the refreshed suicide training package to all FCR teams by 2 September 2021.
Verbatim wording from the response “10. The 2020 suicide training package has been refreshed and expanded to include additional learning that arose from the evidence and conclusion at the Inquest into Matthew’s death, to which Kent Police paid very careful attention. This new suicide training package will be delivered to all FCR teams by 2nd September 2021.” Source location 2021-0177-Response-from-Kent-Police_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 Disseminate enhanced mapping functionality through staff briefings and supervisor-led monthly one-to-one learning discussions.
Verbatim wording from the response “7. A range of briefings were delivered highlighting the enhanced functionality following the death of Matthew Mackell. A briefing was sent to all members of staff with a clear direction for supervisors to ensure the learning was captured by staff through monthly 1-2-1 meetings with the staff they supervise.” Source location 2021-0177-Response-from-Kent-Police_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 Deliver mandatory continuous professional development training to FCR teams through a scheduled five-week rotation.
Verbatim wording from the response “1. Every Thursday, a mandatory learning and development day is undertaken. On these learning and development days, specific Continuous Professional Development Training packages are delivered on a 5-week rotation to cover all FCR teams. Each package covers a specific theme such as suicide or firearms.” Source location 2021-0177-Response-from-Kent-Police_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 Refresh and expand the suicide training package with learning from the inquest evidence and conclusion.
Verbatim wording from the response “10. The 2020 suicide training package has been refreshed and expanded to include additional learning that arose from the evidence and conclusion at the Inquest into Matthew’s death, to which Kent Police paid very careful attention. This new suicide training package will be delivered to all FCR teams by 2nd September 2021.” Source location 2021-0177-Response-from-Kent-Police_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 Require staff who miss the full rotation to complete online training and quality-assure their understanding individually.
Verbatim wording from the response “3. Those who are unable to attend a session across the whole 5-week rotation period (which is minimal in number) are identified by the Command duties team via the database. These members of staff are required to self-serve the training package they missed through online learning (comprised of the slides, trainer notes and any other training materials used in the training package when it was delivered).” Source location 2021-0177-Response-from-Kent-Police_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 training identification, recording, rotation, monitoring and scheduling systems are sufficient to address the Coroner’s concerns.
Verbatim wording from the response “4. With reference to the terms of the regulation 28 report, I trust that this is sufficient to reassure the Coroner that Kent Police has in place (i) an effective system to identify those that require training/updating and of the keeping a record of the specific training/updating received by individual operatives and the date it was undertaken; (ii) a structured system to produce a regular training rotation which monitored and recorded individual satisfactory progress; and (iii) a system which clearly identifies what training/updating had been received thus identifying those who might otherwise be missed and when training/updating was scheduled to take place.” Source location 2021-0177-Response-from-Kent-Police_Published
Open published response
11 Nov 2013 Timothy Patrick CLAYTON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to use appropriate senior or judicial channels to challenge a coroner’s decision View source Failure to comply with the coroner’s judicial decision View source Failure to leave organ-donation decisions conferred on the coroner with the coroner 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
Timothy Patrick CLAYTON · 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
Timothy Patrick Clayton died after sustaining an unsurvivable traumatic head injury during a sustained attack in which he was kicked to the head and body. Although his family consented to organ donation and the coroner decided not to object, Kent Police contacted the family about the effect on the homicide prosecution, leading them to withdraw consent. The report’s principal concern was that this placed an improper burden on the grieving family and subverted the coroner’s decision, resulting in six organs not being donated.
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 Kent Police; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate senior or judicial channels to challenge a coroner’s decision
Wider context from the report “1. Kent Police approached Mr Clayton’s family to consider a decision that is, by law, conferred upon HM Coroner. This action placed Mr Clayton’s family in desperately difficult and desperately painful position. Having already given their consent to donation, they were asked to go back on this and to make a further decision based upon the likely success of prosecution of Mr Clayton’s killer, rather than this separate decision resting with a trained, experienced, dispassionate judge – the coroner.
This must have added horribly to their distress, and it was a wholly improper burden to place upon them.
2. As the coroner with responsibility for this matter, I did not make the decision not to object to organ donation on a whim. I did so after a great deal of discussion and thought.
Though I am a senior coroner with particular experience of organ donation, a subject on which I have lectured to doctors, nurses and police officers on several occasions, I nevertheless sought out a senior coroner colleague on a Sunday afternoon, to try to ensure that I had not missed anything.
I was transparent in my thinking, I listened carefully to all advice, including that of the senior investigating officer, and I gave detailed reasons for my decision. Nevertheless, that police officer sought to subvert my judicial decision.
He did not ask a more senior police officer to contact me to discuss the matter further. He did not seek to challenge in a higher court. Instead, he effectively reversed the decision made by a judge because he preferred his own view of the matter, and he did this by bringing pressure to bear on a grieving family.
In short, a police officer has subverted the rule of law.
You may be surprised that I write to you about this matter by way of a prevention of future death (PFD) report. I do so because in this instance, six organs were lost to their potential recipients - two lungs, two kidneys, a small bowel and a pancreas. Six organs represents six 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 Kent Police; that does not assign responsibility.
PFD Monitor interpretation Failure to comply with the coroner’s judicial decision
Wider context from the report “1. Kent Police approached Mr Clayton’s family to consider a decision that is, by law, conferred upon HM Coroner. This action placed Mr Clayton’s family in desperately difficult and desperately painful position. Having already given their consent to donation, they were asked to go back on this and to make a further decision based upon the likely success of prosecution of Mr Clayton’s killer, rather than this separate decision resting with a trained, experienced, dispassionate judge – the coroner.
This must have added horribly to their distress, and it was a wholly improper burden to place upon them.
2. As the coroner with responsibility for this matter, I did not make the decision not to object to organ donation on a whim. I did so after a great deal of discussion and thought.
Though I am a senior coroner with particular experience of organ donation, a subject on which I have lectured to doctors, nurses and police officers on several occasions, I nevertheless sought out a senior coroner colleague on a Sunday afternoon, to try to ensure that I had not missed anything.
I was transparent in my thinking, I listened carefully to all advice, including that of the senior investigating officer, and I gave detailed reasons for my decision. Nevertheless, that police officer sought to subvert my judicial decision.
He did not ask a more senior police officer to contact me to discuss the matter further. He did not seek to challenge in a higher court. Instead, he effectively reversed the decision made by a judge because he preferred his own view of the matter , and he did this by bringing pressure to bear on a grieving family.
In short, a police officer has subverted the rule of law.
You may be surprised that I write to you about this matter by way of a prevention of future death (PFD) report. I do so because in this instance, six organs were lost to their potential recipients - two lungs, two kidneys, a small bowel and a pancreas. Six organs represents six 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 Kent Police; that does not assign responsibility.
PFD Monitor interpretation Failure to leave organ-donation decisions conferred on the coroner with the coroner
Wider context from the report “1. Kent Police approached Mr Clayton’s family to consider a decision that is, by law, conferred upon HM Coroner . This action placed Mr Clayton’s family in desperately difficult and desperately painful position. Having already given their consent to donation, they were asked to go back on this and to make a further decision based upon the likely success of prosecution of Mr Clayton’s killer, rather than this separate decision resting with a trained, experienced, dispassionate judge – the coroner .
This must have added horribly to their distress, and it was a wholly improper burden to place upon them.
2. As the coroner with responsibility for this matter, I did not make the decision not to object to organ donation on a whim. I did so after a great deal of discussion and thought.
Though I am a senior coroner with particular experience of organ donation, a subject on which I have lectured to doctors, nurses and police officers on several occasions, I nevertheless sought out a senior coroner colleague on a Sunday afternoon, to try to ensure that I had not missed anything.
I was transparent in my thinking, I listened carefully to all advice, including that of the senior investigating officer, and I gave detailed reasons for my decision. Nevertheless, that police officer sought to subvert my judicial decision.
He did not ask a more senior police officer to contact me to discuss the matter further. He did not seek to challenge in a higher court. Instead, he effectively reversed the decision made by a judge because he preferred his own view of the matter, and he did this by bringing pressure to bear on a grieving family.
In short, a police officer has subverted the rule of law.
You may be surprised that I write to you about this matter by way of a prevention of future death (PFD) report. I do so because in this instance, six organs were lost to their potential recipients - two lungs, two kidneys, a small bowel and a pancreas. Six organs represents six lives.
” 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