8 Dec 2023 Claire Nicole Briggs · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses View source Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service 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
Claire Nicole Briggs · 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
Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.
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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 Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
Wider context from the report “The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022.
Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved.
Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses .
” 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 Brief Force Control Room Supervisors and Force Incident Managers on the Joint Operating Protocol.
Verbatim wording from the response “Lancashire Police are already working closely with North-West Regional Forces and North-West Ambulance Service in relation to agreed processes in the Joint Operating Protocol. The document will provide clarity and guidance to Control Room staff regarding escalation of incidents due to delays. It will also give operational officers at the scene of an incident guidance and information to obtain direct clinical advice from North-west Ambulance Service prior to them arriving on the scene of an incident. Implementation was initially via email/briefing to all Force Control Room Supervisors and Force Incident Managers.” Source location Response from Lancashire Constabulary
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 Implement the regional Standard Operating Procedure on information sharing in relation to incident logs (Version 1.0).
Verbatim wording from the response “Lancashire Police have been working with North-West Regional Forces and NWAS to finalise, agree and implement a Joint Operating Protocol (JOP). This was initially agreed and the final version V1.0 of the Regional Standard Operating Procedure – Information Sharing in Relation to Incident Logs went live on Thursday 12th October 2023. It was also agreed with the regional Forces and NWAS that monthly meetings will continue until North-West Fire and GMP were able to proceed with the agreement.” Source location Response from Lancashire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monthly meetings with regional forces and ambulance services to agree the Joint Operating Protocol.
Verbatim wording from the response “Lancashire Police have been working with North-West Regional Forces and NWAS to finalise, agree and implement a Joint Operating Protocol (JOP). This was initially agreed and the final version V1.0 of the Regional Standard Operating Procedure – Information Sharing in Relation to Incident Logs went live on Thursday 12th October 2023. It was also agreed with the regional Forces and NWAS that monthly meetings will continue until North-West Fire and GMP were able to proceed with the agreement.” Source location Response from Lancashire Constabulary
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 Sign off Lancashire Police’s version 1.3 Joint Operating Protocol document.
Verbatim wording from the response “Rollout via email briefing was due to take place to operational officers and Control Room staff to be made aware of the purpose and aims of the JOP, how it applies to that agency and how it should be used by staff. However, this has been delayed due to GMP having issues with the wording in the document about the responsibilities of the lead agency. Further meetings have now taken place with all regional forces to agree the wording. Version 1.3 was due to go live on 31/01/2024, however this is still waiting sign off from GMP and Fire and Rescue. Lancashire Police are happy and have signed off with the Version 1.3 document, and we are just waiting for confirmation of go live from North-west Ambulance Service who are leading on the document.” Source location Response from Lancashire Constabulary
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 Confirmation of the Joint Operating Protocol’s go-live rests with North-West Ambulance Service, pending sign-off from GMP and Fire and Rescue.
Verbatim wording from the response “Rollout via email briefing was due to take place to operational officers and Control Room staff to be made aware of the purpose and aims of the JOP, how it applies to that agency and how it should be used by staff. However, this has been delayed due to GMP having issues with the wording in the document about the responsibilities of the lead agency. Further meetings have now taken place with all regional forces to agree the wording. Version 1.3 was due to go live on 31/01/2024, however this is still waiting sign off from GMP and Fire and Rescue. Lancashire Police are happy and have signed off with the Version 1.3 document, and we are just waiting for confirmation of go live from North-west Ambulance Service who are leading on the document.” Source location Response from Lancashire Constabulary
Open published response
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 Lancashire Constabulary; 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 Lancashire Constabulary; 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 Lancashire Constabulary; 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 Deliver a three-day firearms licensing training package to department staff, including the Chief Inspector.
Verbatim wording from the response “In the absence of any current formal training from the College of Policing, Lancashire has introduced the following:” Source location Response from Lancashire Constabulary
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 Train Force Incident Commanders in the procedure for revoking firearm and shotgun certificates.
Verbatim wording from the response “• Our scheme of delegation allows for a Force Incident Commander (a Chief Inspector role) to revoke either a Firearm or Shotgun Certificate. They have received inhouse training into this procedure.” Source location Response from Lancashire Constabulary
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 agreed Mowbray Partners online training package, updated for statutory-guidance changes.
Verbatim wording from the response “• This year further training delivered through Mowbray Partners has been agreed. This online package is updated to reflect changes in the Statutory Guidance.” Source location Response from Lancashire Constabulary
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue embedding training and CPD for Firearms Licensing Department staff while updating training records for legislative changes.
Verbatim wording from the response “We are not complacent and recognise the need for all staff within the Firearms Licensing Department to have adequate training of a satisfactory standard in applying both the Home Office Guidance on Firearms Licensing Law (November 2022) and the Statutory Guidance for Chief Officer of Police (February 2023). We will continue to embed training, CPD and ensure training records are updated to ensure we keep our staff up to date with any legislative changes and do all we can to keep the public safe.” Source location Response from Lancashire Constabulary
Open published response
29 Aug 2019 Michael Hoolickin · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 15 Insufficient capacity to cross-reference offender intelligence across offenders and agencies View source Failure to require ACOs to access offender records View source Lack of formal information-sharing procedures for integrated teams View source Poor or absent records by SPOs and ACOs View source Failure to undertake multi-agency reviews after high-risk offenders under multi-agency management kill someone View source Lack of training on accessing drug test results View source Failure to update OASYS risk assessments View source Insufficient planning and preparation for service amalgamation View source N-Delius failing to provide timely access to current offender information View source Inadequate agenda, minutes, attendance records and meeting records for IOM cohort meetings View source Failure to accurately share information about offenders between police forces View source Lack of induction training and office procedures on local drug-testing practices View source Lack of clarity and specific instructions on ACO warnings View source Lack of clear arrangements for initiating police curfew checks View source Failure to record licence conditions on the Police National Computer View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Hoolickin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Hoolickin was attacked and stabbed in an unprovoked assault on 14 October 2016 and died at Manchester Royal Infirmary on 17 October 2016. The report identifies organisational and management failures in supervising the perpetrator, including failures concerning drug testing, information sharing and provision of relevant information, which resulted in a missed opportunity to initiate recall to prison. The Inquest found that this probably contributed to Michael Hoolickin’s death, although it was not causative of the attack.
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 Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacity to cross-reference offender intelligence across offenders and agencies
Wider context from the report “During the course of the Inquest questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders . In addition whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to require ACOs to access offender records
Wider context from the report “There is no expectation for an ACO to access an offenders records on the case management system in order to inform themselves or to consider whether there is any further relevant 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 Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of formal information-sharing procedures for integrated teams
Wider context from the report “The evidence before the Court was there are no Standard Operating procedures or formal processes in place for the sharing of information when teams are integrated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Poor or absent records by SPOs and ACOs
Wider context from the report “The Court had serious concerns as to the poor records or complete lack of records particularly by SPOs and the ACOs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake multi-agency reviews after high-risk offenders under multi-agency management kill someone
Wider context from the report “The failure to undertake a multi-agency review in cases where a high risk offender subject to multi-agency management has gone on to take someone’s life means both organisational and individual failings are not identified and there is a missed opportunity to learn lessons in order to prevent 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 Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of training on accessing drug test results
Wider context from the report “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results . As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to update OASYS risk assessments
Wider context from the report “At no stage after March 2016 was the offenders OASYS risk assessment updated . Moreover the lack of formal supervision meant this was not addressed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient planning and preparation for service amalgamation
Wider context from the report “The Court has concerns as to the planning and preparation required for the amalgamation of any new service in order to alleviate the evidenced problems which occurred as a direct result of the previous Transforming Rehabilitation programme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation N-Delius failing to provide timely access to current offender information
Wider context from the report “Numerous witnesses gave evidence as to the difficulties in accessing this system , its design and the time it takes to access the different parts which hold pertinent information about an offender , describing this as prohibitive. For example for Offender managers trying to read through the file to obtain current information there is nowhere which would easily show the most up to date curfew or the most up to date position as to how often drug testing is being conducted .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Inadequate agenda, minutes, attendance records and meeting records for IOM cohort meetings
Wider context from the report “The evidence before the Court was that in respect of the multi-agency IOM meetings there was no formal agenda, no formal minutes, no accurate record kept of these meetings by either GMP or the NPS and no way of ascertaining who had attended these meetings .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately share information about offenders between police forces
Wider context from the report “There was a complete breakdown of communication and information sharing between GMP and Lancashire Constabulary which lead to only information about one of the two offenders being passed on . More importantly there was confusion between the forces as to which offender was being discussed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of induction training and office procedures on local drug-testing practices
Wider context from the report “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results. As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity and specific instructions on ACO warnings
Wider context from the report “The Court found there is a lack of clarity and specific instructions to the NPS on this point.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of clear arrangements for initiating police curfew checks
Wider context from the report “The Court was satisfied from the evidence that there is no clear understanding as to the initiation of curfew checks . It was clear to the Court there was confusion as to whether an offender on a curfew will automatically be subject to curfew checks carried out by the Police or whether such checks will only be conducted following a specific request by the NPS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to record licence conditions on the Police National Computer
Wider context from the report “The Court heard that an offenders’ licence conditions are not held on the Police National Computer database . Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence.
” 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 uncertainty about information sharing was isolated and did not indicate systemic failures.
Verbatim wording from the response “The lack of certainty as to what information was being shared was an isolated incident and was not demonstrative of any systemic failing(s). We have detailed below how Lancashire Constabulary operates in practice in this area.” Source location 2019-0292-Response-from-Lancashire-Constabulary.-Redactedf
Open published response
Concerns raised 11 Failure to carry and use personal protective equipment View source Failure of probation staff to engage in full updating training View source Failure to challenge or support change in domestic abuse risk during probation supervision View source Failure to allocate an appropriately protective MAPPA level for offenders with significant domestic abuse histories who have not been fully tested before release View source Failure to detail licence conditions during MAPPA Level 1 management View source Failure to obtain information during initial attendances on reported domestic abuse incidents View source Insufficient probation staffing capacity for complex and demanding casework View source Failure to evidence implementation of recommended safety changes View source Lack of mandated joined-up inter-agency communication at offender release or when new personal relationships develop View source Deficiencies in initial grading of calls to identify initial responses View source Failure to maintain mandatory inter-agency information sharing for MAPPA Level 1 management View source See 8 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
Cherylee Yvette Shennan · 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
Cherylee Yvette Shennan, a 40-year-old woman, was murdered on 17 March 2014 by a former offender who had subjected her to domestic abuse, including serious violence. The report raised concerns about inadequate inter-agency communication and management of the perpetrator, including the absence of a mandatory process for sharing information when an offender with a known history of domestic abuse was managed at MAPPA Level 1.
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 Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to carry and use personal protective equipment
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses, the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment . Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not, and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence:
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure of probation staff to engage in full updating training
Wider context from the report “3) Finally it was also accepted by senior probation witnesses that although staff had access to updated training information, due to pressures of their workloads they lacked the time to engage in full updating training .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to challenge or support change in domestic abuse risk during probation supervision
Wider context from the report “2) Evidence was further heard regarding the Report of the Chief Inspector of Probation 2019 and in particular the finding that "Many individuals were drifting through their supervision period without being challenged or supported to change their prediction for domestic abuse " and that "The number of probation professionals is now at a critical level. There is a national shortage of professional probation staff and especially those mainly responsible for more complex and demanding casework". It was agreed by those senior probation witnesses that staffing and workloads had been an issue in this matter, as found by the jury, and furthermore continued to be so.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate an appropriately protective MAPPA level for offenders with significant domestic abuse histories who have not been fully tested before release
Wider context from the report “1) During the course of the inquest statistics regarding the nature of domestic abuse were repeatedly reviewed and accepted by senior member of both probation and police services. In particular domestic abuse features in about half of all cases managed by probation staff and that in the year to the end of 2018 of the 659 homicides 1 in 10 were committed by a partner. Evidence was heard of the MAPPA process, for the managing of risk of offenders to be released on licence, and for the interagency sharing of information regarding those offenders. During the course of the evidence it was made clear that the perpetrator in this instance was a very dangerous individual, who was described as controlling and manipulative, and who, it was accepted by the witnesses involved in his management, was likely to have controlled his meetings by his nature, and by partial disclosures of information. The underlying issue that arose from both the various reviews that took place after the death of Cherylee Shennan, and from the inquest was that there was no substantial interagency communication following the perpetrator's release on licence, which would, the jury found, have allowed the sharing of his licence conditions and action plans to be put in place by local police forces. The jury concluded that such a failing possibly contributed to the death on the 17th March 2014. At the inquest no evidence was heard regarding any changes to MAPPA or the guidance given. Whilst the evidence heard was that the MAPPA level allocated to an individual is fluid, and would be based upon their risks and presentation at that time, my concern centres on the issue that an offender who has served a significant sentence and accordingly has never been fully tested before release on licence, and who has a significant history of domestic abuse and violence, will still be released on MAPPA level 1 . On the evidence that was heard there remains no mandated process for joined up inter-agency working or communication at the point of their release, or when they develop new personal relationships.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to detail licence conditions during MAPPA Level 1 management
Wider context from the report “The perpetrator was managed on release at MAPPA Level 1. Following his release there were no local MAPPA 1 meetings, no inter-agency meetings and no significant inter-agency communications regarding the perpetrator, no detailing of his licence conditions , and no information regarding either his nature or the trigger factors for his offending. Evidence was heard regarding the findings of two separate reviews that took place following the death of Cherylee, and the recommendations that were made as a result of those reviews, in particular centred on the lack of inter-agency communications. My concern is that despite this, and the findings of the report, when evidence was heard regarding how systems had changed, there is still no mandatory process for the sharing of information between agencies where the offender despite a known, and extensive, history of domestic abuse and identified trigger factors, is then managed at MAPPA Level 1.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain information during initial attendances on reported domestic abuse incidents
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses, the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment. Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not, and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence:
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient probation staffing capacity for complex and demanding casework
Wider context from the report “2) Evidence was further heard regarding the Report of the Chief Inspector of Probation 2019 and in particular the finding that "Many individuals were drifting through their supervision period without being challenged or supported to change their prediction for domestic abuse" and that "The number of probation professionals is now at a critical level . There is a national shortage of professional probation staff and especially those mainly responsible for more complex and demanding casework ". It was agreed by those senior probation witnesses that staffing and workloads had been an issue in this matter , as found by the jury, and furthermore continued to be so .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to evidence implementation of recommended safety changes
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses, the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment. Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not , and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence :
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of mandated joined-up inter-agency communication at offender release or when new personal relationships develop
Wider context from the report “1) During the course of the inquest statistics regarding the nature of domestic abuse were repeatedly reviewed and accepted by senior member of both probation and police services. In particular domestic abuse features in about half of all cases managed by probation staff and that in the year to the end of 2018 of the 659 homicides 1 in 10 were committed by a partner. Evidence was heard of the MAPPA process, for the managing of risk of offenders to be released on licence, and for the interagency sharing of information regarding those offenders. During the course of the evidence it was made clear that the perpetrator in this instance was a very dangerous individual, who was described as controlling and manipulative, and who, it was accepted by the witnesses involved in his management, was likely to have controlled his meetings by his nature, and by partial disclosures of information. The underlying issue that arose from both the various reviews that took place after the death of Cherylee Shennan, and from the inquest was that there was no substantial interagency communication following the perpetrator's release on licence , which would, the jury found, have allowed the sharing of his licence conditions and action plans to be put in place by local police forces. The jury concluded that such a failing possibly contributed to the death on the 17th March 2014. At the inquest no evidence was heard regarding any changes to MAPPA or the guidance given. Whilst the evidence heard was that the MAPPA level allocated to an individual is fluid, and would be based upon their risks and presentation at that time, my concern centres on the issue that an offender who has served a significant sentence and accordingly has never been fully tested before release on licence, and who has a significant history of domestic abuse and violence, will still be released on MAPPA level 1. On the evidence that was heard there remains no mandated process for joined up inter-agency working or communication at the point of their release, or when they develop new personal relationships .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in initial grading of calls to identify initial responses
Wider context from the report “Following the death of Cherylee, her death, and actions taken in the months leading up to it were the subject of two detailed reviews. Following the Domestic Homicide Review a number of recommendations were made by the author of the Individual Management Report, Mr Gary Fishwick including concerns regarding initial grading of calls to identify initial responses , the obtaining of information as part of initial attendances on reported domestic abuse incidents and the carrying and use of personal protective equipment. Whilst the recommendations were made, Mr Fishwick could give no evidence at the inquest into the death of Cherylee to indicate whether those recommendations had in fact been actioned or not, and accordingly whether anything had changed following the death of Cherylee and the learning exercise that were subsequently undertaken.
In particular reference was made to, but unsupported by documentation, or any other form of evidence:
• Policies reflecting recommended changes;
• Information sharing agreements between agencies;
• MARAC emergency policy or notes;
• DASH Training or policy regarding obtaining GP details; and
• Audits of Grade 2 ‘Ethical fails’ and reasons for such fails.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lancashire Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain mandatory inter-agency information sharing for MAPPA Level 1 management
Wider context from the report “The perpetrator was managed on release at MAPPA Level 1. Following his release there were no local MAPPA 1 meetings, no inter-agency meetings and no significant inter-agency communications regarding the perpetrator , no detailing of his licence conditions, and no information regarding either his nature or the trigger factors for his offending. Evidence was heard regarding the findings of two separate reviews that took place following the death of Cherylee, and the recommendations that were made as a result of those reviews, in particular centred on the lack of inter-agency communications . My concern is that despite this, and the findings of the report, when evidence was heard regarding how systems had changed, there is still no mandatory process for the sharing of information between agencies where the offender despite a known, and extensive, history of domestic abuse and identified trigger factors, is then managed at MAPPA Level 1.
” 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 Lead a multi-agency redesign of MARAC to test live-time information sharing, tasking, lead-professional coordination and wider household safeguarding.
Verbatim wording from the response “Lancashire Constabulary are leading a multi-agency systems thinking review of the MARAC process and this is encompassing the journey from initial referral through to the MARAC meeting itself.” Source location 2019-0244-Response-by-Lancashire-Constabulary_Redacted
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 Implement a merits-based MASH safeguarding model focused on individual vulnerability, partnership working, information sharing and early intervention.
Verbatim wording from the response “A Corporate systems thinking review of MASH was conducted from 2016-18 and amongst a number of changes implemented was a move from a process-driven response to safeguarding referrals to a model where MASH staff understood their role in supporting people and keeping them safe, achieving this by considering each case on its merits, including the specific needs of the victim, adult and/or children and responding accordingly in partnership. Staff Supervisors/Team Leaders were trained and are now focused on this approach to recognising the risk, sharing information to achieve early interventions.” Source location 2019-0244-Response-by-Lancashire-Constabulary_Redacted
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 Replace system-generated email sharing with personal email addresses in Connect so senders receive delivery-failure alerts and can rectify unsuccessful information transfers.
Verbatim wording from the response ““In 2014 the force recorded vulnerability reports via an IT system called “Sleuth”. This was achieved through the submission of a PVP (Protecting vulnerable persons) report, which the MASH would share. At that time, information was predominantly shared by a system generated email within sleuth. It was identified that sending emails directly through the Sleuth system did not inform the sender if they failed to be delivered. In light of this when the constabulary changed its IT system from “Sleuth” to “Connect” on 27th November 2018, the operating practice for sharing information changed with it. It was agreed that when information is shared via email it must be done via a personal email address rather than a system generated address.” Source location 2019-0244-Response-by-Lancashire-Constabulary_Redacted
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 Refresh MASH staff messaging periodically on identifying life-licensed perpetrators as high risk and sharing referral information to prompt safeguarding action.
Verbatim wording from the response “The Lancashire Constabulary are a key stakeholder in the MASH (Multi-Agency Sharing Hub), which has dedicated and co-located National Probation Service staff able to access national databases to ensure quality research can be conducted on criminal matters subject of safeguarding referrals – in particular those with previous convictions and actionable orders – such as licence conditions.” Source location 2019-0244-Response-by-Lancashire-Constabulary_Redacted
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 Adopt a force-wide Safeguarding, Investigation and Prevention model and embed it in vulnerability training and frontline coaching.
Verbatim wording from the response “The constabulary through its Public Protection Unit has adopted a force-wide model of “SIP” – Safeguarding, Investigation & Prevention which is for officers/staff to apply to all incidents they deal with and will help appreciate wider vulnerabilities of the individuals, families, groups and environments they come into contact with and instil ‘professional curiosity’ in dealing with vulnerability, not least domestic abuse. SIP is incorporated into vulnerability training in all related courses/inputs and has recently been delivered at ‘Vulnerability Coach lunch sessions to over 250 frontline police officers/staff which has seen the recruitment of over 100 Vulnerability coaches in these roles to support, guide and coach their colleagues.” Source location 2019-0244-Response-by-Lancashire-Constabulary_Redacted
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 Implement a Pan-Lancashire MARAC protocol requiring immediate emergency referral and high-risk prioritisation for relevant life-licensed domestic-abuse homicide offenders.
Verbatim wording from the response “Specifically, with regards to perpetrators with homicide convictions and urgent MARAC referral, a Pan-Lancashire MARAC Operating Protocol Document was agreed in April 2016 which referenced specifically the procedure relating to Emergency MARAC, and reflects a response to the DHR in question.” Source location 2019-0244-Response-by-Lancashire-Constabulary_Redacted
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 Responsibility for referring relevant life-licensed offenders to MARAC lies with the offender manager.
Verbatim wording from the response “Specifically, with regards to perpetrators with homicide convictions and urgent MARAC referral, a Pan-Lancashire MARAC Operating Protocol Document was agreed in April 2016 which referenced specifically the procedure relating to Emergency MARAC, and reflects a response to the DHR in question.” Source location 2019-0244-Response-by-Lancashire-Constabulary_Redacted
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 Pan-Lancashire MARAC operating protocol already addresses urgent referrals and high-risk prioritisation for relevant offenders.
Verbatim wording from the response “Specifically, with regards to perpetrators with homicide convictions and urgent MARAC referral, a Pan-Lancashire MARAC Operating Protocol Document was agreed in April 2016 which referenced specifically the procedure relating to Emergency MARAC, and reflects a response to the DHR in question.” Source location 2019-0244-Response-by-Lancashire-Constabulary_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing MASH arrangements provide research, information sharing and referral of life-licensed perpetrators to relevant agencies, including Probation and Social Care.
Verbatim wording from the response “The Lancashire Constabulary are a key stakeholder in the MASH (Multi-Agency Sharing Hub), which has dedicated and co-located National Probation Service staff able to access national databases to ensure quality research can be conducted on criminal matters subject of safeguarding referrals – in particular those with previous convictions and actionable orders – such as licence conditions.” Source location 2019-0244-Response-by-Lancashire-Constabulary_Redacted
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations