9 Jan 2026 Ayan SEDIQI · Prevention of Future Deaths report Greater Lincolnshire
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Concerns raised 1 Lack of public awareness about who, where and how to report immediate dangers to road users View source
Responses linked to these concerns
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Ayan SEDIQI · 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
Ayan Sediqi, aged 7 months, died on 3 January 2025 from injuries sustained when the vehicle in which he was travelling slid on ice and collided with a tree on the A1. The ice formed where water was flowing across the carriageway from a blocked drainage pipe. The principal concern was a lack of public awareness about who, where and how motorists should report conditions presenting an immediate danger to road users.
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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 Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of public awareness about who, where and how to report immediate dangers to road users
Wider context from the report “Responsibility for road repairs and drainage of Lincolnshire’s roads is shared between Lincolnshire County Council and the Highways Agency and is dependent on the particular road and location. Maintenance and repair of drains at the A1 at this point is the responsibility of National Highways. Both National Highways (Midlands Region) and Lincolnshire County Council described their websites during the inquest. Both include an online reporting process for concerns and faults encountered on the roads. Lincolnshire County Council also have a general telephone number for their Customer Service Centre (office hours) and outside this time, if the fault represents an immediate danger, their online guidance recommends contacting the police on 101. The National Highways website refers to reporting any emergency via 999, and that any other incidents relating to maintenance issues can be reported to their Customer Contact Centre on the number provided. This operates on a 24/7 basis. The Highways Agency also advised that they also do have available signage which displays their telephone number, but that this is usually only deployed, on a temporary basis, at sites of major pre-planned roadworks.
Under the heading ‘Report a Road Traffic Incident’ the Lincolnshire Police website advises that in an emergency situation (this includes incidents where there is an ‘immediate danger to life’), the user should call 999. Their online system for reporting road traffic incidents to the police refers to reporting collisions and driving offences only.
As part of my investigation, the National Highways (Midlands Region), Lincolnshire County Council and Lincolnshire Police all checked their reporting systems, and confirmed they had not received any reports about flowing water or ice on this stretch of the A1 on 2 January 2025, and for the period of two months prior to this accident.
Given the duration and extent of the flowing water / ice on the A1 at the location of this collision, and the number of road users who would have passed over it, it is my view that there is a lack of public awareness as to who, where and how motorists should report circumstances which present a risk of immediate danger to road users.
” 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 Promote National Highways’ 24/7 Customer Contact Centre number through public-facing materials, community engagement, digital communications and routine messaging.
Verbatim wording from the response “National Highways Customer Contact Centre Promotion:
We will work with National Highways to support and amplify the promotion of their 24/7 Customer Contact Centre number within Lincolnshire Police engagement activity relating to road-related issues. This will include incorporating the number into our public-facing materials, community engagement sessions, digital communications, and routine messaging. The purpose of this action is to ensure that members of the public have greater clarity about who to contact and how to contact relevant agencies to receive timely information and take appropriate action. Strengthening this awareness will support faster issue resolution and help reduce the likelihood of similar circumstances arising in the future.” Source location Response from Lincolnshire 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 National Highways is responsible for triaging and responding to concerns about the A1 in Lincolnshire.
Verbatim wording from the response “We believe that the action we are taking enables National Highways to best inform the public in Lincolnshire about how to report crimes to the relevant responsible organisation. Whilst we are clear that the responsibility to triage and respond to concerns around the A1 in Lincolnshire rests with National Highways, we understand that our engagement reach locally is more likely to reach the intended audience, and therefore represents a better opportunity to prevent further incidents.” Source location Response from Lincolnshire Police
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6 Jan 2026 Robert Shaun GRACEY · Prevention of Future Deaths report Greater Lincolnshire
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Concerns raised 3 Lack of an ABD protocol between police forces and the local ambulance service View source Allocation of ABD referrals to only a category 2 response in the absence of police restraint View source Lack of an NHS Pathways allocation pathway for ABD 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
Robert Shaun GRACEY · 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
Robert Shaun Gracey died in hospital on 29 September 2021 after police restraint and transportation following behaviour associated with cocaine use. The jury found that the effects of cocaine, restraint and struggle against restraint contributed to his death. Concerns included the absence of a Lincolnshire protocol for treating suspected excited delirium as a medical emergency, inadequate police training and monitoring, and delays or shortcomings in medical response and de-escalation.
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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 Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of an ABD protocol between police forces and the local ambulance service
Wider context from the report “1. Despite a very clear recommendation made in a letter dated 24 July 2019 by DAC Twist on behalf of the NPCC that "police forces have established ABD protocols with their local ambulance service so that suspected ABD incidents are treated as medical emergencies (i.e. Cat 1, with a response time of 8 minutes)", there is still no such protocol in Lincolnshire .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Allocation of ABD referrals to only a category 2 response in the absence of police restraint
Wider context from the report “3. Under the current NHS Pathways system a referral for ABD will only be allocated a category 2 response in the absence of police restraint .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of an NHS Pathways allocation pathway for ABD
Wider context from the report “2. Under the current NHS Pathways system, ABD does not have its own allocation pathway .
” 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 Work with EMAS and Forum partners to develop and align ABD practices and training, including response times and restraint practices.
Verbatim wording from the response “Lincolnshire Police will continue to work with EMAS and partners within the Forum in order to develop and align practices and training to deal with ABD, response times, and restraint practices.” Source location 2026-0004 - Response from Lincolnshire Police
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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 Share learning from the coronial process with EMAS to support ABD guidance development and implementation.
Verbatim wording from the response “Lincolnshire Police is working with the East Midlands Police Force Clinical Governance Forum (‘the Forum’) to implement a policy in relation to ABD. The Forum includes the East Midlands Ambulance Service (EMAS) and since September 2025 learning from the Coronial process has been shared with EMAS with a view to creating and then implementing guidance in relation to this issue.” Source location 2026-0004 - Response from Lincolnshire Police
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with EMAS and the Clinical Governance Forum to implement an ABD joint-working policy.
Verbatim wording from the response “Lincolnshire Police is working with the East Midlands Police Force Clinical Governance Forum (‘the Forum’) to implement a policy in relation to ABD. The Forum includes the East Midlands Ambulance Service (EMAS) and since September 2025 learning from the Coronial process has been shared with EMAS with a view to creating and then implementing guidance in relation to this issue.” Source location 2026-0004 - Response from Lincolnshire 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 EMAS is responsible for leading the joint ABD policy because the medical response is a crucial element and EMAS is best placed to lead.
Verbatim wording from the response “All Forces in the East Midlands contribute to the work of the Forum. The Forum as a whole decided that the basis of the work should be carried out by EMAS given that the medical response was a crucial element of the policy and therefore EMAS were best placed to lead upon it. The joint working policy will therefore inform the response on the part of other Police Forces within the East Midlands.” Source location 2026-0004 - Response from Lincolnshire Police
Open published response
23 Jun 2025 David Lee WALSH · Prevention of Future Deaths report Greater Lincolnshire
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Concerns raised 2 Failure to immediately report highway-condition-related injury or fatality collisions to the Highways Department View source Delays in reviewing collision information for highway safety intervention 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
David Lee WALSH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Lee Walsh died at the scene after the Mercedes GLC300 he was travelling in left the road at Whitegates Farm, Tetney Lock Road, Tetney, and entered the Louth Canal on 6 January 2024. The concern was that highway-related collisions are not reported directly to the Highways Department immediately, meaning incidents may occur before the annual review and potentially before preventative action is taken.
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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 Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to immediately report highway-condition-related injury or fatality collisions to the Highways Department
Wider context from the report “During the evidence provided by the Highways Department, the Highways Officer reported that road traffic collisions, where there are injuries or fatalities that may have been contributed to by the condition of the highway, are not immediately reported directly to the Highways Department by the Police . The Police complete a Stat 19 Form which is then sent to the Lincolnshire Road Safety Partnership. The information from the Stat 19 Form is then collated and placed onto the WINGS software programme which is a Council owned software programme. This information is reviewed on an annual basis where the types of incidents are considered along with the traffic flow on that road and it gives a score. Based on the score there is then a ranking of sites where there has been more than one collision within a set area (known as a Cluster). The score is used to decide where the Highways Department should intervene first on looking at potential safety improvements. The Accident Investigation Team and the Road Safety Partnership then look at each of those Cluster Sites and investigate those sites. Consideration will then be given to what improvements could be made to the highway to reduce the risk of future incidents. As these reports are only considered annually there is the possibility that other incidents can occur prior to the annual review that could have been prevented had a report been made to the Highways Department at the time of the incident .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Delays in reviewing collision information for highway safety intervention
Wider context from the report “During the evidence provided by the Highways Department, the Highways Officer reported that road traffic collisions, where there are injuries or fatalities that may have been contributed to by the condition of the highway, are not immediately reported directly to the Highways Department by the Police. The Police complete a Stat 19 Form which is then sent to the Lincolnshire Road Safety Partnership. The information from the Stat 19 Form is then collated and placed onto the WINGS software programme which is a Council owned software programme. This information is reviewed on an annual basis where the types of incidents are considered along with the traffic flow on that road and it gives a score. Based on the score there is then a ranking of sites where there has been more than one collision within a set area (known as a Cluster). The score is used to decide where the Highways Department should intervene first on looking at potential safety improvements. The Accident Investigation Team and the Road Safety Partnership then look at each of those Cluster Sites and investigate those sites. Consideration will then be given to what improvements could be made to the highway to reduce the risk of future incidents. As these reports are only considered annually there is the possibility that other incidents can occur prior to the annual review that could have been prevented had a report been made to the Highways Department at the time of the incident.
” 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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Lincolnshire 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 Lincolnshire 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 Lincolnshire 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
31 Aug 2022 Dainton Harley Hill Cressell GITTOS · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 2 Neglect affecting vulnerable children View source Failure to adequately test evidence and reconsider charging criteria in suspected child neglect cases 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
Dainton Harley Hill Cressell GITTOS · 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
Dainton Harley Hill, an 11-year-old vulnerable child with cerebral palsy who could not speak, bear his own weight, or call for help, was left unsupervised in a bath on 22 January 2021 and was later found unresponsive. The inquest concluded that parental neglect in failing to supervise him contributed directly to his death, which was consistent with drowning. Concerns were raised about the lack of supervision, failure to use a non-slip bath mattress, prior social services records concerning neglect and emotional harm, and the decision not to bring charges.
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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 Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Neglect affecting vulnerable children
Wider context from the report “I refer to all the evidence heard at the Inquest particularly, that of DC ████████ and the Police’s own expert Dr. ████████, (recited above) and do not accept why any charges have not been brought against either or both parents focusing on s1(1) Children and Young Persons Act 1933
The police are asked to review their file again in view of the many concessions made by CPS and the findings as to cause of death now made in the Coroner’s Court (admittedly on a different standard of proof but they are still findings after hearing evidence).
Neglect runs right through this case and irrespective of the parent’s allegations against each other in the Coroner’s Court the belief is that the evidence needs to be tested and if agreed charging criteria reconsidered as there are 3 other siblings .
A vulnerable child aged 11 is dead.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately test evidence and reconsider charging criteria in suspected child neglect cases
Wider context from the report “I refer to all the evidence heard at the Inquest particularly, that of DC ████████ and the Police’s own expert Dr. ████████, (recited above) and do not accept why any charges have not been brought against either or both parents focusing on s1(1) Children and Young Persons Act 1933
The police are asked to review their file again in view of the many concessions made by CPS and the findings as to cause of death now made in the Coroner’s Court (admittedly on a different standard of proof but they are still findings after hearing evidence).
Neglect runs right through this case and irrespective of the parent’s allegations against each other in the Coroner’s Court the belief is that the evidence needs to be tested and if agreed charging criteria reconsidered as there are 3 other siblings.
A vulnerable child aged 11 is dead.
” Open source report
6 Jul 2021 Levi Craig Don Pettit · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 5 Failure to report welfare incidents to another officer View source Lack of officer awareness of the Concern for Welfare Policy Document View source Failure to track the disposition of completed mental health proformas View source Failure to make a PNN when dealing with welfare incidents View source Failure to complete a mental welfare proforma report View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Levi Craig Don Pettit · 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
Levi Craig Don Pettit was reported to police as having suicidal ideations on 8 December 2019. Four days later, he died by suicide; concerns included the handling of the police response, including the failure to complete or make required referrals and uncertainty about relevant policy and 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 Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to report welfare incidents to another officer
Wider context from the report “(II) PC ████████ admitted he used his discretion in dealing with the deceased and did not make a PNN ,complete a mental welfare proforma report, or reported the incident to any other officer on the night
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of officer awareness of the Concern for Welfare Policy Document
Wider context from the report “(I) PC ████████ was not aware of the Lincolnshire Police Concern for Welfare Policy Document PD238
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to track the disposition of completed mental health proformas
Wider context from the report “(III) DS ████████ when asked did not know what happened to the mental health proforma when completed
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to make a PNN when dealing with welfare incidents
Wider context from the report “(II) PC ████████ admitted he used his discretion in dealing with the deceased and did not make a PNN ,complete a mental welfare proforma report, or reported the incident to any other officer on the night
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a mental welfare proforma report
Wider context from the report “(II) PC ████████ admitted he used his discretion in dealing with the deceased and did not make a PNN ,complete a mental welfare proforma report , or reported the incident to any other officer on the night
” 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 Recirculate relevant guidance to Force Control Room officers and staff to reinforce policy awareness.
Verbatim wording from the response “As mentioned in my answer to question 1, above, I will ensure that the relevant guidance is recirculated to officers and staff in the FCR to remind them of the importance of the relevant policies in place.” Source location 2021-0231-Response-from-Lincolnshire-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 Recirculate the Concern for Welfare policy among Force Control Room staff and embed it in incident decision-making.
Verbatim wording from the response “To reassure ourselves that our guidance to officers and staff in the FCR is being adhered to, I have ensured that the relevant policy document is recirculated among our FCR staff, and informs our decision making process when receiving, allocating, reviewing and closing incidents of this nature.” Source location 2021-0231-Response-from-Lincolnshire-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 The officer acted appropriately, reported the incident through the command system, and received appropriate oversight; detention and a PPN were not required.
Verbatim wording from the response “I would expect PC ████████ to have used his discretion in dealing with Levi. In the circumstances, my understanding is the officer dealt with Levi as he felt necessary, and having reviewed his action on the night I believe he was right to do so. Levi was not presenting in such a manner as to justify a detention under section 136 of the Mental Health Act 1983. PC ████████ did actually report the incident by updating it onto the Force Command and Control system. All reported incidents attended are updated by the officer and are ultimately overseen by the FCR Inspectors who cover that time period. I am satisfied that there was appropriate oversight of PC ████████’s actions on the evening.” Source location 2021-0231-Response-from-Lincolnshire-Police_Published
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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 Frontline officers need not know the Concern for Welfare Policy because it governs Force Control Room processes, not frontline guidance.
Verbatim wording from the response “I am in agreement with you that PC ████████ “...did act appropriately” and, “...went the extra mile” with regards to his actions on the evening with Levi. I would not expect frontline officers to know the detail, nor even the existence of a “Concern for Welfare Policy”. The Policy is designed to document our approach to calls for service through the Force Control Room, rather than as guidance for frontline officers. You will note that Document PD238 was written by Force Control Room (FCR) Inspector ████████ and is annually reviewed by the FCR inspector to ensure that it is still legislatively and ethically compliant. It is not a guidance document for frontline officers.” Source location 2021-0231-Response-from-Lincolnshire-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 Officers need not understand the mental-health proforma data workflow because it does not affect care; existing training and administrator checks suffice.
Verbatim wording from the response “I would not expect DS ████████ to know what happens to the mental health proforma once completed. Officers are trained (see below) to understand that the mental health proforma provides a statistical return that is used by the Home Office and other stakeholders to understand the local data for mental health policing. It is not a referral mechanism. We do have an administrator who checks against our incidents to ensure that mental health proforma have been completed when required. Understanding the mechanics of the workflow of this statistical submission would not contribute to officers’ work “on the ground”.” Source location 2021-0231-Response-from-Lincolnshire-Police_Published
Open published response
25 Feb 2016 David Palmer · Prevention of Future Deaths report South Lincolnshire
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Concerns raised 1 Lack of secure storage of unlicensed firearms 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
David Palmer · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Palmer, aged 59, died from a massive head injury caused by an unlicensed shotgun. The report notes that unlicensed firearms are generally not stored securely and may be available for impulsive use, and states that three of four firearm deaths investigated involved unlicensed weapons.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of secure storage of unlicensed firearms
Wider context from the report “In the three and a half years I have investigated 4 deaths resulting from self-inflicted firearm wounds. Three of those involved unlicensed weapons. These weapons are generally not stored securely and are thus available for impulsive use .
” Open source report
4 Jan 2016 Mark Anthony Holdsworth · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 1 Failure to communicate recent suicide threat information to arresting and custody staff 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
Mark Anthony Holdsworth · 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
Mark Anthony Holdsworth was released from police custody at 00.26 hrs on 23 January 2015 and was later struck by a freight train after being laid on the railway line between Lincoln and Doncaster. The report states that he had recently threatened to kill himself, but this information was not brought to the attention of the arresting officers or custody staff before his release. The investigation concluded that he took his life.
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 Lincolnshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate recent suicide threat information to arresting and custody staff
Wider context from the report “Shortly prior to his arrest, other officers took the complainant and her mother to Spring Lodge for an ABE/WVI interview. On route, ████████ Mother ████████ told the officers that Mr Holdsworth had said he would 'kill himself if released' This information was, I am told, later added to the incident log but was not drawn to the attention of either the arresting officers or the custody staff or Custody Sergeant.
There is not criticism of the risk assessment procedure undertaken by the custody staff when Mr Holdsworth was booked in at Lincoln station but it's clear that they lacked the significant information that Mr Holdsworth had very recently threatened to kill himself.
I am not sure what time the incident log was updated (I have not seen it) but I appreciate that it is impracticable to suggest that custody staff examine incident logs regularly because of the pressure of time and work.
” 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