25 Nov 2022 Philip John BATTLE · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 4 Unavailability of commissioned mental-health crisis intervention resources View source Failure of ambulance triage to identify a person who could check the caller’s safety View source Failure of ambulance triage to assess presenting mental-health and self-harm risks View source Failure of ambulance, police and health services to coordinate and share mental-health crisis intervention resources View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Philip John BATTLE · 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
Philip John Battle died by suicide on 8 July 2022 after contacting the ambulance service about an overdose and an attempted hanging. The report raised concerns that the ambulance triage process focused on physical health rather than immediate mental-health and self-harm risks, and that no attempt was made to contact someone who could check on his safety. It also identified limited coordination and shared mental-health crisis resources between ambulance, police and health services.
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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of commissioned mental-health crisis intervention resources
Wider context from the report “Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety. Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative. Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.
” 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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance triage to identify a person who could check the caller’s safety
Wider context from the report “Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety . Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative . Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.
” 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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance triage to assess presenting mental-health and self-harm risks
Wider context from the report “Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety. Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative. Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.
” 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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance, police and health services to coordinate and share mental-health crisis intervention resources
Wider context from the report “Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety. Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative. Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.
” Open source report
15 Jun 2020 Grant Alexander Macdonald · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Unsafe junction for cars crossing the carriageway to the central reservation to carry out a turn manoeuvre 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
Grant Alexander Macdonald · 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
Grant Alexander Macdonald, aged 27, died on 19 August 2019 after suffering significant injuries in a motorcycle collision with a Mercedes on Hornby Road, Liverpool. Concerns were raised that the junction was unsafe, particularly for vehicles crossing the carriageway to turn, and that there had been a number of collisions there.
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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Unsafe junction for cars crossing the carriageway to the central reservation to carry out a turn manoeuvre
Wider context from the report “In this case there were a number of contributory factors to the collision, including the manner in which the motorcycle was being driven and the speed at which it had been driven, however, issues were raised at the inquest by the family and Merseyside Police suggestive of the fact that the junction is unsafe and that there have been a number of collisions at that junction. There is concern it is unsafe for a car to go across the carriageway to the central reservation to carry out a turn manoeuvre . The Court would request the Council to review the safety of this junction.
” 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 Existing engineering measures, signage, road markings and physical infrastructure did not contribute to the fatal collision.
Verbatim wording from the response “It is our Highways Engineer’s opinion, that no engineering measures, signage, lines or physical infrastructure currently in place, or lack thereof, contributed to this fatal collision.” Source location 2020-0131-Response-from-Liverpool-City-Council_Redacted.pdf
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 Closing the central-reservation gaps is not justified at present because collision numbers are relatively low and closure could create further safety and access problems.
Verbatim wording from the response “Of these, 4 collisions involved vehicles performing U-turns. 2 were at the gap in the central reservation at the main MHP Walton car park entrance to the west of Hornby Close (in 2010 and 2012), 1 was at the gap in the central reservation at Hornby Place (in 2018), and the other was the fatal collision at the gap in the central reservation at the service road leading to Walton train station in 2019.” Source location 2020-0131-Response-from-Liverpool-City-Council_Redacted.pdf
Open published response
29 Mar 2017 John Clarke Jaundoo · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 7 Failure to perform regular and timely validation visits View source Failure to refer or admit high risk offenders only to accommodation capable of appropriately managing their risks View source Failure to exercise influence and oversight over supported living accommodation and probation services View source Failure to provide timely, accurate and up to date offender information View source Failure to verify procedures for effective service delivery and public protection View source Failure to review and revise risk assessments dynamically View source Failure to recall offenders to prison or prevent referral to unsuitable supported living accommodation View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Clarke Jaundoo · 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
John Clarke Jaundoo, aged 24, was found with multiple stab wounds under Garston Bridge in the early hours of 15 April 2010 and died later in hospital. Three men who lived in the same supported living accommodation were subsequently convicted of his murder, and the inquest concluded that he died as a result of unlawful killing. The inquiry identified concerns about the referral and accommodation of high-risk offenders, failures to provide accurate and up-to-date information and review risk assessments, and missed oversight opportunities by Liverpool City Council.
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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to perform regular and timely validation visits
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” 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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to refer or admit high risk offenders only to accommodation capable of appropriately managing their risks
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises .
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” 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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to exercise influence and oversight over supported living accommodation and probation services
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust , they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” 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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely, accurate and up to date offender information
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” 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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to verify procedures for effective service delivery and public protection
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority .
” 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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to review and revise risk assessments dynamically
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation, it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” 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 Liverpool City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recall offenders to prison or prevent referral to unsuitable supported living accommodation
Wider context from the report “In respect of the then Probation Trust
(1) Offender 2 should have been recalled to prison and not referred to or accepted into supported living accommodation , it was wholly unsuitable for him and in particular when his behaviour was deteriorating to such an extent in the Approved Premises that his bed was withdrawn.
(2) Offender 3 a high risk offender should never have been referred to or admitted to supported living accommodation (upon his release from prison), the only suitable accommodation where the risks that he posed could be appropriately managed being Approved Premises.
(3) Timely, accurate and up to date information was not provided in respect of offenders 2 & 3 and;
(4) The risk assessment which should have been a dynamic process was not reviewed/revised in particular as it should have been in respect of offender 2 when his behaviour started to deteriorate so substantially and which also included alcohol consumption a known precursor to his offending.
In respect of Liverpool City Council (Adult Social Services)
(1) Missed a number of significant opportunities to properly exercise their influence and oversight function of both the then supported living accommodation provider and the Probation Trust, they also missed opportunities to perform regular, timely validation visits and to satisfy themselves of the procedures that were in place to ensure the aims of the service were being effectively delivered and that public protection (including of staff and other service users) was the overriding priority.
” 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