5 Nov 2021 Katrina Makunova · Prevention of Future Deaths report Inner South London
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Concerns raised 4 Failure to consistently record knife possession View source Failure to recognise knife possession in risk assessments View source Failure to investigate and identify gang affiliation as a risk factor View source Insufficient Child Safety Unit workforce capacity to fulfil safeguarding responsibilities safely View source See 1 more concern
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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
Katrina Makunova · 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
Katrina Makunova had experienced abuse, coercive and controlling behaviour, and threats before she was fatally pushed by her ex-boyfriend on 12 July 2018. The report identified concerns about knives and gang affiliation not being consistently recognised or recorded as risk factors, and about workload pressures affecting the capacity of police Child Safety Units to carry out safeguarding effectively and safely.
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 Mayor's Office for Policing and Crime; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently record knife possession
Wider context from the report “Concern 1:
Whilst significant steps have been taken to recognize contextual abuse by all the organizations since the death, there remains a concern. Police officers knew of the perpetrator’s wearing of a knife. Possession of a knife was not recognized in risk assessments and not always recorded by police, nor social services . It was also unclear from police evidence when gang affiliation should be explored and when it would be recognized as a risk. Those around Katrina, knew of her past and present association with gang members; yet this too never seems to have been investigated and identified by police as a risk factor. Evidence was heard from her brother and another witness that her fear of what harm the might do led her not to make a full disclosure of his controlling behaviour to the police.
” 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 Mayor's Office for Policing and Crime; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise knife possession in risk assessments
Wider context from the report “Concern 1:
Whilst significant steps have been taken to recognize contextual abuse by all the organizations since the death, there remains a concern. Police officers knew of the perpetrator’s wearing of a knife. Possession of a knife was not recognized in risk assessments and not always recorded by police, nor social services. It was also unclear from police evidence when gang affiliation should be explored and when it would be recognized as a risk. Those around Katrina, knew of her past and present association with gang members; yet this too never seems to have been investigated and identified by police as a risk factor. Evidence was heard from her brother and another witness that her fear of what harm the might do led her not to make a full disclosure of his controlling behaviour to the police.
” 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 Mayor's Office for Policing and Crime; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate and identify gang affiliation as a risk factor
Wider context from the report “Concern 1:
Whilst significant steps have been taken to recognize contextual abuse by all the organizations since the death, there remains a concern. Police officers knew of the perpetrator’s wearing of a knife. Possession of a knife was not recognized in risk assessments and not always recorded by police, nor social services. It was also unclear from police evidence when gang affiliation should be explored and when it would be recognized as a risk. Those around Katrina, knew of her past and present association with gang members; yet this too never seems to have been investigated and identified by police as a risk factor . Evidence was heard from her brother and another witness that her fear of what harm the might do led her not to make a full disclosure of his controlling behaviour to the police.
” 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 Mayor's Office for Policing and Crime; that does not assign responsibility.
PFD Monitor interpretation Insufficient Child Safety Unit workforce capacity to fulfil safeguarding responsibilities safely
Wider context from the report “Concern 2:
The workload pressures in the Child Safety Units of the MPS were considerable and cited by officers who had been disciplined as reasons for some failures. However data presented to the court by the MPS did not reassure that the MPS would be able to establish a CSU workforce of sufficient capacity to enable officers to fulfil their safeguarding role effectively and safely .
” Open source report
26 Feb 2021 Mr Joseph Agnew · Prevention of Future Deaths report Inner South London
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Concerns raised 6 Failure to recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness View source Failure to train officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable” View source Failure of post-incident performance review and organisational learning processes View source Failure to train officers on when to refer an intoxicated person for medical attention View source Lack of a safe referral facility for acutely intoxicated homeless people found on buses View source Failure to train officers to effectively monitor breathing and recognise dangerous breathing patterns View source See 3 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.
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AI-generated summary
Mr Joseph Agnew · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Joseph Agnew suffered an out-of-hospital cardiac arrest after being removed from a bus and left in a bus shelter, was later found unresponsive, and died five days after admission with a devastating brain injury. The report raised concerns about police training and assessment of intoxicated people with reduced responsiveness, including recognising snoring and monitoring breathing, post-incident learning, and the lack of a safe referral facility for acutely intoxicated homeless people found on buses.
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 Mayor's Office for Policing and Crime; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness
Wider context from the report “2. For the attention of CoLP, MPS and College of Policing:
No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness , nor how to monitor breathing. My independent expert in A&E gave evidence that snoring indicates partial airway obstruction . He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention . The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing. He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing.
” 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 Mayor's Office for Policing and Crime; that does not assign responsibility.
PFD Monitor interpretation Failure to train officers to assess whether an intoxicated person meets the criteria for being “drunk and incapable”
Wider context from the report “1. For the attention of CoLP and College of Policing:
CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable” . A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention.
” 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 Mayor's Office for Policing and Crime; that does not assign responsibility.
PFD Monitor interpretation Failure of post-incident performance review and organisational learning processes
Wider context from the report “3. For the attention of the MPS:
Two MPS officers who attended the scene gave evidence that they would do nothing different even in hindsight. No evidence was presented as to the post incident performance reviews and individual learning , and there is uncertainty about the adequacy of the corporate process of learning from incidents . There is a lack of assurance to the public that the risks related to the decisions of these officers or other incidents have been mitigated for the future .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mayor's Office for Policing and Crime; that does not assign responsibility.
PFD Monitor interpretation Failure to train officers on when to refer an intoxicated person for medical attention
Wider context from the report “1. For the attention of CoLP and College of Policing:
CoLP officers were not taught how to assess people to meet the agreed criteria for finding someone “drunk and incapable”. A senior officer was not content that the officers involved had given a satisfactory level of questioning nor welfare checks. The risk to life continues since there appears to be no clarity for officers from their training as to when to refer an intoxicated person for medical attention .
” 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 Mayor's Office for Policing and Crime; that does not assign responsibility.
PFD Monitor interpretation Lack of a safe referral facility for acutely intoxicated homeless people found on buses
Wider context from the report “4. For the attention of the Mayor of London:
Evidence was heard that whilst the police can refer chronic rough sleepers to charities, there is no facility to which police can refer acutely intoxicated homeless people found on buses . It was reported that such facilities do exist elsewhere and that they create a place of safe refuge where monitoring can be effectively conducted. The potential of such a facility to save lives is drawn to the attention of the Mayor.
” 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 Mayor's Office for Policing and Crime; that does not assign responsibility.
PFD Monitor interpretation Failure to train officers to effectively monitor breathing and recognise dangerous breathing patterns
Wider context from the report “2. For the attention of CoLP, MPS and College of Policing:
No police officers who gave evidence understood the significance of snoring in a person with a reduced level of consciousness, nor how to monitor breathing . My independent expert in A&E gave evidence that snoring indicates partial airway obstruction. He dismissed perceptions of officers that there was such a thing as good or bad snoring. He opined that in a person with reduced consciousness officers should assume that snoring needs medical attention. The person needs assessment to exclude when it is not a concern. Whilst he acknowledged the difficulty of assessing breathing, he stressed its importance as an indication of medical emergency, gave little weight to the value of chest movements which officers used, and highlighted the danger signs of very slow or very fast breathing . He also stressed that concern for medical attention should be triggered by unrousability. The evidence suggested that officers were unaware of all these matters and had not learnt how to effectively monitor breathing .
” 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