Recipient

Merseyside Police

First report 15 Jun 2020•Latest report 8 Dec 2023

Recipient record

Reports, concerns and published responses

Policing · Police force. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 5
Published responses: 60%
Concerns addressed: 4
Stated actions: 14

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

60%published responses found

14stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Merseyside Police linked to the concerns in each report. Select any concern, action or position to view the source wording.

8 Dec2023
Manchester South
Concerns raised2
1. Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
2. Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
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

Claire Nicole Briggs · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.

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 Merseyside Police; that does not assign responsibility.
PFD Monitor interpretation
Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses
Wider context from the report
“The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022. Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved. Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Merseyside Police; that does not assign responsibility.
PFD Monitor interpretation
Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service
Wider context from the report
“The evidence I heard was that a Joint Operating Protocol between the North West Ambulance Service and the five regional police forces designed to address the issues of which emergency service should take responsibility for incidents involving drug overdoses and the method by which the police officers attending such incidents prior to the arrival of the ambulance service can escalate their concerns over a person suspected to have taken a drug overdose, was in an advanced stage of completion, but was stalled in July 2022. Whilst I heard that discussions have recently recommenced, they now encompass the Right Care, Right Person model, the findings of the Manchester Arena Bombing Enquiry and that additionally, the Fire and Rescue Service and the British Transport Police have now become involved. Pending agreement of a Joint Operating Protocol, there does not appear to be any consistent and reliable understanding in place across the police forces and the North West Ambulance Service to provide clarity as to the roles of the respective services and the method by which concerns about individual patients can be escalated to the ambulance service by police officers dealing with those who are suspected to have taken drug overdoses. ”
Open source report
8 Mar2023
Plymouth, Torbay and South Devon
Concerns raised3
1. Failure to condition firearms licensing delegation on adequate training
2. Absence of a mandatory requirement for role-specific firearms licensing training
3. Lack of nationally accredited training for firearms licensing staff
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Complete nationally recognised training for all firearms enquiry officers.
  Stated completed
2. Action
  Enrol all firearms licensing staff in Mowbray Partners’ online training.
  Stated completed
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 Merseyside 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 Merseyside 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 Merseyside 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
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
Complete nationally recognised training for all firearms enquiry officers.

Verbatim wording from the response
“In terms of training and continuous professional development, all Merseyside Police Firearms Enquiry Officers have completed the nationally recognised training package delivered by South Yorkshire Police. Furthermore, all staff are enrolled on the online training offered by Mowbray Partners. I welcome the recommendation that all Firearms Licensing staff are appropriately accredited.”

Source location
Response from Merseyside Police
Page 1 · response
Published 10 March 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Enrol all firearms licensing staff in Mowbray Partners’ online training.

Verbatim wording from the response
“In terms of training and continuous professional development, all Merseyside Police Firearms Enquiry Officers have completed the nationally recognised training package delivered by South Yorkshire Police. Furthermore, all staff are enrolled on the online training offered by Mowbray Partners. I welcome the recommendation that all Firearms Licensing staff are appropriately accredited.”

Source location
Response from Merseyside Police
Page 1 · response
Published 10 March 2023
Open published response
25 Nov2022
Liverpool and the Wirral
Concerns raised4
1. Unavailability of commissioned mental-health crisis intervention resources
2. Failure of ambulance triage to identify a person who could check the caller’s safety
3. Failure of ambulance triage to assess presenting mental-health and self-harm risks
1. Failure of ambulance, police and health services to coordinate and share mental-health crisis intervention resources
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review and assess NWAS interoperability models and relevant best practice when establishing and evaluating the mental-health triage service.
  Stated completed
Respondent positions 1
1. Position
  Existing separate police and NWAS cars are considered more effective than joint operability for Merseyside communities.
  Existing arrangements considered sufficient
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 Merseyside Police; 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 Merseyside Police; 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 Merseyside Police; 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 Merseyside Police; 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
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review and assess NWAS interoperability models and relevant best practice when establishing and evaluating the mental-health triage service.

Verbatim wording from the response
“Merseyside Police when setting up this service and indeed though review of the service and best practice, have looked at and considered inter-operability models with NWAS, however, they are not considered within this area to be the best use of personnel, as effectively it would lead to a vehicle crewed by three personnel, one of whom would almost always be surplus to requirements and indeed I would suggest that there will be more resource available if the current model is maintained.”

Source location
Response from Meryside Police
Page 2 · response
Published 28 November 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing separate police and NWAS cars are considered more effective than joint operability for Merseyside communities.

Verbatim wording from the response
“Merseyside Police when setting up this service and indeed though review of the service and best practice, have looked at and considered inter-operability models with NWAS, however, they are not considered within this area to be the best use of personnel, as effectively it would lead to a vehicle crewed by three personnel, one of whom would almost always be surplus to requirements and indeed I would suggest that there will be more resource available if the current model is maintained.”

Source location
Response from Meryside Police
Page 2 · response
Published 28 November 2022
Open published response
4 Mar2022
Liverpool and the Wirral
Concerns raised2
1. Failure to conduct five-minute observations at frequent but unpredictable times
2. Inadequate recording of individual five-minute observations
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

Sarah-Louise Jennifer Doyle · 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

Sarah-Louise Jennifer Doyle, aged 19, was found hanging in her room while detained under the Mental Health Act and subject to five-minute observations. She was taken to hospital but died at 01:40 on 27 February 2022; concerns were raised that observations were recorded at predictable times and may not have been precise.

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 Merseyside Police; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct five-minute observations at frequent but unpredictable times
Wider context from the report
“On a review of the five minute observations these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc. It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations. The observations were covered by one signature with a downward arrow. In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations. ”
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 Merseyside Police; that does not assign responsibility.
PFD Monitor interpretation
Inadequate recording of individual five-minute observations
Wider context from the report
“On a review of the five minute observations these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc. It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations. The observations were covered by one signature with a downward arrow. In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations. ”
Open source report
15 Jun2020
Liverpool and the Wirral
Concerns raised1
1. Unsafe junction for cars crossing the carriageway to the central reservation to carry out a turn manoeuvre
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

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 Merseyside Police; 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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Lack of consistent and reliable understanding of respective emergency service roles for suspected drug overdoses

Lack of a consistent and reliable method for police escalation of suspected drug overdose concerns to the ambulance service

Concerns raised3

Failure to condition firearms licensing delegation on adequate training

Absence of a mandatory requirement for role-specific firearms licensing training

Lack of nationally accredited training for firearms licensing staff

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised4

Unavailability of commissioned mental-health crisis intervention resources

Failure of ambulance triage to identify a person who could check the caller’s safety

Failure of ambulance triage to assess presenting mental-health and self-harm risks

Failure of ambulance, police and health services to coordinate and share mental-health crisis intervention resources

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Concerns raised2

Failure to conduct five-minute observations at frequent but unpredictable times

Inadequate recording of individual five-minute observations

Concerns raised1

Unsafe junction for cars crossing the carriageway to the central reservation to carry out a turn manoeuvre

Actions described in response 2

Actions described in response 1

Respondent positions 1