5 Dec 2024 Mazeedat Adeoye · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Inadequate supervision of social workers View source Failure to properly record the rationale for critical NRPF decisions View source Failure to communicate observed heat signatures during searches View source Culture tolerating unprofessional and antagonistic behaviour towards vulnerable people View source Failure to oversee arbitrary decisions made by junior staff View source Failure to periodically review social workers’ caseloads View source Failure to constrain inappropriate behaviour within the NRPF team View source Failure to appropriately assess heat signatures during searches View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mazeedat Adeoye · 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
Mazeedat Adeoye, a two-year-old girl, drowned on 29 January 2022 after falling into a water-filled plastic refuse bin while playing alone and inadequately supervised in a volunteer carer’s garden. The report identifies concerns about failures by local authority child services to arrange appropriate temporary care, as well as concerns regarding police search procedures, social-worker conduct and supervision, and inadequate record-keeping.
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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of social workers
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised , and their caseloads were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record the rationale for critical NRPF decisions
Wider context from the report “4. Inadequate standards of note-keeping meant that the rationale for critical decisions made by the NRPF were not properly recorded . The absence of clear records diminished both communication within the team and accountability.
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate observed heat signatures during searches
Wider context from the report “1. NPAS helicopter resources were utilised in the search for Mazeedat on 29th January 2022. At 16.40, a small circular heat signature was observed by a tactical flight officer within the garden where Mazeedat’s body was ultimately located. The shape and size of the object meant that the object was “discounted” in the search and its presence was not communicated to anyone . Mazeedat was discovered 11 minutes later by a police dog unit on the ground. Whereas the delay in locating Mazeedat did not contribute to her tragic death, the decision to discount such a heat signature could, in another case, amount to a risk of fatal harm.
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Culture tolerating unprofessional and antagonistic behaviour towards vulnerable people
Wider context from the report “2. The Adeoye family interactions with the local authority, child services team were characterised by unprofessional behaviour from social workers . A culture existed within the team that tolerated and therefore encouraged overtly antagonistic behaviour towards vulnerable people . Should this hostile environment continue to be enabled, sub-optimal care outcomes will result with an ongoing risk of fatal harm.
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Failure to oversee arbitrary decisions made by junior staff
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised, and their caseloads were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked .
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Failure to periodically review social workers’ caseloads
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised, and their caseloads were not periodically reviewed . The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Failure to constrain inappropriate behaviour within the NRPF team
Wider context from the report “3. The NRPF team was poorly managed. Social workers were not adequately supervised, and their caseloads were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately assess heat signatures during searches
Wider context from the report “1. NPAS helicopter resources were utilised in the search for Mazeedat on 29th January 2022. At 16.40, a small circular heat signature was observed by a tactical flight officer within the garden where Mazeedat’s body was ultimately located. The shape and size of the object meant that the object was “discounted” in the search and its presence was not communicated to anyone. Mazeedat was discovered 11 minutes later by a police dog unit on the ground. Whereas the delay in locating Mazeedat did not contribute to her tragic death, the decision to discount such a heat signature could, in another case, amount to a risk of fatal harm.
” 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 NPAS training and operational practices to identify improvements supporting future search safety.
Verbatim wording from the response “Whilst acknowledging that the delay in locating Mazeedat did not contribute to her tragic death, I fully accept that our training and operational practices require a review to ensure that future deaths are prevented wherever possible. In coming to my decisions I have liaised with ████████, Head of Flight Operations, ████████, Tactical Flight Officer and technical SME, ████████, Training and Quality Standards Manager and ████████, Regional Operations Manager. There is a large breadth of knowledge and experience between these staff members, both in wider aviation and policing.” Source location Response from National Police Air Service
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 Incorporate the incident footage as a case study and training tool in the next NPAS training course.
Verbatim wording from the response “I will however utilise this footage as a case study / training tool for NPAS that may give perspective to search scenarios moving forward. Should a situation present itself in a similar way it may cause a TFO to think beyond the info / intel where time and circumstances allow. This will be incorporated from the next training course that commences on 14th February.” Source location Response from National Police Air Service
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 Investigating every heat source on every incident is impracticable and could be counterproductive by causing delays that contribute to future deaths.
Verbatim wording from the response “Moving forwards, to investigate every heat source on every incident would not be practicable and may be counter productive, leading to delays that could also contribute to future deaths. There will always be a balance to be maintained.” Source location Response from National Police Air Service
Open published response
8 Jun 2023 Ivan Rumenov Ignatov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Insufficient guidance for custody sergeants assessing detainee risk View source Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services View source Inaccessibility of post-release detainee information due to language or literacy barriers View source Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system View source Lack of guidance for releasing detainees without an address to reside at View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ivan Rumenov Ignatov · 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
Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for custody sergeants assessing detainee risk
Wider context from the report “ii. There is not sufficient guidance given to custody sergeants on a national basis of how to assess a person’s risk .
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
Wider context from the report “iv. There is a lack of knowledge and/or understanding amongst emergency services and search and rescue services, especially around terminology, process and communication for them to be able to work together when an incident arises without confusion or misunderstanding arising . I would request that consideration is given to further national and local training or guidance across emergency and search and rescue services to ensure communication can be facilitated without delay, and ensure terms and processes are understood to avoid any doubt of what action is being taken when an incident is ongoing.
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of post-release detainee information due to language or literacy barriers
Wider context from the report “v. Leaflets given to detainees when released from police custody are not always accessible due to language or literacy barriers and I would request that consideration is given nationally by NHS England and all Police Forces to ensure that any documentation detainees, especially any providing help and assistance, is accessible to them.
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Insufficient identification, collation and recording of factors increasing detainee risk on the Niche system
Wider context from the report “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or others .
” 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 National Police Air Service; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for releasing detainees without an address to reside at
Wider context from the report “iii. There is no guidance, that I am aware of, which addresses what should be done by police forces, and particularly custody sergeants, when a person is to be released without an address to reside at and I would request consideration is given to such guidance being provided.
” 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 Hold joint familiarisation briefings for all NPAS and HMCG staff, including communications teams.
Verbatim wording from the response “• A series of joint familiarisation briefings to be held between HMCG and NPAS - this will encompass all staff to ensure corporacy across both organisations and to reflect the fact that as a National Service, there may be occasions when landlocked bases do have to respond to incidents involving HMCG/ Water rescue. It will also include the Comms departments of both agencies.” Source location Response from National Police Air Service
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 Consider extending familiarisation briefings to relevant force communications teams and approach the RNLI about equivalent engagement.
Verbatim wording from the response “• This familiarisation briefing will be considered for roll-out to Comms element of Forces where water-based rescue is frequent i.e.; South Coast, North Yorkshire, Northumberland, Lancashire to ensure they have awareness of each agency and capabilities of each. An approach for the same to be made to the RNLI.” Source location Response from National Police Air Service
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 Hold monthly communications meetings between NPAS and HMCG operations-centre leads to debrief notable incidents and assess lessons learned.
Verbatim wording from the response “• Monthly Comms meetings to be held between Head of Ops Centre/ Equivalent HMCG staff member to de-brief incidents of note and assess lessons learnt.” Source location Response from National Police Air Service
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 Develop and distribute a joint quick-action card prioritising establishment of an Emergency Services Airwave channel, with national partners asked to support dissemination.
Verbatim wording from the response “• Work to be commenced to develop a joint "quick action card" which will be distributed to all Forces and which prioritises the need for the Host Force ( in this case Dorset Police) to set an Emergency Services channel on Airwave which would allow early communication. We will be asking for Chief Coastguard and NPCC assistance to push this course of action.” Source location Response from National Police Air Service
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Home Force, rather than NPAS, should open the Emergency Services channel to enable communication between the relevant emergency services.
Verbatim wording from the response “The second actions related to Section 5 subsection 2 part vi of the report and concentrated on the communication between the relevant emergency services. In brief, the home force, NPAS and HMCG all have access to Airwave and an Emergency Services channel should have been opened by the Home Force. This would have allowed the 3 services to communicate easily and is covered by the JESIP principles for matters of this type. RNLI do not have Airwave but have access to VHF which the HMCG also has so they are able to communicate in this way.” Source location Response from National Police Air Service
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 RNLI and HMCG can communicate using VHF, so RNLI’s lack of Airwave access does not prevent communication by existing arrangements.
Verbatim wording from the response “The second actions related to Section 5 subsection 2 part vi of the report and concentrated on the communication between the relevant emergency services. In brief, the home force, NPAS and HMCG all have access to Airwave and an Emergency Services channel should have been opened by the Home Force. This would have allowed the 3 services to communicate easily and is covered by the JESIP principles for matters of this type. RNLI do not have Airwave but have access to VHF which the HMCG also has so they are able to communicate in this way.” Source location Response from National Police Air Service
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations