1 May 2026 Natasha Hill · Prevention of Future Deaths report Inner South London
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Concerns raised 7 Limited national dissemination of local safeguarding protocols View source Failure to formally review safeguarding, domestic violence or controlling or coercive behaviour risks affecting teenagers approaching 18 View source Lack of consistent criteria and central guidance for safeguarding offender management functions View source Lack of specific protection for young people against adults creating safeguarding risks View source Lack of one single national policy for policing and child sexual exploitation View source Lack of guidance on missing persons, runaways and return-to-home interviews View source Lack of a young person's team covering transition from under-18 services to adult safeguarding teams View source See 4 more concerns
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AI-generated summary
Natasha Hill · 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
Natasha Hill, who had been in care and was experiencing grooming, exploitation, self-harm, substance misuse and domestic violence, was pronounced dead at her abuser’s home in the early hours of 15 April 2018. The jury concluded that she was unlawfully killed by her abuser. The report raised concerns about safeguarding during the transition to adulthood, protection from exploitation and domestic abuse, and coordination of relevant policing and safeguarding policies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Limited national dissemination of local safeguarding protocols
Wider context from the report “• To consider the wider dissemination of existing local protocols nationally , for example the London Exploitation Protocol.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to formally review safeguarding, domestic violence or controlling or coercive behaviour risks affecting teenagers approaching 18
Wider context from the report “• Anyone requiring/needing/suffering
o Safeguarding
o Domestic violence
o Controlling/ coercive behaviour
And incurring the consequential risks, as a teenager approaching 18 should be formally reviewed by an adult safeguarding team ad the independent reviewing officer .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent criteria and central guidance for safeguarding offender management functions
Wider context from the report “• Re safeguarding offender management, the use of VOO's and the creation of POETs/ DAPST and RMUs: consideration should be given to the creation of one set of criteria with one name whose role it is to cover and create a central guidance .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of specific protection for young people against adults creating safeguarding risks
Wider context from the report “• Thought should be given to the creation of a young person's protection by way of creation of an extension to the CAWN for the young person, against the adult creating that safeguarding risk e.g. young person's abuse warning notice.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of one single national policy for policing and child sexual exploitation
Wider context from the report “• The creation of one single national policy for policing and child sexual exploitation following the groundwork laid down by Operation Hydrant and local Forces.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on missing persons, runaways and return-to-home interviews
Wider context from the report “• The provision of guidance in respect of missing persons/ runaways and the return to home interviews to assist the actions of the police and local councils.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a young person's team covering transition from under-18 services to adult safeguarding teams
Wider context from the report “• Thought should be given to creating a young person's team covering the transition from under 18 (MACE) to adult safeguarding teams e.g. For the period 18-22 .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request additional transition-to-adulthood wording in the College of Policing Child Abuse Authorised Professional Practice draft.
Verbatim wording from the response “We have taken an urgent review of the Child Abuse Authorised Professional Practice that is currently out for consultation through the College of Policing. There is much within the draft APP that aligns with transitional safeguarding principles, particularly its emphasis on vulnerability, exploitation, coercion and control, trauma informed practice, professional curiosity, information sharing and avoiding victim blaming. However a gap has been identified relating to transition to adulthood, and we have requested that additional wording is included. You can find the consultation here until 4th August 2026: Child abuse APP – have your say | College of Policing.” Source location Response from National Police Chiefs Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the College of Policing Child Abuse Authorised Professional Practice draft for transition-to-adulthood gaps.
Verbatim wording from the response “We have taken an urgent review of the Child Abuse Authorised Professional Practice that is currently out for consultation through the College of Policing. There is much within the draft APP that aligns with transitional safeguarding principles, particularly its emphasis on vulnerability, exploitation, coercion and control, trauma informed practice, professional curiosity, information sharing and avoiding victim blaming. However a gap has been identified relating to transition to adulthood, and we have requested that additional wording is included. You can find the consultation here until 4th August 2026: Child abuse APP – have your say | College of Policing.” Source location Response from National Police Chiefs Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote disruption as a safeguarding intervention through NPCC conferences and learning events.
Verbatim wording from the response “conferences and learning events have promoted the use of disruption as a safeguarding intervention, encouraging agencies to move beyond reactive measures and develop coordinated, preventative responses to perpetrators and exploitation networks.” Source location Response from NPCC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The legal framework provides no direct adult equivalent to a CAWN or nationally adopted young person’s abuse warning notice.
Verbatim wording from the response “Child Abduction Warning Notice (CAWN) is, by design, a child protection tool and ceases to apply once the young person reaches 18. The DHR demonstrates how this created a significant safeguarding gap: the risk posed by the perpetrator remained unchanged, but one of the key disruption mechanisms available to agencies fell away when Natasha became an adult.” Source location Response from National Police Chiefs Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No statutory Return Home Interview requirement or exploitation framework automatically continues into adulthood.
Verbatim wording from the response “For children, Return Home Interviews (RHIs) are a key safeguarding intervention. They provide an opportunity to understand why a child went missing, whether exploitation or abuse has occurred, what support is required and what action should be taken to prevent further harm. The information gathered should inform safeguarding planning, disruption activity and multi-agency risk management.” Source location Response from NPCC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No equivalent adult protection notice to a CAWN or nationally adopted young person's abuse warning notice currently exists within the divided legal framework.
Verbatim wording from the response “Child Abduction Warning Notice (CAWN) is, by design, a child protection tool and ceases to apply once the young person reaches 18. The DHR demonstrates how this created a significant safeguarding gap: the risk posed by the perpetrator remained unchanged, but one of the key disruption mechanisms available to agencies fell away when Natasha became an adult.” Source location Response from NPCC
Open published response
23 Apr 2026 Thomas Alexander Ferdinand MAYHEW (known as Ned) · Prevention of Future Deaths report East Sussex
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Concerns raised 1 Delays in routing emergency calls concerning apparently deceased persons to ambulance services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Thomas Alexander Ferdinand MAYHEW (known as Ned) · 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 6 May 2024, 16-year-old Ned Mayhew was found hanging in a wooded area after leaving school and was taken to hospital, where his death was confirmed on 9 May 2024 following brain stem testing. The principal concern was that routing an emergency call reporting an apparently deceased person to the police before the ambulance service may result in valuable minutes being lost during the limited period in which treatment might prevent death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Delays in routing emergency calls concerning apparently deceased persons to ambulance services
Wider context from the report “I heard expert evidence from a Consultant Intensive Care Physician, who explained that there is a limited window of time (approximately ten minutes) during which emergency life-saving treatment can be provided to a person who has applied a ligature, such that cerebral hypoxia may be prevented. Cerebral hypoxia, if not reversed, may ultimately lead to cardiac arrest and death. The expert confirmed that if medical intervention is delivered within this critical period, death may be prevented.
The expert further confirmed that a person who has applied a ligature may appear deceased to an observer, for example, displaying no movement and being unconscious, while nevertheless remaining within that ten-minute window during which the outcome may still be altered.
I also heard evidence regarding the Public Emergency Call Service Code of Practice (“PECS”). I was told that where a member of the public contacts emergency services to report the discovery of an apparently deceased person, the call would likely be directed to the police in line with the PECS. In addition, I heard that where a caller is unsure which emergency service they require, the operator must connect the caller to the police, in accordance with a request made by the National Police Chiefs’ Council.
Having considered the expert evidence, I am of the view that in these critical circumstances every second is of importance. The process of routing a caller to the police, who may then refer the matter to the ambulance service and/or instruct an ambulance to attend, carries a risk that valuable minutes may be lost.
” Open source report
30 Mar 2026 Oliver John Roberts · Prevention of Future Deaths report Dorset
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Concerns raised 2 Lack of practical guidance on making communications data applications View source Lack of practical guidance on authorising communications data applications View source
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Oliver John Roberts · 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
Oliver John Roberts was found suspended by a ligature in a wooded area on 28 January 2024, after being reported missing and after communications data had been requested by police. The principal concern was a lack of practical national guidance for police officers on when and how to make communications data requests, including urgent Grade 2 applications; in this case, the Grade 2 request was submitted almost 24 hours after he was reported missing.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of practical guidance on making communications data applications
Wider context from the report “(1) There is a lack of guidance to assist Police Officers in the practical application of their powers to obtain communications data, whether that be under a Grade 1, 2 or 3 application.
(2) Communications data can be obtained by Police forces in England and Wales pursuant to the Investigatory Powers Act 2016 (the Act). In November 2018 the Home Office issued the Communication Data Codes of Practice (the Codes of Practice) which is a document that extends to 144 pages and relates to the exercise of functions conferred by virtue of Parts 3 & 4 of the Act.
(3) Requests are submitted by police representatives to their Communication Data Investigation Teams to access data, and this will be done in different ways depending on the grading of the request.
(4) Grade 1 requests are made when there is an immediate risk to life. Grade 2 requests are made when there is an exceptionally urgent requirement for the prevention or detection of serious crime; a credible and immediate threat to national security; or a serious concern for the welfare of a vulnerable person where urgent provision of the communications data will have an immediate and positive impact on the investigation or operation. Grade 3 requests are made when matters that are not urgent but, where appropriate, will include specific or time-critical issues such as bail dates; court dates; where persons are in custody; or where there is a specific line of investigation into a serious crime and early disclosure by the telecommunications operator or postal operator will directly assist in the prevention or detection of that crime.
(5) Section 5 of Codes of Practice refers to the application process and Section 6 deals with the authorisation of the application, however there is no practical guidance, such as Authorised Professional Practice Guidance, to assist Forces and their officers, as to how and when applications should be made and authorisations should be given.
(6) In this case a Grade 2 application was submitted almost 24 hours after Ollie was reported missing. Once submitted, Ollie was found within 2 hours and 9 minutes. This application was submitted in writing, however evidence was given that in some circumstances a verbal application for a Grade 2 request can be made if the Grade 2 application is urgent. There is a lack of guidance to police officers nationally as to what would constitute a Grade 2 urgent application and what should be done in writing and what should be done verbally.
(7) I am concerned the circumstances of Ollie’s death could occur again as a result of the lack of practical guidance to Police Forces and their staff as to when and how to make data communication requests pursuant to the Investigatory Powers Act 2016 .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of practical guidance on authorising communications data applications
Wider context from the report “(1) There is a lack of guidance to assist Police Officers in the practical application of their powers to obtain communications data, whether that be under a Grade 1, 2 or 3 application.
(2) Communications data can be obtained by Police forces in England and Wales pursuant to the Investigatory Powers Act 2016 (the Act). In November 2018 the Home Office issued the Communication Data Codes of Practice (the Codes of Practice) which is a document that extends to 144 pages and relates to the exercise of functions conferred by virtue of Parts 3 & 4 of the Act.
(3) Requests are submitted by police representatives to their Communication Data Investigation Teams to access data, and this will be done in different ways depending on the grading of the request.
(4) Grade 1 requests are made when there is an immediate risk to life. Grade 2 requests are made when there is an exceptionally urgent requirement for the prevention or detection of serious crime; a credible and immediate threat to national security; or a serious concern for the welfare of a vulnerable person where urgent provision of the communications data will have an immediate and positive impact on the investigation or operation. Grade 3 requests are made when matters that are not urgent but, where appropriate, will include specific or time-critical issues such as bail dates; court dates; where persons are in custody; or where there is a specific line of investigation into a serious crime and early disclosure by the telecommunications operator or postal operator will directly assist in the prevention or detection of that crime.
(5) Section 5 of Codes of Practice refers to the application process and Section 6 deals with the authorisation of the application, however there is no practical guidance, such as Authorised Professional Practice Guidance, to assist Forces and their officers, as to how and when applications should be made and authorisations should be given .
(6) In this case a Grade 2 application was submitted almost 24 hours after Ollie was reported missing. Once submitted, Ollie was found within 2 hours and 9 minutes. This application was submitted in writing, however evidence was given that in some circumstances a verbal application for a Grade 2 request can be made if the Grade 2 application is urgent. There is a lack of guidance to police officers nationally as to what would constitute a Grade 2 urgent application and what should be done in writing and what should be done verbally.
(7) I am concerned the circumstances of Ollie’s death could occur again as a result of the lack of practical guidance to Police Forces and their staff as to when and how to make data communication requests pursuant to the Investigatory Powers Act 2016.
” 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 Individual police forces are responsible for providing suitable risk-based training for staff on communications-data requests.
Verbatim wording from the response “It is also relevant to note that force capabilities vary. For example, West Yorkshire Police operate a 24/7 Communications Data Investigation Unit with an on-duty SPoC at all times, accessible to operational staff. Other forces may still operate on an on-call basis, which can affect local processes but does not alter national legal thresholds. Due to the difference in processes across force areas, each force remains responsible for ensuring that suitable risk-based training is provided for staff. This would be especially true for officers at the rank of Sergeant or Inspector, who would normally undertake a risk assessment and set relevant investigative actions – including the consideration to request communications data.” Source location Response from the National Police Chiefs' Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing operational guidance, statutory codes and specialist advice are considered sufficient to support communications-data grading and urgent authorisation decisions.
Verbatim wording from the response “Points of Contact (SPOCs). These specialists are trained experts in the Investigatory Powers Act 2016 and are best placed to advise whether a Grade 1 or Grade 2 application is appropriate.” Source location Response from the National Police Chiefs' Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The College of Policing leads national policing standards, Authorised Professional Practice and related national guidance and training development.
Verbatim wording from the response “In providing this response, we have worked closely with the College of Policing, who lead in areas such as setting national policing standards, including the provision of Authorised Professional Practice (APP). I will not seek to repeat the information that they have provided to you, other than to support their comments around the training and national guidance that already exists and is readily available to officers and staff. I welcome their ongoing process of developing further training specifically for the communications data SPoC community, focused on fast-time decision-making.” Source location Response from the National Police Chiefs' Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communications-data SPOCs are responsible for deciding grading, urgency and whether applications should be verbal or written.
Verbatim wording from the response “I am not aware of any national guidance that prescribes when an operational officer must submit a communications data request. Decisions regarding grading, urgency, and whether a request should be made verbally or in writing properly sit with communications data SPOCs. In making those decisions, SPOCs are expected to undertake a risk assessment, apply the statutory thresholds, and fully document their decisions and actions.” Source location Response from the National Police Chiefs' Council
Open published response
Concerns raised 2 Failure to implement the STEP campaign across all police forces in England and Wales View source Lack of local and national recording of police officer suicide and attempted-suicide cases during police misconduct investigations View source
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AI-generated summary
Benjamin WEBSDALE · 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
Benjamin Websdale, a serving police officer, died by suicide on 16 January 2025 while under investigation for alleged police misconduct. The report raised concerns about the lack of local or national recording of police suicides or suicide attempts during police misconduct investigations, and about inconsistent implementation of the STEP suicide trauma education and prevention campaign across police forces.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the STEP campaign across all police forces in England and Wales
Wider context from the report “2. Similarly I heard evidence that Police officers are repeatedly exposed to high levels of suicide incidents and trauma yet not all Police forces in England and Wales had implemented the recorded “STEP” campaign (Suicide Trauma Education Prevention) .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of local and national recording of police officer suicide and attempted-suicide cases during police misconduct investigations
Wider context from the report “1. Evidence was heard at the Inquest that there is no local or national recording of cases where police officers have died by suicide or who have attempted suicide whilst under police investigation for an offence of Police Misconduct . Without this information the Police service cannot identify if suicide is more prevalent amongst Police Officers and whether additional measures need to be put in place to support officers who are in this position.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the national Trauma Support Model, including trauma tracking, psychological assessments, and mandatory trauma and suicide prevention training.
Verbatim wording from the response “In relation to the second matter of concern, exposure to suicide is a common occurrence for police officers and many police staff, requiring regular, and on occasion, specialist support. The STEP campaign is supported by the NPCC, but a far more detailed and ambitious national approach is being developed, which all forces are involved in. The Trauma Support Model adopts a more holistic view of trauma and brings together a range of activities and interventions such as trauma tracking using incident data, annual psychological assessments and mandatory trauma prevention and suicide prevention training for new recruits and supervisors.” Source location 2026-0094 - Response from National Police Chiefs Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Approve a requirement for police forces to report a consistent suicide-related dataset to the Chief Medical Officer for policing.
Verbatim wording from the response “The overall issue of police related suicides will be resolved by a requirement to report a consistent data set into the Chief Medical Officer for policing. The paper recommending this change was tabled at Chief Constable’s Council in March 2026, and I am pleased to confirm that this was approved.” Source location 2026-0094 - Response from National Police Chiefs Council
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7 Oct 2025 Ann Sabrina LASKOWSKY · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 4 Lack of dissemination and promotion of the Partner Triage Line to operational police officers View source Lack of clear training on assessing whether a person is responsive or unresponsive View source Lack of specific policy, guidance or training on using the Partner Triage Line View source Lack of clear training on assessing whether a person is breathing normally View source See 1 more concern
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Ann Sabrina LASKOWSKY · 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
Ann Sabrina Laskowsky was found unresponsive at home on 5 October 2024 after police attended when an inactivity alarm was triggered. She was taken to hospital later that day and died on 6 October 2024 from naturally occurring disease contributed to by self-neglect and exacerbated by longstanding alcohol dependence. The principal concerns were the adequacy and clarity of police first-aid training, including recognising abnormal breathing and unresponsiveness, and officers’ knowledge, use and training regarding the Partner Triage Line.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of dissemination and promotion of the Partner Triage Line to operational police officers
Wider context from the report “2. The knowledge, use and training in respect of available resources
In the course of the Inquest, I heard evidence in respect of a resource or service, known as the ’Partner Triage Line’. This is a service which has been provided for a number of years by the Yorkshire Ambulance Service which provides a direct line for police officers to speak to a medical practitioner at the emergency operations centre, to seek advice, with the facility for the Officer to send photographs to the practitioner to help inform their advice and an ability for the practitioner to conduct a live video assessment.
Differing evidence was heard at inquest in terms of the knowledge of individual officers in respect of that service, with one officer being unaware that there was a service or resource.
In the course of my investigation, I received further evidence confirming that the telephone number for the ‘Partner Triage Line’ is visible and accessible in the contact environment and is then sent to officers on request, but that it is not known or promoted to those officers carrying out operational duties , who are those who are likely to need it the most.
I have significant concerns in relation to the knowledge of this valuable resource and its overall lack of use and promotion amongst those Officer who might need it the most. In particular my concerns relate to the following:-
a. The lack of knowledge and use of the service throughout West Yorkshire Police given the lack of dissemination and promotion amongst all of the officers to whom it would be of benefit , providing them with the tools to enable them to properly and effectively carry out their duties; and
b. The lack of specific policy, guidance or training for Officers in respect of how the service can be used to support them in carrying out their duties, enabling them to keep members of the public safe. This is of particular concern, given that the service has now been available for a number of years.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear training on assessing whether a person is responsive or unresponsive
Wider context from the report “1. The adequacy of First Aid Training provided by West Yorkshire Police
The body worn camera footage which was played during the course of the inquest, clearly shows that when the Officers arrived, they found Ann lying slumped on the sofa, appearing pale with an increased respiratory rate. Ann was profoundly unwell and required urgent medical attention.
The attending Officers did not recognise the severity of Ann's condition and instead considered that Ann was asleep but could not be woken. This of itself, raises significant concerns in respect of the nature and adequacy of the training that had been provided to the officers at the time.
Expert evidence received during the course of the Inquest concluded that even if the Officers had sought medical attention when they attended, given the severity of her condition, such treatment would not have prevented her death.
During the course of the Inquest, evidence was received from a variety of sources, in respect of nature and quality of the First Aid Training provided to Officers, in both their initial training and their annual refresher training.
This evidence demonstrated an overwhelming lack of clarity in terms of the way in which officers are trained to assess whether an individual is alive, breathing and conscious , something which it is expected that Officers can assess, in line with their authorised professional practice. The very nature of this evidence was such as to raise significant concerns as to the impact of this training upon the preservation of life.
There were two main areas in which the lack of clarity and consequent inadequacy of training were of particular concern:-
a. The assessment of whether a person is breathing normally and how this is to be assessed; and
b. Whether an individual is responsive or unresponsive, particularly in cases where there may be some involuntary movements from the individuals concerned .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of specific policy, guidance or training on using the Partner Triage Line
Wider context from the report “2. The knowledge, use and training in respect of available resources
In the course of the Inquest, I heard evidence in respect of a resource or service, known as the ’Partner Triage Line’. This is a service which has been provided for a number of years by the Yorkshire Ambulance Service which provides a direct line for police officers to speak to a medical practitioner at the emergency operations centre, to seek advice, with the facility for the Officer to send photographs to the practitioner to help inform their advice and an ability for the practitioner to conduct a live video assessment.
Differing evidence was heard at inquest in terms of the knowledge of individual officers in respect of that service, with one officer being unaware that there was a service or resource.
In the course of my investigation, I received further evidence confirming that the telephone number for the ‘Partner Triage Line’ is visible and accessible in the contact environment and is then sent to officers on request, but that it is not known or promoted to those officers carrying out operational duties, who are those who are likely to need it the most.
I have significant concerns in relation to the knowledge of this valuable resource and its overall lack of use and promotion amongst those Officer who might need it the most. In particular my concerns relate to the following:-
a. The lack of knowledge and use of the service throughout West Yorkshire Police given the lack of dissemination and promotion amongst all of the officers to whom it would be of benefit, providing them with the tools to enable them to properly and effectively carry out their duties; and
b. The lack of specific policy, guidance or training for Officers in respect of how the service can be used to support them in carrying out their duties , enabling them to keep members of the public safe. This is of particular concern, given that the service has now been available for a number of years.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear training on assessing whether a person is breathing normally
Wider context from the report “1. The adequacy of First Aid Training provided by West Yorkshire Police
The body worn camera footage which was played during the course of the inquest, clearly shows that when the Officers arrived, they found Ann lying slumped on the sofa, appearing pale with an increased respiratory rate. Ann was profoundly unwell and required urgent medical attention.
The attending Officers did not recognise the severity of Ann's condition and instead considered that Ann was asleep but could not be woken. This of itself, raises significant concerns in respect of the nature and adequacy of the training that had been provided to the officers at the time.
Expert evidence received during the course of the Inquest concluded that even if the Officers had sought medical attention when they attended, given the severity of her condition, such treatment would not have prevented her death.
During the course of the Inquest, evidence was received from a variety of sources, in respect of nature and quality of the First Aid Training provided to Officers, in both their initial training and their annual refresher training.
This evidence demonstrated an overwhelming lack of clarity in terms of the way in which officers are trained to assess whether an individual is alive, breathing and conscious , something which it is expected that Officers can assess, in line with their authorised professional practice. The very nature of this evidence was such as to raise significant concerns as to the impact of this training upon the preservation of life.
There were two main areas in which the lack of clarity and consequent inadequacy of training were of particular concern:-
a. The assessment of whether a person is breathing normally and how this is to be assessed ; and
b. Whether an individual is responsive or unresponsive, particularly in cases where there may be some involuntary movements from the individuals concerned.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement revised First Aid Learning Programme content mandating assessment of breathing and responsiveness in Learning Outcome 1.3.
Verbatim wording from the response “Whilst the College of Policing are responsible for the Police First Aid Learning Programme, and the quality assurance of the same through their licensing regime, the National Police Chiefs' Council (NPCC) Health, Safety and Welfare portfolio work closely with the College to ensure that the content of the FALP is fit for purpose. A full review of the content was conducted by a panel of doctors and paramedics in 2023 which has been implemented this year, and I can confirm that an assessment of whether a person is breathing and responsiveness levels are mandated in Learning Outcome 1.3. Exactly how this is taught is not mandated nationally to allow for local variations in practice which is determined by each forces' Clinical Governance group with the input of a consultant-level doctor meeting criteria laid down in NPCC guidelines.” Source location Response from National Police Chief's Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nationally standardised teaching methods are not mandated; each force’s clinical governance group determines them with consultant-level medical input.
Verbatim wording from the response “Whilst the College of Policing are responsible for the Police First Aid Learning Programme, and the quality assurance of the same through their licensing regime, the National Police Chiefs' Council (NPCC) Health, Safety and Welfare portfolio work closely with the College to ensure that the content of the FALP is fit for purpose. A full review of the content was conducted by a panel of doctors and paramedics in 2023 which has been implemented this year, and I can confirm that an assessment of whether a person is breathing and responsiveness levels are mandated in Learning Outcome 1.3. Exactly how this is taught is not mandated nationally to allow for local variations in practice which is determined by each forces' Clinical Governance group with the input of a consultant-level doctor meeting criteria laid down in NPCC guidelines.” Source location Response from National Police Chief's Council
Open published response
11 Mar 2025 Marta Elena Vento · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 5 Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release View source Unavailability of National Record Locator access for South West ambulance care in Dorset View source Lack of guidance and tools for assessing violence risk in MOSOVO-managed offenders View source Lack of a process for sharing remanded prisoners’ risk information with sentencing courts View source Lack of practical national guidance for continuity of prisoners’ healthcare on release View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Marta Elena Vento · 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
Marta Elena Vento was working alone as a hotel receptionist in Bournemouth when she was fatally beaten in an unprovoked attack on 9 December 2020. The report raises concerns about the sharing of remand prisoners’ risk information with sentencing courts, continuity of mental healthcare after release from prison, risk assessment of violent offenders managed by MOSOVO units, and access to patient information through the National Record Locator.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of some mental healthcare trusts to accept referrals for homeless prisoners on release
Wider context from the report “Evidence was given that this is not the process nationally in that some mental healthcare trusts will not accept a referral if a person is homeless . There is no national guidance about the continuity of care for prisoners upon release from prison when homeless .
I am concerned that this lack of continuity of care could lead to 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 National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of National Record Locator access for South West ambulance care in Dorset
Wider context from the report “Evidence was given by the Head of Clinical Development and Organisational Development at South West Ambulance Service NHS Foundation Trust (SWAST) that in the South West region all Integrated Care Boards (ICBs), apart from the ICB in Dorset, NHS Dorset, are at some stage of implementing the use of NRL so that SWAST can access this information to assist in the provision of care to those they treat.
Evidence was given that as this would limit the information SWAST had access to about a patient in Dorset , this would impact upon the care provided to those in Dorset by SWAST which could lead to a future death.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and tools for assessing violence risk in MOSOVO-managed offenders
Wider context from the report “The risk assessments detailed in the guidance are aimed at the assessment of the sexual risk of offenders and evidence was given that there is no bespoke risk assessment tool or guidance to assess the violence of such offenders to assist staff within MOSOVO units to undertake their role . There is, therefore, a lack of guidance on how to risk assess and manage offenders who are managed under MOSOVO when they present with the risk of violence, or an escalating risk of violence .
I am concerned that this will result in a failure to identify the risk of violence, or the increasing risk of violence, in those being managed by MOSOVO which may lead to a further death.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for sharing remanded prisoners’ risk information with sentencing courts
Wider context from the report “Evidence was given by the Head of the Offender Management Unit (OMU) at HMP Winchester, a Senior Probation Officer, that there is currently no formal process or guidance in place for the sharing of information by a prison with the Criminal Courts to provide an update of the person's behaviour in prison which may increase their risk of harm or risk offending .
It was explained that the person who could enquire about this at Court, if asked, would be the duty Probation Officer, and that this is especially more challenging to complete when a fast delivery report is requested.
There is currently no process from a prison perspective to share information to the sentencing Court other than that contained within the Prison Escort Record (PER), which is not provided to the sentencing Judge, the lawyers at Court or Probation staff .
I am concerned that the full extent of a remanded prisoner’s risk of harm to the public may not be appreciated by the sentencing Judge, which could impact upon the sentence imposed upon a prisoner and I am concerned that this lack of sharing of information could lead to 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 National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of practical national guidance for continuity of prisoners’ healthcare on release
Wider context from the report “There is a lack of national guidance to assist all healthcare providers to ensure continuity of care for a prisoner with health care needs, whether physical or mental health needs, upon release from prison . There are national standards of care and NICE guidelines in place, however none of these provide practical guidance around the delivery of care to ensure continuity of care .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reiterate the request for a full review of the Active Risk Management System process.
Verbatim wording from the response “The NPCC MOSOVO Lead liaises regularly with the College of Policing who develop the training for MOSOVO staff in England and Wales and who produce Authorised Professional Practice. I will ask that the NPCC Lead request the College of Policing review their APP and training material to highlight more strongly the consideration of violence within the assessment when considering the formulation of the risk management plan. In addition, we have previously requested from the College of Policing a full review of the ARMS process as part of normal good practice and will reiterate this need.” Source location Response from NPCC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request a review of MOSOVO authorised professional practice and training materials to strengthen consideration of violence in risk assessments and management plans.
Verbatim wording from the response “The NPCC MOSOVO Lead liaises regularly with the College of Policing who develop the training for MOSOVO staff in England and Wales and who produce Authorised Professional Practice. I will ask that the NPCC Lead request the College of Policing review their APP and training material to highlight more strongly the consideration of violence within the assessment when considering the formulation of the risk management plan. In addition, we have previously requested from the College of Policing a full review of the ARMS process as part of normal good practice and will reiterate this need.” Source location Response from NPCC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The established ARMS assessment and risk management process should identify serious violence risks when known to and properly assessed by the assessor.
Verbatim wording from the response “The risk assessment process police use for sexual offenders is the Active Risk Management System (ARMS), which has been in use by Police in England and Wales since 2014 and is well established. This system assesses 11 factors both risk and protective bespoke to the offenders personal circumstances at the time of assessment alongside their static risk of sexual recidivism based on the OASys Sexual Predictor (OSP). These are combined to provide an overall level of risk and most importantly a risk management plan articulating the plan to mitigate the risks identified and to support the offenders desistance. We would expect that this activity should look at the offenders circumstances holistically and should identify risks of serious violence as part of the overall assessment if known to the assessor and if undertaken adequately.” Source location Response from NPCC
Open published response
4 Mar 2025 Robert John EVANS · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Lack of guidance, training and an urgent medical response pathway for non-arrested detainees suspected of swallowing drugs View source Lack of guidance for providing continued-monitoring advice on release of detainees suspected of swallowing drugs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert John EVANS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert John EVANS was found dead at his home in Liverpool on 3 July 2022. His death resulted from drug use and underlying pneumonia, with fractures sustained during police detention contributing more than minimally to his death. The principal concerns were the lack of guidance, training, medical escalation and information-sharing when a person detained for a drug search is suspected of swallowing drugs, particularly after release from detention.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance, training and an urgent medical response pathway for non-arrested detainees suspected of swallowing drugs
Wider context from the report “The court heard that College of Policing Guidance for Custody Officers and Detention Officers provides that “...If officers know or suspect that a detainee has swallowed or packed drugs...they must treat the person as being in need of urgent medical attention and transfer them straight to hospital”. However: (a) a person detained for a search under the Misuse of Drugs Act does not come to the attention of a Custody or Detention Officer, unless arrested ; (b) there is no guidance (known to the court) to assist officers involved in such a search as to what they should do ; (c) there is seemingly no power for officers to convey to hospital somebody detained under these provisions (but not arrested), if that is against their wishes .
The upshot seems to be that, whilst the risk arising from swallowing a package containing drugs is the same in each case, there is a material difference between how different types of detainee are managed, depending upon whether an arrest has taken place .
Officers told the court that if somebody declines an offer of medical attention they simply monitor their condition, for signs of any change or deterioration. However, even if that is effective and adequate, any monitoring inevitably ends when the individual is released from detention. In this case that was little more than an hour after the suspected swallowing event.
When he was returned home, officers gave no advice to the Deceased or his family about the need for continued monitoring. There appears to be no guidance directed towards them as to what advice should be given. One officer said that nothing could be said to the family (about the need to keep him under close watch, because of the risk), because that would breach the individual’s right to privacy.
It occurs to me that a person suspected of involvement in a drugs deal (even if nothing is found on a search) might well be keen to avoid further attention from the police and/or medical services as quickly as possible, for fear of something being found that might incriminate them.
I am concerned that a person detained for the purposes of a search under the Misuse of Drugs Act, who is then suspected of having swallowed drugs, might be exposed to a risk of death (or other significant harm) if they do not receive the sort of medical attention which the guidance to Custody and Detention Officers considers an ‘urgent’ requirement , and/or if they are not given appropriate guidance on their release from detention. I am further concerned that officers are not given guidance or training in how to address this risk, by means of communication or otherwise .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for providing continued-monitoring advice on release of detainees suspected of swallowing drugs
Wider context from the report “The court heard that College of Policing Guidance for Custody Officers and Detention Officers provides that “...If officers know or suspect that a detainee has swallowed or packed drugs...they must treat the person as being in need of urgent medical attention and transfer them straight to hospital”. However: (a) a person detained for a search under the Misuse of Drugs Act does not come to the attention of a Custody or Detention Officer, unless arrested; (b) there is no guidance (known to the court) to assist officers involved in such a search as to what they should do; (c) there is seemingly no power for officers to convey to hospital somebody detained under these provisions (but not arrested), if that is against their wishes.
The upshot seems to be that, whilst the risk arising from swallowing a package containing drugs is the same in each case, there is a material difference between how different types of detainee are managed, depending upon whether an arrest has taken place.
Officers told the court that if somebody declines an offer of medical attention they simply monitor their condition, for signs of any change or deterioration. However, even if that is effective and adequate, any monitoring inevitably ends when the individual is released from detention . In this case that was little more than an hour after the suspected swallowing event.
When he was returned home, officers gave no advice to the Deceased or his family about the need for continued monitoring . There appears to be no guidance directed towards them as to what advice should be given . One officer said that nothing could be said to the family (about the need to keep him under close watch, because of the risk), because that would breach the individual’s right to privacy.
It occurs to me that a person suspected of involvement in a drugs deal (even if nothing is found on a search) might well be keen to avoid further attention from the police and/or medical services as quickly as possible, for fear of something being found that might incriminate them.
I am concerned that a person detained for the purposes of a search under the Misuse of Drugs Act, who is then suspected of having swallowed drugs, might be exposed to a risk of death (or other significant harm) if they do not receive the sort of medical attention which the guidance to Custody and Detention Officers considers an ‘urgent’ requirement, and/or if they are not given appropriate guidance on their release from detention. I am further concerned that officers are not given guidance or training in how to address this risk, by means of communication or otherwise.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work across relevant portfolios to establish appropriate aftercare and safeguarding following stop and search, supporting a consistent approach.
Verbatim wording from the response “Safeguarding is a key area of focus for the NPCC and we are committed to working across relevant NPCC portfolios to ensure there is appropriate aftercare / safeguarding following a stop & search and will work to ensure a consistent approach that keeps people safe.” Source location Response from National Police Chiefs' Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Regulation 28 document to identify appropriate responses to incidents involving suspected drug ingestion.
Verbatim wording from the response “The NPCC Stop & Search portfolio has reviewed the Regulation 28 document and will work to ensure officers are equipped to resolve incidents such as these in the most appropriate manner. The portfolio will work with other national policing portfolios and stakeholders, to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them.” Source location Response from National Police Chiefs' Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with national policing portfolios and stakeholders to provide refreshed training and guidance on available policing powers.
Verbatim wording from the response “The NPCC Stop & Search portfolio has reviewed the Regulation 28 document and will work to ensure officers are equipped to resolve incidents such as these in the most appropriate manner. The portfolio will work with other national policing portfolios and stakeholders, to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them.” Source location Response from National Police Chiefs' Council
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police may disclose necessary private information to family or next of kin to protect vital interests and prevent serious harm.
Verbatim wording from the response “The suggestion that an officer cannot share information with a next of kin, or other family, to manage risk and prevent serious injury or death, is misguided. The police can disclose private information about a data subject if it is necessary to protect the vital interests of the data subject or another person. This typically applies in life-or-death situations, such as suspected drug ingestion (UK” Source location Response from National Police Chiefs' Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police currently lack power to convey a person detained under these provisions to hospital against their wishes.
Verbatim wording from the response “As noted within the Authorised Professional Practice, there is clear guidance for what Custody Officers should do, when presented with a detainee who is suspected of having packed or swallowed drugs. I agree with your observations that there is a material difference between the action taken for those arrested, and those who are not. Further to this there is currently no power for officers to convey to hospital somebody detained under these provisions against their wishes. Whilst custody is heavily regulated with law, policies, procedures and best practice, fundamentally, an officers primary role is to preserve life and the risks in such cases should be recognised and further mitigated.” Source location Response from National Police Chiefs' Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national training covers proportionate information disclosure in suspected drug ingestion cases, including the minimum necessary information principle.
Verbatim wording from the response “GDPR Article 6(1)(d)). There are also similarly worded exemptions within the Data Protection Act 2018. There is already in place, national training modules that cover this subject in detail, and include scenarios where disclosure is proportionate as necessary, whilst emphasising the importance of disclosing the minimum amount of information necessary, to achieve the objective sought.” Source location Response from National Police Chiefs' Council
Open published response
14 Jan 2025 Anugrah Abraham (“Anu”) · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Unclear imminent adjustments for police officers disclosing suicidal thoughts before occupational health assessment View source Failure to investigate the quality of occupational health care after a death View source Lack of specialist Registered Mental Health nurses in the occupational health unit View source Failure to maintain accurate documented information on PCDA student officer progression View source Failure to learn from deaths and reflect on occupational health care processes View source Stress associated with the Police Constable Degree Apprenticeship route 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
Anugrah Abraham (“Anu”) · 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
Anugrah Abraham (“Anu”), a serving West Yorkshire police officer, died by hanging on 4 March 2023 after leaving home the previous afternoon; the inquest recorded a conclusion of suicide. The report identified concerns about the management of his mental health, including delayed and inadequate Occupational Health responses, unclear action when he disclosed suicidal thoughts, poor information sharing, and aspects of the PCDA and Regulation 13 processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Unclear imminent adjustments for police officers disclosing suicidal thoughts before occupational health assessment
Wider context from the report “3. The court heard as to the increase in mental health issues amongst Police Officers nationally. Despite this, the question of what imminent adjustments should be made or considered once an officer discloses suicidal thoughts, was unclear . This is before an OHU appointment . In this case Anu’s mental deterioration was reportedly directly linked to his role as a police officer. It is acknowledged that this is a difficult issue and there will be issues such as confidentiality to consider.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the quality of occupational health care after a death
Wider context from the report “2. Following Anu’s death there was no investigation into the quality of care afforded to him by the OHU within WYP . Hence at the time of the inquest, there had been no reflection by practitioners as to the quality of care provided and no learning in respect of processes and procedures. It was accepted that following the inquest there were matters which would be considered. The lack of investigation meant learning from deaths in order to prevent future deaths was not addressed.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist Registered Mental Health nurses in the occupational health unit
Wider context from the report “1. The court heard that most OHU referrals within police forces now relate to mental health issues as opposed to physical health issues. Despite this, there are no specialist Registered Mental Health nurses recruited into WYP OHU . Indeed the court heard the situation within WYP may be indicative of the national picture.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate documented information on PCDA student officer progression
Wider context from the report “5. Ensuring there is a full understanding across Police forces as to the PCDA and the sharing of accurate information with all those involved in the management of student officers so there is clear documented records and understandings as to how a student officer is progressing and whether they are likely to become an efficient constable .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from deaths and reflect on occupational health care processes
Wider context from the report “2. Following Anu’s death there was no investigation into the quality of care afforded to him by the OHU within WYP. Hence at the time of the inquest, there had been no reflection by practitioners as to the quality of care provided and no learning in respect of processes and procedures . It was accepted that following the inquest there were matters which would be considered. The lack of investigation meant learning from deaths in order to prevent future deaths was not addressed .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Stress associated with the Police Constable Degree Apprenticeship route
Wider context from the report “4. Whilst the court heard there are now different routes into policing and there is no longer a requirement to undertake a degree. The court heard from a significant number of officers who had undertaken the PCDA. Many of the witnesses told the court of the impact this route into policing had on them at the time, including the levels of stress they incurred . The PCDA does continue to operate .
” Open source report
8 Jan 2025 Matthew Brierley · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 4 Failure to provide proactive contact and support to men at elevated suicide risk View source Markedly elevated suicide risk among men in comparable circumstances View source Failure to undertake detailed individual risk assessment when applying bail conditions View source Delays in examination of devices and case decisions prolonging risk during bail View source See 1 more concern
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AI-generated summary
Matthew Brierley · 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
Matthew Brierley died in the car park of Buttermere Court Hotel on 24 April 2024, after being arrested, bailed and placed under conditions that prevented him from living at home or having unsupervised contact with his children and stepdaughter. The inquest concluded that his death was suicide. Concerns included the potentially prolonged period before decisions were made about his devices and case, the use of standard bail conditions without an apparent specific risk assessment, and the lack of proactive follow-up support after his release on bail.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide proactive contact and support to men at elevated suicide risk
Wider context from the report “(3) Police acknowledged the increased risk and completed a standard assessment form when Matthew was released - he denied any risk and also declined referral to Liaison and Diversion service. A Family Contact Officer was also appointed but the onus remained on Matthew to seek help and there was no proactive contact which might have been helpful as men in Matthew's situation are less likely to seek help due to feelings of shame and embarrassment .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Markedly elevated suicide risk among men in comparable circumstances
Wider context from the report “(1) It is recognized that men in Matthew's circumstances are at a markedly elevated risk of suicide . Several papers refer to this - I found Kothari et al (Journal of Forensic and Legal Medicine, July 2021) particularly informative. They quote 3.2% of those arrested in operation Notarise committing suicide and explore reasons why this group is particularly vulnerable.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake detailed individual risk assessment when applying bail conditions
Wider context from the report “(2) I was told that when released on bail Matthew was informed that examination of devices and a decision in his case might take up to 18 months. Being suspended from work and unable to live at home removed normality and stability from Matthew and likely impaired his ability to cope with his situation. The length of time taken to reach a decision seems excessive, prolonging the time Matthew would be at risk. I was told devices can be "triaged" within a matter of days or more quickly, surely ceases such as this should be dealt with more expeditiously? It seems that "standard" bail conditions are applied but I am not aware of any suggestion of a specific risk to Matthew's stepdaughter , might a more detailed individual assessment of risk be helpful? I should record that Matthew's phone was examined after his death and that images found were not of a grade that would have led to a prosecution.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Delays in examination of devices and case decisions prolonging risk during bail
Wider context from the report “(2) I was told that when released on bail Matthew was informed that examination of devices and a decision in his case might take up to 18 months. Being suspended from work and unable to live at home removed normality and stability from Matthew and likely impaired his ability to cope with his situation. The length of time taken to reach a decision seems excessive, prolonging the time Matthew would be at risk . I was told devices can be "triaged" within a matter of days or more quickly , surely ceases such as this should be dealt with more expeditiously? It seems that "standard" bail conditions are applied but I am not aware of any suggestion of a specific risk to Matthew's stepdaughter, might a more detailed individual assessment of risk be helpful? I should record that Matthew's phone was examined after his death and that images found were not of a grade that would have led to a prosecution.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the prevention report and recommendations with UK custody leads to strengthen suicide-risk consideration in investigative strategies and digital-device triage.
Verbatim wording from the response “I have shared a copy of this prevention of future deaths report with all custody leads within the UK, with a recommendation to ensure that the risk of suicide within cohorts such as Matthew’s, are included within the investigative strategies and particularly the triage of digital devices, and that risk assessments are tailored to the individual circumstances of the investigation.” Source location Response from National Police Chief's Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request qualitative information from relevant police forces and analyse returned data to identify post-release suicide-risk factors.
Verbatim wording from the response “The next phase of the research discussed today, will be for each force from which one of those deaths occurred, to answer further qualitative questions to identify commonalities. At present, we do not ask the key questions that identify the impact upon somebody’s life, following their arrest. Questions proposed include subjects such as:” Source location Response from National Police Chief's Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete research reviewing five years of post-custody suicide data to identify commonalities and inform prevention.
Verbatim wording from the response “1 and 3 – A lot of research has been undertaken already, to try and identify any commonalities between instances of post custody suicide. The objective is to establish a post release risk assessment process that will identify those most at risk, and initiate a process to mitigate that risk, with further support such as a mandatory referral to support agencies. The current research has identified from a review of five years of data from the IOPC:” Source location Response from National Police Chief's Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an evidence-led post-release risk assessment process with mandatory referrals to partner support agencies for identified high-risk individuals.
Verbatim wording from the response “1 and 3 – A lot of research has been undertaken already, to try and identify any commonalities between instances of post custody suicide. The objective is to establish a post release risk assessment process that will identify those most at risk, and initiate a process to mitigate that risk, with further support such as a mandatory referral to support agencies. The current research has identified from a review of five years of data from the IOPC:” Source location Response from National Police Chief's Council
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigating officers must apply individual circumstances to risk assessments and supervisors must ratify disposal decisions.
Verbatim wording from the response “Assessments of risk should always be individualised. Whilst there will be a question set used to conduct a pre-release risk assessment, the responses should be applied to the individual circumstances of the investigation, by the OIC and ratified by their supervisor when making a disposal decision. Bail conditions should only be applied where it is necessary and proportionate to do so. There is a” Source location Response from National Police Chief's Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The investigating officer must identify risks for digital-device submissions, which the Digital Forensics Unit uses to prioritise examinations.
Verbatim wording from the response “2 – In relation to the examination of digital devices, timescales vary between forces, but it is not uncommon for those considered to be linked to lower risk investigations, not to be processed for many months. It will be for the officer in charge (OIC) of the investigation to identify all risks within their submission to their Digital Forensics Unit (or equivalent), which is then used to prioritise the examination of those devices. The factors in this investigation should have resulted in a much quicker interrogation of the device than the 18 months estimated. The fact that Matthew was on bail, should have seen the investigation progressed within the requisite bail periods, but I cannot comment upon any individual backlog or otherwise that the force concerned may have been managing.” Source location Response from National Police Chief's Council
Open published response
13 Aug 2024 Angela · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 3 Insufficient frontline staff understanding of domestic abuse and coercive and controlling behaviour View source Failure of the domestic abuse risk assessment form to clearly include psychological harm from coercive and controlling behaviour within serious harm View source Non-adoption of the new domestic abuse risk-assessment tool 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
Angela · 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
Angela was murdered by her husband at their home on 26 December 2018, aged 41. Before her death, she reported assault and elements of coercive control to Thames Valley Police, but the reported crimes were not recorded or investigated, relevant information was not considered in the risk assessment, and the risk was graded as standard rather than medium. The report raises concerns about frontline understanding of domestic abuse and coercive control, the clarity of the DOM5 risk assessment form, and the non-adoption of a newer domestic abuse risk-assessment tool.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient frontline staff understanding of domestic abuse and coercive and controlling behaviour
Wider context from the report “1. Whether sufficient steps have been taken to ensure that frontline staff have a clear understanding of domestic abuse and coercive and controlling behaviour – to think not just about physical abuse, but also about controlling behaviour and how that may escalate .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the domestic abuse risk assessment form to clearly include psychological harm from coercive and controlling behaviour within serious harm
Wider context from the report “2. I am concerned that Thames Valley Police’s DASH risk assessment form (called a DOM5) does not make it sufficiently clear that the definition of “serious harm” can include psychological harm from coercive and controlling behaviour . It may be that other formulations of this document nationally do make this clear – I have looked only at the form used by Thames Valley 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 National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Non-adoption of the new domestic abuse risk-assessment tool
Wider context from the report “3. I heard evidence about a new tool for risk assessing domestic abuse, created by the College of Policing. Both the senior Thames Valley Police officer and the College of Policing witness gave evidence that this system is likely to result in better risk assessment for domestic abuse. As I understand it, this new tool has not been adopted by Thames Valley Police at this time , because of competing financial priorities, and an issue with compatibility with the Niche system.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and license the DA Matters training course for first responders and domestic-abuse champions, with specialist-provider delivery and trainer development.
Verbatim wording from the response “responding to coercive and controlling behaviour, the impact of such behaviours on victims, including the clear links to victim suicide and the heightened risk posed by suspects who use coercion and control in their abuse of victims. This consists of a one-day course for responders and a two-day course for ‘champions,’ those with a more involved, mentoring role. DA Matters was developed with the support of ‘Safelives,’ (a national service for victims of DA), and other key stakeholders including Women’s Aid, Suzy Lamplugh Trust, and other specialist support services. The course was piloted and evaluated in 2016 and a model of delivery, (which included co-delivery with a DA specialist) is promoted through the licensing of the product (essentially outlining the conditions by which forces must use the training course).” Source location Response from NPCC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop, pilot and evaluate the DARA risk-assessment tool and aligned training for identifying coercive-control patterns.
Verbatim wording from the response “Simultaneous to the learning products, the College carried out a review of the implementation of domestic abuse, stalking and honour based crime (DASH) risk assessment ‘tool’ introduced into policing in 2009. Working alongside Cardiff University the review findings and report prompted the development of a new tool for use by initial responders, more focused on patterns of behaviour with a focus on coercion and control rather than incidences of specific behaviours. The Domestic Abuse Risk Assessment (DARA) and aligned training was piloted and evaluated in three forces, with subsequent testing in further forces to ensure effectiveness The evaluation found that the DARA uncovered more cases of coercive and controlling behaviour (CCB), and gave officers more accurate information to use professional judgement to assess and respond to risk.” Source location Response from NPCC
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 Work with police forces and relevant IT providers to drive implementation of the nationally launched DARA risk-assessment process.
Verbatim wording from the response “The DARA was launched nationally in November 2022. Unfortunately, implementation has not been as smooth as anticipated due to competing demands for amending the various IT systems used for recording the risk assessment process, however, the NPCC and the College have been working closely with forces and relevant IT providers to drive implementation.” Source location Response from NPCC
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 Review the policing implementation of the DASH risk-assessment tool.
Verbatim wording from the response “Simultaneous to the learning products, the College carried out a review of the implementation of domestic abuse, stalking and honour based crime (DASH) risk assessment ‘tool’ introduced into policing in 2009. Working alongside Cardiff University the review findings and report prompted the development of a new tool for use by initial responders, more focused on patterns of behaviour with a focus on coercion and control rather than incidences of specific behaviours. The Domestic Abuse Risk Assessment (DARA) and aligned training was piloted and evaluated in three forces, with subsequent testing in further forces to ensure effectiveness The evaluation found that the DARA uncovered more cases of coercive and controlling behaviour (CCB), and gave officers more accurate information to use professional judgement to assess and respond to risk.” Source location Response from NPCC
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 Provide learning materials and classroom training content on coercive and controlling behaviour and its legislation.
Verbatim wording from the response “A programme of work was developed to improve the policing response to DA, including a project to examine existing risk assessment processes for victims of DA, a review of the existing training curriculum and the development of APP for this area of work. In 2015 with the inception of new legislation for the offence of coercive and controlling behaviour, several products were made available on the College learning network (College Learn) aimed at embedding knowledge of the legislation. Using a video briefing, two victims provide an insight of their lived experience of controlling and coercive behaviour, while advice and guidance is also given on the legislation. In addition, forces were provided with a new training guide and content for a half-day classroom session so that there was an option for face-to-face inputs.” Source location Response from NPCC
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 Embed domestic-abuse learning, including risk assessment and protective-order responses, within all entry routes into policing.
Verbatim wording from the response “More broadly DA is embedded in the curriculum for all entry routes into policing with various supporting products available to deliver against the curriculum (for example, areas such as Domestic Violence Disclosure Scheme (DVDS), Domestic Violence Protection Orders (DVPOs), response to DA /Stalking (Abusive Relationship digital learning, Domestic Abuse Risk Assessment (DARA/DASH) are catered for).” Source location Response from NPCC
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 Delivery of the national domestic-abuse training curriculum was not centrally undertaken; individual police forces were responsible for delivering it.
Verbatim wording from the response “Although this was not centrally delivered forces were encouraged to deliver against the national curriculum using the specific products available.” Source location Response from NPCC
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 DARA implementation was delayed by competing demands to amend police IT systems, limiting the speed of national implementation.
Verbatim wording from the response “The DARA was launched nationally in November 2022. Unfortunately, implementation has not been as smooth as anticipated due to competing demands for amending the various IT systems used for recording the risk assessment process, however, the NPCC and the College have been working closely with forces and relevant IT providers to drive implementation.” Source location Response from NPCC
Open published response
Concerns raised 12 Failure to provide formal written LDS mental health assessments to police View source Lack of a documented LDS mental health plan for custody View source Unavailability of appropriate LDS-police liaison templates View source Lack of local or national procedures for obtaining mental health assessments during intoxication View source Difficulty obtaining collateral mental health information from other services View source Failure of LDS and police information sharing about custody mental health presentation View source Unavailability of a 24-hour LDS service in custody View source Lack of formal police documentation of family concerns about mental health deterioration View source Lack of formal written handovers of mental health presentation between police officers View source Lack of guidelines for undertaking formal mental health assessments in intoxicated individuals View source Lack of formal documentation procedures for LDS and police custody care View source Lack of police decision-making guidelines for further mental health assessment or Appropriate Adult support View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Miles Ethan Hurley · 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
Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formal written LDS mental health assessments to police
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a documented LDS mental health plan for custody
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody .
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriate LDS-police liaison templates
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of local or national procedures for obtaining mental health assessments during intoxication
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated , a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Difficulty obtaining collateral mental health information from other services
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of LDS and police information sharing about custody mental health presentation
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest , was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed ). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a 24-hour LDS service in custody
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal police documentation of family concerns about mental health deterioration
Wider context from the report “2. Lack of relevant Documentation by the Police
Throughout Mr Hurley’s time in custody on the 9th July 2022, his parents spoke to multiple police officers and allied staff on the phone and on attending the custody suite to inform them of their concerns over their son’s sudden deterioration in his mental health on a background of longstanding extreme social anxiety. Whilst this was generally known by the officers within the custody suite, there was no formal documentation, either individually or collectively of these concerns to inform and assist police officers in their decision making .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal written handovers of mental health presentation between police officers
Wider context from the report “1. Lack of effective Communication between police officers
The absence of a formal written handover between police officers regarding how an individual is presenting to be able to more accurately assess and appropriately direct assessment and care, particularly for first time offenders such as Miles who was not known to the police. Prior to and at the time of his arrest he was recognised by members of the public and the arresting police officers as showing significant signs of disturbance in his mental health with incongruent speech, inappropriate behavioural affect, and delusional beliefs such as thinking he was playing ‘Grand Theft Auto’ whilst driving recklessly, on a background of intoxication. The extent and the severity of his mental health difficulties was not adequately conveyed through standard ‘word of mouth’ communication between police officers , complicated by Mr Hurley appearing to be more contained and less obviously mentally unwell in custody.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines for undertaking formal mental health assessments in intoxicated individuals
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal documentation procedures for LDS and police custody care
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures , or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest, was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of police decision-making guidelines for further mental health assessment or Appropriate Adult support
Wider context from the report “3. Lack of effective documentation and communication between the Liaison Diversion Service (LDS) and the police within the custody suite.
a. The use of word of mouth rather than formal written documentation of a mental health assessment compromised the Police’s comprehension of the complexity and nuances of Mile’s mental health difficulties to assist in determining the most appropriate care.
b. The lack of a documented recommended mental health ‘plan’ by the LDS to be followed whilst an individual remains in custody.
c. A lack of nationally agreed guidelines as to when it would be appropriate to undertake a formal mental health assessment when an individual is known to be intoxicated when first detained. I heard evidence that it is not possible to rely on the findings of a formal mental health assessment if undertaken when an individual is intoxicated. Yet, The LDS mental health practitioner was tasked to do so in those circumstances resulting in a ‘qualified’ assessment the significance of which was not recognised prior to Miles’s release from custody.
c. A lack of guidelines to support a LDS practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability. I heard evidence that the LDS mental health practitioner worked from 08:00-20:00 and would not have been available after those hours hence the request for an earlier mental health assessment.
d. A lack of a 24 hour LDS service within custody despite mental health issues being prevalent throughout the day and night for individuals in custody.
d. A lack of effective guidelines to assist the police on decision making as to whether an individual needs a further mental health assessment and/or an Appropriate Adult. The on call social worker (having spoken to Miles’s father), contacted the police to raise concerns about Miles’s mental health and the need to have a mental health assessment and an Appropriate Adult present. This was deemed not necessary by the interviewing officer. There appears to be a conflict in that the police accept they are not qualified to formally assess mental health issues but on the other hand they relied on their assessment that Miles did not need a further mental health assessment or for an appropriate adult to be present.
e. Difficulty in being able to obtain collateral information to assist in a mental health assessment from other Mental Health Services. Evidence was heard that members of Miles’s family contacted the Mental Health helpline with their concerns whilst Miles was in custody but were not afforded the opportunity to share these concerns with the LDS practitioner which would not have been a breach of confidentiality.
” 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 Consider best practice through the Betterment Workstream, including a nationally recognised pre-arrival risk assessment for communicating custody risks.
Verbatim wording from the response “The practice of arresting officers risk assessments being formally completed prior to arrival at custody is inconsistent across forces. Best practice is being considered through the NPCC Betterment Workstream to include a nationally recognised pre arrival risk assessment in place to communicate risks and concerns that may have been raised.” Source location Response from NPCC
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 Raise NHS Trust information-sharing failures between criminal justice pathways as a detainee welfare concern.
Verbatim wording from the response “f) NHS Trust information sharing has also been raised as a concern by the NPCC in that the inability or refusal to share clinical records between criminal justice pathways adds risk to a detainees welfare.” Source location Response from NPCC
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 Raise the lack of a 24-hour Liaison and Diversion Service with NHS England as a custody safety concern.
Verbatim wording from the response “d) A lack of 24-hour LDS service is an issue that has been raised previously with NHSE by the NPCC as an area of concern.” Source location Response from NPCC
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 memorandum concerns should be addressed by Midlands Partnership University NHS Foundation Trust, Sussex Police and MITRE.
Verbatim wording from the response “Within the Regulation 28 you highlighted four main areas of concern. In my role as NPCC Lead for Custody, I will address the first three points. The fourth relates to a Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and MITRE, therefore, these organisations will be best placed to address your concerns. In relation to the areas of concern, please see below:” Source location Response from NPCC
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 NPCC is unable to comment on the mental health plan referred to in the case.
Verbatim wording from the response “b) The NPCC is unable to make comment on the mental health plan referred to in this case.” Source location Response from NPCC
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 Guidance for LDS practitioners on formal mental health assessments is for the LDS provider, not the police.
Verbatim wording from the response “c) Guidelines around supporting a LDS Practitioner as to when it is appropriate to undertake a formal mental health assessment when an individual is intoxicated is a matter for the LDS provider. Whilst it is positive that an assessment was considered in this case, it is unclear from the report whether this was a ‘fitness for detention/release’ assessment that was being requested. An assessment under the Mental Health Act would require an Approved Mental Health Professional to have attended the suite at the request of LDS. LDS practitioners are mental health professionals, and it is within their remit to conduct such an assessment and therefore not for the police to make comment.” Source location Response from NPCC
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 communication issue is a local force matter and outside the NPCC’s remit for comment.
Verbatim wording from the response “a) This is a local force issue and therefore not for the NPCC to make comment.” Source location Response from NPCC
Open published response
8 Aug 2024 Emma Pattison and 2 others · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour View source Failure to ensure full disclosure of shotgun certificate applicants’ medical history View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emma Pattison and 2 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
Between 22:49 on 4 February 2023 and 00:40 on 5 February 2023, George Pattison shot and killed his wife, Emma Pattison, and daughter, Ellette Pattison, before shooting himself. The report raises concerns about online medical consultations potentially bypassing disclosure safeguards for shotgun licensing and about obtaining full information concerning coercive controlling behaviour.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour
Wider context from the report “3. Consideration should be given as to how a licensing authority can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour towards another / 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure full disclosure of shotgun certificate applicants’ medical history
Wider context from the report “1. An applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP , giving rise to a risk that a licensing authority might grant a shotgun certificate to an applicant who has a relevant previous medical history about which the authority is not aware .
2. In consulting an on-line doctor, it is possible for an applicant for a shotgun certificate to avoid the current safeguards relating to full disclosure of their previous and current medical history .
” 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 Require a medical declaration and specific GP or third-party medical report before considering a firearms licence application.
Verbatim wording from the response “Changes have been made to the medical declaration required from an applicant and the requirement for a specific GP report has been introduced – no licence is now considered without the opinion of the applicant’s GP as to any relevant medical concerns or other medical issues which could affect an applicant’s suitability to possess a licence.” Source location Response from NPCC
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 a right to draw adverse inferences when firearms licence applicants are evasive about family members or previous partners.
Verbatim wording from the response “Moving forward, national FEO training will further encourage positive engagement with the applicant and their family/others in their household. FEOs will be expected to ascertain the “domestic health and wellbeing” of the applicant on both initial grant and any renewal. We are hopeful that revised statutory guidance will require interviews and wider engagement with families and FEOs will be required to cover these matters on the new FEO report on suitability. We are also looking to introduce the right to draw adverse inference if an applicant is evasive about family/previous partners and so on.” Source location Response from NPCC
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 Roll out the nationally designed Firearms Enquiry Officer course, including testing, mandatory specialist training, portfolio assessment and external moderation.
Verbatim wording from the response “Substantial changes are being introduced around training and accreditation of Firearms Enquiry Officers (FEOs) (who, in most cases provide the report to decision makers assessing the applicant’s circumstances and comment on suitability following appropriate conversations and visits).” Source location Response from NPCC
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 Introduce a nationally standardised Firearms Enquiry Officer report form requiring comprehensive enquiries, information received and suitability reasoning.
Verbatim wording from the response “We are also introducing a new FEO Report Form for national use which will require more comprehensive detailing of enquiries undertaken, information received (from in person interviews, police systems and wider investigations deemed appropriate on each individual application) and the rationale for their view on suitability. It is intended that this will act both as a prompt to FEOs to ensure all aspects of suitability are properly considered and also build on the increasing focus in more recent versions of the HO guidance around the importance of exercising professional curiosity in all cases.” Source location Response from NPCC
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 Engage partner organisations to improve inter-agency information-sharing for firearms licensing suitability assessments.
Verbatim wording from the response “As a police service, we will continue to engage with partners to improve upon partnership working and inter-agency information-sharing to ensure that those charged with determining firearms licensing applications have as much relevant information as possible to assess an applicant’s suitability to hold a firearms licence in the context of ensuring public safety.” Source location Response from NPCC
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 Office is responsible for implementing proposed firearms licensing reforms, including GP requirements, seizure powers and application restrictions.
Verbatim wording from the response “• HO to proceed with implementation of the outcomes from their August 23 consultation, in particular we would welcome early implementation of
◦ Mandatory requirements for GPs to support the licensing process and complete the medical proformas on every application,
◦ Police being granted powers to enter properties to seize firearms for the purpose of reassessing suitability of licence holders,
◦ A statutory prohibition on applying for a licence for 5 years for anyone who has been sentenced to serve 0-3 years in prison, including suspended sentences.” Source location Response from NPCC
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 Police have little ability to address deliberate concealment of relevant medical information, apart from revoking a licence.
Verbatim wording from the response “There has already been a significant improvement in the medical information available to Firearms Licensing teams through the introduction of the mandatory GP report or medical report from a third party medical provider on application. However, it remains the case that where an applicant deliberately withholds relevant information – not only from the Firearms Licensing team but from their own GP – there is little that police forces can do in many cases to address deliberate dishonesty, save for revoking a licence (which is made clear on the application form and within the HO guidance).” Source location Response from NPCC
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 Regulation of online doctors and information-sharing with registered GPs is a matter for DHSC, with Home Office colleagues progressing it.
Verbatim wording from the response “It is, of course, outside the role and remit of policing to regulate or manage the health sector; this would be a matter for the Department of Health and Social Care and we understand that our HO colleagues are working with their counterparts in the DHSC to progress this issue. As the NPCC Lead, I would welcome any positive moves that are possible to regulate online GPs/prescriptions and require any relevant information to be passed to the GP with whom the individual is registered, so that it is accessible to Firearms Licensing Units when required, to enable a fuller picture to be available to support risk assessments and suitability assessments on applications for grant or renewal of firearms licensing. Exactly the same concerns arise where applicants use private GPs or consultants (outside of a GP referral) which may also remain unknown to firearms licensing teams.” Source location Response from NPCC
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 Policing cannot regulate or manage online healthcare providers because health-sector regulation falls outside its remit.
Verbatim wording from the response “It is, of course, outside the role and remit of policing to regulate or manage the health sector; this would be a matter for the Department of Health and Social Care and we understand that our HO colleagues are working with their counterparts in the DHSC to progress this issue. As the NPCC Lead, I would welcome any positive moves that are possible to regulate online GPs/prescriptions and require any relevant information to be passed to the GP with whom the individual is registered, so that it is accessible to Firearms Licensing Units when required, to enable a fuller picture to be available to support risk assessments and suitability assessments on applications for grant or renewal of firearms licensing. Exactly the same concerns arise where applicants use private GPs or consultants (outside of a GP referral) which may also remain unknown to firearms licensing teams.” Source location Response from NPCC
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 circumstances of deliberate online medical concealment and dishonest declarations appear difficult to address through legislation.
Verbatim wording from the response “The difficulties posed by this case however appear difficult to legislate against;” Source location Response from NPCC
Open published response
Concerns raised 3 Failure of procedures to support appropriately prompt response to collision alerts indicating possible risk to life View source Inadequate training for responding to serious car crash detection alerts View source Insufficient police understanding of serious car crash detection technology View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
George Robert DILLON · 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
George Robert DILLON, aged 19, lost control of his car on a country road on 18 May 2023 and collided with a tree. He suffered catastrophic injuries and died in hospital on 20 May 2023. The report raised concerns about the understanding, training and procedures for responding promptly to automatic emergency calls from devices indicating a possible collision and risk to life.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of procedures to support appropriately prompt response to collision alerts indicating possible risk to life
Wider context from the report “A. At 22.26pm Hampshire Constabulary’s control room received an automated telephone call from the deceased’s i-Phone indicating that the deceased had been in a serious car crash and was not responding to their i-Phone. The operator logged “no direct request made and cannot hear anything distinctive in the background – no sounds of distress/disturbance. An accurate location was provided by the i-Phone.
B. The iPhone was called back, but the call went straight to voicemail.
C. The control room supervisor forwarded the message to the intelligence team to establish who the i-Phone belonged to and whether there was any serious harm or risk to life at that time.
D. By 22.43 the intelligence team had drawn a blank. But for a separate telephone call from a member of the public at 22.45, further steps may have been made to make contact (one of which, an “!cetrak” message which was sent to the i-Phone at 22.59 asking whether there was an emergency and requesting a 999 call if so) or a Police vehicle may have been assigned to attend the GPS co-ordinates provided by the i-Phone or no further action taken.
E. The evidence indicated that false alarms from electronic devices such as telephones and watches are commonplace, and that locations received from such devices was often inaccurate and liable to involve substantial Police time in tracking the device down.
F. The Apple serious car crash detection automatic calls were a recent development at the time of the index accident. Other manufacturers have launched a similar feature. The investigating officer stated during the inquest that “not enough is known (by the police) about this technology within people’s personal phones.”
G. I am concerned that the understanding, training and procedures need review to assist with appropriately prompt response in situations where there is an indication of a collision where a risk to life may exist.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate training for responding to serious car crash detection alerts
Wider context from the report “A. At 22.26pm Hampshire Constabulary’s control room received an automated telephone call from the deceased’s i-Phone indicating that the deceased had been in a serious car crash and was not responding to their i-Phone. The operator logged “no direct request made and cannot hear anything distinctive in the background – no sounds of distress/disturbance. An accurate location was provided by the i-Phone.
B. The iPhone was called back, but the call went straight to voicemail.
C. The control room supervisor forwarded the message to the intelligence team to establish who the i-Phone belonged to and whether there was any serious harm or risk to life at that time.
D. By 22.43 the intelligence team had drawn a blank. But for a separate telephone call from a member of the public at 22.45, further steps may have been made to make contact (one of which, an “!cetrak” message which was sent to the i-Phone at 22.59 asking whether there was an emergency and requesting a 999 call if so) or a Police vehicle may have been assigned to attend the GPS co-ordinates provided by the i-Phone or no further action taken.
E. The evidence indicated that false alarms from electronic devices such as telephones and watches are commonplace, and that locations received from such devices was often inaccurate and liable to involve substantial Police time in tracking the device down.
F. The Apple serious car crash detection automatic calls were a recent development at the time of the index accident. Other manufacturers have launched a similar feature. The investigating officer stated during the inquest that “not enough is known (by the police) about this technology within people’s personal phones.”
G. I am concerned that the understanding, training and procedures need review to assist with appropriately prompt response in situations where there is an indication of a collision where a risk to life may exist.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient police understanding of serious car crash detection technology
Wider context from the report “A. At 22.26pm Hampshire Constabulary’s control room received an automated telephone call from the deceased’s i-Phone indicating that the deceased had been in a serious car crash and was not responding to their i-Phone. The operator logged “no direct request made and cannot hear anything distinctive in the background – no sounds of distress/disturbance. An accurate location was provided by the i-Phone.
B. The iPhone was called back, but the call went straight to voicemail.
C. The control room supervisor forwarded the message to the intelligence team to establish who the i-Phone belonged to and whether there was any serious harm or risk to life at that time.
D. By 22.43 the intelligence team had drawn a blank. But for a separate telephone call from a member of the public at 22.45, further steps may have been made to make contact (one of which, an “!cetrak” message which was sent to the i-Phone at 22.59 asking whether there was an emergency and requesting a 999 call if so) or a Police vehicle may have been assigned to attend the GPS co-ordinates provided by the i-Phone or no further action taken.
E. The evidence indicated that false alarms from electronic devices such as telephones and watches are commonplace, and that locations received from such devices was often inaccurate and liable to involve substantial Police time in tracking the device down.
F. The Apple serious car crash detection automatic calls were a recent development at the time of the index accident. Other manufacturers have launched a similar feature. The investigating officer stated during the inquest that “not enough is known (by the police) about this technology within people’s personal phones.”
G. I am concerned that the understanding, training and procedures need review to assist with appropriately prompt response in situations where there is an indication of a collision where a risk to life may exist.
” 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 Direct a task-and-finish group to create an agreed national position on automated crash-detection calls, including e-call, mobile-phone and wearable notifications.
Verbatim wording from the response “In my role as NPCC lead for Contact Management I chair the National Contact Management Steering Group (NCMSG), which is made up of representatives from all police forces in England and Wales, plus Police Scotland and the Police Service of Northern Ireland. Attendees also include representatives from government departments, HMICFRS, College of Policing and BT. I will be directing a task and finish group from the NCMSG on 13th September 2024 to work in fast time to create an agreed national position in relation to automated calls, including e-call, mobile phone crash detection and wearables notifications.” Source location Response from NPCC
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 Review and refresh the Code of Practice for the Public Emergency Call Service, including arrangements for SOS alerts using UK GSM networks.
Verbatim wording from the response “I also chair the 999/112 Liaison Committee, which is a cross emergency service and governmental board, with attendees from BT, Vodafone and Ofcom supported by the Department for Science, Innovation and Technology. This committee have ownership of the Code of Practice for the Public Emergency Call Service (PECS) which is the definitive document which deals with the method of handling 999/112 public emergency telephone calls between call handling agents and the emergency authorities. This is currently under review and includes in Memorandum of” Source location Response from NPCC
Open published response
3 Jun 2024 Tcherno Bari · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 12 Failure to ensure police access to the written risk assessment View source Failure to provide attending police officers with the written risk rating View source Failure to maintain an accurate and up-to-date missing person policy View source Lack of police officer awareness of the required risk rating View source Failure to communicate the RCRP challenge process to BSMHFT View source Delays in communicating police disagreement with the reported risk category View source Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise View source Lack of formal notification of police disagreement about risk category View source Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients View source Failure to inform BSMHFT when missing patient investigations are closed View source Failure to invite police representatives to daily appraisal meetings View source Failure of routine monitoring to ensure completion of the risk rating View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tcherno Bari · 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
Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police access to the written risk assessment
Wider context from the report “(7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment , or require attending constables, or later the Locate team, to request a copy of the risk assessment . In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide attending police officers with the written risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy . I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’ , and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an accurate and up-to-date missing person policy
Wider context from the report “(5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP . I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer awareness of the required risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’ . Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’ .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the RCRP challenge process to BSMHFT
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT . Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it . However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process . Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Delays in communicating police disagreement with the reported risk category
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later , and WMP often close missing patient investigations without informing BSMHFT.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise
Wider context from the report “(8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. RCRP and APP appear to regard reports from mental health clinicians no differently to those from members of the public, and family and friends of the missing person . Context: police witnesses agreed that BSMHFT clinicians were the experts on mental health diagnosis, including identifying those conditions that carry an increased risk of suicide, and assessing the risk of suicide generally. However, this case demonstrates how in the heat of the moment an (inexperienced) attending constable can overlook that expertise and quickly dismiss it .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal notification of police disagreement about risk category
Wider context from the report “(6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category . BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients , and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case, and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform BSMHFT when missing patient investigations are closed
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to invite police representatives to daily appraisal meetings
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case , and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’ .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of routine monitoring to ensure completion of the risk rating
Wider context from the report “(2) A ‘monitoring tool’ in the BSMHFT Missing Patient Policy requires routine monitoring to ensure nurses are completing ‘appendix A’ and ‘appendix B’, but not ‘appendix C – risk rating’ . Context: I was told this is under review, however I was concerned this is still outstanding 9 months following the death .
” 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 Develop and publish national Right Care Right Person guidance, toolkit and implementation materials for police forces and partner agencies.
Verbatim wording from the response “It is also worthy of note that the first phase of the NPCC/College of Policing RCRP guidance was not published until July 2023 (alongside the NPA) which included the Senior responsible officer SRO role, Baseline and evaluation criteria and communication plan considerations modules.
The policy considerations, force control room implementation and e-learning modules were published in December 2023. This was followed by the Implementation principles for incidents involving children in June 2024. It is our understanding that West Midlands Police are currently reviewing their policies and procedures against the Right Care Right Person national guidance.” Source location Response from NPCC
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 RCRP did not apply because the case was treated as a missing person involving immediate risk requiring police response.
Verbatim wording from the response “The Missing persons framework is another distinct policy area which falls outside of RCRP when it is established that a persons whereabouts cannot be ascertained and all reasonable enquiries have been made by the informant to ascertain their whereabouts.” Source location Response from NPCC
Open published response
25 Apr 2024 Dr Jonathan Harvey Shaw · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Inability to retain consignments beyond the 30-day holding period View source Lack of training for joint working on managing overseas consignments of the substance View source Lack of national guidance on joint working for managing overseas consignments of the substance View source Lack of a legal requirement to alert the local police force before releasing consignments View source Lack of a legal requirement to request a welfare check before releasing consignments View source Lack of legal powers to seize consignments of the substance 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.
×
AI-generated summary
Dr Jonathan Harvey Shaw · 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
Dr Jonathan Harvey Shaw took his own life by intentionally ingesting the contents of a package purchased online from a Malaysian company. The package had been stopped by UK Border Force but was released without consultation with Greater Manchester Police, after which Dr Shaw used its contents to end his life. The report identifies concerns about the 30-day limit on holding the consignment and the absence of national guidance or training for police and UK Border Force on managing such consignments and coordinating welfare checks or safe destruction.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Inability to retain consignments beyond the 30-day holding period
Wider context from the report “The UK Border Force do not have the legal powers to seize a consignment of ████████ because it is not a prohibited poison under the Poisons Act 1972. If there is an ongoing police investigation or police interest in a particular consignment, the UK Border Force can use section 19 of the Police and Criminal Evidence Act 1984 to stop and hold. However the holding power is limited to 30 days, after which the consignment must be released .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of training for joint working on managing overseas consignments of the substance
Wider context from the report “There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on joint working for managing overseas consignments of the substance
Wider context from the report “There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a legal requirement to alert the local police force before releasing consignments
Wider context from the report “There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a legal requirement to request a welfare check before releasing consignments
Wider context from the report “There is no national guidance or training provided to Police Forces or the UK Border Force on joint working around the management of ████████ from overseas which have been ordered by individuals inside the UK for the purpose of ending their own life. There is no legal requirement to alert the local police force before a consignment is released or to request a welfare check during which the recipient could be invited to agree to the safe destruction of the parcel by the police or UK Border Force .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of legal powers to seize consignments of the substance
Wider context from the report “The UK Border Force do not have the legal powers to seize a consignment of ████████ because it is not a prohibited poison under the Poisons Act 1972. If there is an ongoing police investigation or police interest in a particular consignment, the UK Border Force can use section 19 of the Police and Criminal Evidence Act 1984 to stop and hold. However the holding power is limited to 30 days, after which the consignment must be released.
” Open source report
19 Dec 2023 Chloe Elizabeth MACDERMOTT · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Lack of prominent signposting to organisations providing suicide-prevention help View source Internet availability and delivery of an unspecified item to individual users in the UK View source Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide View source Failure of effective border and customs controls for delivery of an unspecified item to UK users View source Lack of age or other access restrictions for children, vulnerable teenagers and vulnerable adults View source Failure to effectively remove posts containing details of suicide methods 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.
×
AI-generated summary
Chloe Elizabeth MACDERMOTT · 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
Chloe Elizabeth MACDERMOTT died at home in the early hours of 23 May 2021 after ingesting a substance purchased through Amazon US. The report identifies concerns about online forums encouraging, assisting and counselling suicide, inadequate age restrictions and signposting to help, harmful content not being effectively removed, and the availability and delivery of the product to UK users without effective border or customs controls.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of prominent signposting to organisations providing suicide-prevention help
Wider context from the report “(6) No prominent signposting is in place to organisations from whom help is available to prevent suicide .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Internet availability and delivery of an unspecified item to individual users in the UK
Wider context from the report “(9) The availability of ████████ through the internet and its delivery to individual users in the UK with a non-commercial or agricultural use.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Open chatrooms permitting the exchange of information and methods that encourage, assist, counsel or procure suicide
Wider context from the report “(3) ████████ is a forum that permits material to be exchanged and reviewed within its open chatrooms whereby suicide is encouraged, assisted, counselled and procured through the provision and exchange of information and methods .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of effective border and customs controls for delivery of an unspecified item to UK users
Wider context from the report “(10) The ability for UK users to purchase ████████ through Amazon in the United States and to take delivery in the United Kingdom without effective border and/or custom controls .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of age or other access restrictions for children, vulnerable teenagers and vulnerable adults
Wider context from the report “(5) No age or other restrictions are in place to prevent access to children, vulnerable teenagers and vulnerable adults .
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively remove posts containing details of suicide methods
Wider context from the report “(7) Posts are made by users containing details of methods of suicide without any effective administration to remove such harmful content .
” Open source report
25 Oct 2023 Carl FULLALOVE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 5 Failure of ABD training and recognition processes to identify nuanced signs in drug intoxication and consider prone-restraint risks View source ABD training failing to support reliable identification of underlying medical conditions and referral in dynamic settings View source First-aid training failing to include calming-intervention training View source Rigid ABD training focused on specific symptoms and failing to support recognition of other signs View source Training and research material omitting stimulant-drug effects and calming upright de-escalation before restraint View source See 2 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
Carl FULLALOVE · 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
Carl Fullalove was arrested after being observed jumping on cars, behaving bizarrely and appearing to be under the influence of a substance. He was placed in prone restraint during a search in custody, became non-responsive and suffered cardiac arrest, and subsequently died in hospital. The principal concerns were that signs of acute behavioural disturbance or illness were not recognised, the risks of prone restraint and stimulant drugs were not sufficiently considered, and training did not adequately address calming intervention in an upright position.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of ABD training and recognition processes to identify nuanced signs in drug intoxication and consider prone-restraint risks
Wider context from the report “(1)Whilst the jury did not make any finding of acute behavioural disturbance (ABD) in this case, much evidence was heard about the training in identification of the signs and symptoms. National training of police officers on the identification of ABD is focused on a triad of warning flags being, hot to touch, exhibiting constant or near constant activity and extreme agitation or aggression. Some evidence identified that Carl Fullalove did not exhibit these triad symptoms but did exhibit other nuanced symptoms in the long list delivered in training. It was evident that his symptoms were not recognised as ABD due to drug intoxication, and that the consequential risks associated with prone restraint were not therefore considered. Prone restraint ultimately led to his death. There were six experts providing evidence to the inquest two of whom identified that Carl would not have died had he been recognised as unwell at the point of arrest and assessed by a health care practitioner. Such attention would have provided a calming intervention for his heart rate and breathing prior to being placed in prone restraint, which exerted additional pressure on his ability to breath freely.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation ABD training failing to support reliable identification of underlying medical conditions and referral in dynamic settings
Wider context from the report “(3)Significant training on ABD had been delivered by Cheshire Constabulary through the College of Policing Personal Safety Training package module, the key to which was to identify an underlying medical condition to refer to a health care practitioner. That may be a lot to expect of police officers in a dynamic fast paced setting. The use of the term ABD may be a distraction.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation First-aid training failing to include calming-intervention training
Wider context from the report “(5)The First Aid Learning Programme (FALP) will be in place within Forces by April 2024 and includes amongst other things positional asphyxia, unconscious and not breathing, and ABD but does not mention training in calming intervention that on balance of probabilities may have led to a different outcome in this case.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Rigid ABD training focused on specific symptoms and failing to support recognition of other signs
Wider context from the report “(2)A research paper before the inquest, namely ‘Consensus on Acute Behavioural Disturbance in the UK, September 2023 recommends that the focus remain on the triad of warning signs. ABD is clearly difficult to distinguish from drug intoxication by a non-medical practitioner. The rigidity of the training with focus on specific symptoms can cause police officers to miss other signs. The Superintendent, and head of ‘Protecting Vulnerable People’ for Cheshire accepted that with hindsight the use of prone restraint was inadvisable in this case.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Training and research material omitting stimulant-drug effects and calming upright de-escalation before restraint
Wider context from the report “(4)The effect of stimulant drugs and the need for calming de-escalation in an upright position, rather than prone restraint, had not been noted in either the training material or the research paper presented to the Court. This is on the background of recognising from College of Policing guidance that a high percentage of deaths in prone restraint are in drug related cases.
” Open source report
6 Oct 2023 John George CONDRON · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of agreed timescales for informing suspects of police decisions to take no further action View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John George CONDRON · 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 George Condron was found dead at his home on 2 November 2017, suspended from loft roof beams by a rope ligature. He was under police investigation and had not been informed that no further action had been decided in relation to the most serious allegation, which the report states exacerbated the extreme anxiety and stress he was experiencing. The principal concern was the absence of an agreed timescale or protocol for informing suspects of such decisions, with concern that further self-inflicted deaths could occur as a result.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed timescales for informing suspects of police decisions to take no further action
Wider context from the report “(1) I received evidence confirming the absence of any agreed protocol relating to timescales for a suspect to be informed by the police of a decision to take no further action in respect of allegations made against them . At the conclusion of the Inquest, it was confirmed that this was the position both at the time of Mr Condron’s death in November 2017 and at the conclusion of the Inquest in September 2023.
(2) I received evidence that at a National Level, the Victim’s Code of Practice provides that a victim has a right to be informed of key decisions in an investigation within 5 working days, or within 1 working day if they are eligible for Enhanced Rights. This includes a decision by the police to take no further action in respect of the allegations they have made. There is no such code of practice in respect of informing suspects of the same .
(3) I have concerns that further self-inflicted deaths will occur in circumstances where a suspect is not informed, within a specified time period, of a decision to take no further action in respect of allegations made against them .
” Open source report
2 Oct 2023 Jack Peter Zarrop · Prevention of Future Deaths report West London
View report summary
Concerns raised 3 Lack of adequate mental health training for Custodial Nurse Practitioners seeing high-risk and complex patients in police custody View source Failure to train agency healthcare staff in the ACCT process and the threshold for opening an ACCT View source Failure of the 2003 Home Office circular to recognise suicide and self-harm risk as a core competency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jack Peter Zarrop · 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
Jack Peter Zarrop, who had a history of mental-health difficulties, alcohol abuse and previous suicide attempts, died by suicide while in custody. The jury identified failures relating to referral to Liaison and Diversion services, opening an ACCT, access to relevant history, and removal of a bedsheet and closure of a hatch as main contributing factors. The report raised concerns about the use and training of Custodial Nurse Practitioners in police custody and the training of agency prison healthcare staff in the ACCT process.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate mental health training for Custodial Nurse Practitioners seeing high-risk and complex patients in police custody
Wider context from the report “1. The use of Custodial Nurse Practitioners (CNPs) in Police custody instead of doctors. The 2003 Home Office circular appeared to envisage nurses working alongside doctors, when this is not how they are deployed. CNPs are also seeing high risk and complex patients without adequate training in mental health . The deployment in Police custody of CNPs places detained persons at risk of death in the future . The 2003 Home Office circular also does not recognise the risk of suicide and self-harm as being a core competency.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to train agency healthcare staff in the ACCT process and the threshold for opening an ACCT
Wider context from the report “2. The training of agency staff in the ACCT process and recognising the appropriate threshold to open an ACCT . The training of agency staff in ACCT does not appear to be part of the commissioning process by NHS England and individual providers do not appear to provide training to agency staff in the ACCT process . This places residents in prison at risk of death, given the high level of usage of agency healthcare staff in prison.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the 2003 Home Office circular to recognise suicide and self-harm risk as a core competency
Wider context from the report “1. The use of Custodial Nurse Practitioners (CNPs) in Police custody instead of doctors. The 2003 Home Office circular appeared to envisage nurses working alongside doctors, when this is not how they are deployed. CNPs are also seeing high risk and complex patients without adequate training in mental health. The deployment in Police custody of CNPs places detained persons at risk of death in the future. The 2003 Home Office circular also does not recognise the risk of suicide and self-harm as being a core competency .
” 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 Provide the latest draft National Healthcare Specification, including requirements for governance, qualifications, competency assessment and clinical supervision.
Verbatim wording from the response “Chief Officers are able to use the National Healthcare Specification to determine the type of medical care they require. The Specification can be tailored by forces should they not require all elements, and they can tender for the services they need; but the document is clear with regard training and qualifications. I attach the latest version of the service specification (draft until ratified by NHSE Clinical Reference Group – Nov 2023), which may be useful, and would like to highlight the following sections which I hope will provide you with reassurance:” Source location Response from National Police Chief's Council
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 Work with NHS England and other stakeholders to deliver a fit-for-purpose police custody healthcare service specification.
Verbatim wording from the response “I have reviewed the 2003 circular and would like to highlight that custodial healthcare has changed considerably since that point. The 2003 circular refers to the practice of using Police Surgeons in custody, this role is no longer in existence. Police Custody is a very regulated and scrutinised area of policing, it plays a pivotal role in the criminal justice process and cares for some of the most challenging and vulnerable people in society at what is often a very testing time. Our aim is to be effective, safe and to ensure that people are treated fairly, with as much dignity as possible. Having professional officers and staff who are well trained is essential. The NPCC Custody Portfolio works closely with NHS England, partners, and other stakeholders to deliver a service specification that is fit for purpose.” Source location Response from National Police Chief's Council
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 national healthcare specification adequately addresses custody healthcare qualifications, competency, supervision and training for doctors, nurses and paramedics.
Verbatim wording from the response “Chief Officers are able to use the National Healthcare Specification to determine the type of medical care they require. The Specification can be tailored by forces should they not require all elements, and they can tender for the services they need; but the document is clear with regard training and qualifications. I attach the latest version of the service specification (draft until ratified by NHSE Clinical Reference Group – Nov 2023), which may be useful, and would like to highlight the following sections which I hope will provide you with reassurance:” Source location Response from National Police Chief's Council
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 2003 circular is outdated because the police surgeon role no longer exists and custodial healthcare has substantially changed.
Verbatim wording from the response “I have reviewed the 2003 circular and would like to highlight that custodial healthcare has changed considerably since that point. The 2003 circular refers to the practice of using Police Surgeons in custody, this role is no longer in existence. Police Custody is a very regulated and scrutinised area of policing, it plays a pivotal role in the criminal justice process and cares for some of the most challenging and vulnerable people in society at what is often a very testing time. Our aim is to be effective, safe and to ensure that people are treated fairly, with as much dignity as possible. Having professional officers and staff who are well trained is essential. The NPCC Custody Portfolio works closely with NHS England, partners, and other stakeholders to deliver a service specification that is fit for purpose.” Source location Response from National Police Chief's Council
Open published response
3 Jul 2023 Andre Felipe Mendes Moura · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of formal training on suspected feigned unresponsiveness View source Failure to share AVPU findings with other officers View source Failure to recognise and perform the safety officer role during restraint incidents View source Failure to use objective AVPU checks for unresponsiveness View source Lack of formal measurement of ABD training knowledge View source Failure of ABD training to enable recognition in real-life settings View source Failure to require body worn video during prisoner escorts nationally View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andre Felipe Mendes Moura · 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
Andre Moura died on 7 July 2018 after suffering cardiac arrest in a police vehicle while under arrest and being transported following a significant struggle. The report identified concerns about officers’ recognition and training in acute behavioural disturbance, use of objective responsiveness checks, the safety officer role, and the absence of body-worn camera recording during escort.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal training on suspected feigned unresponsiveness
Wider context from the report “4. Many of the officers who gave evidence indicated that they believed that Mr Moura was feigning his lack of responsiveness. This was despite the fact that there was very limited evidence of officers carrying out the recognised AVPU checks. Officers relied on their own perceptions rather than AVPU. An officer who did carry out AVPU did not clearly share his lack of responsiveness with other officers. The Inquest heard that there is no formal training on what officers should do if they believe a prisoner under arrest is feigning unresponsiveness . Clarification and enforcement of the need for objective use of AVPU may well prevent subjective assessments leading to erroneous and potentially fatal conclusions that a prisoner is feigning lack of responsiveness;
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to share AVPU findings with other officers
Wider context from the report “4. Many of the officers who gave evidence indicated that they believed that Mr Moura was feigning his lack of responsiveness. This was despite the fact that there was very limited evidence of officers carrying out the recognised AVPU checks. Officers relied on their own perceptions rather than AVPU. An officer who did carry out AVPU did not clearly share his lack of responsiveness with other officers . The Inquest heard that there is no formal training on what officers should do if they believe a prisoner under arrest is feigning unresponsiveness. Clarification and enforcement of the need for objective use of AVPU may well prevent subjective assessments leading to erroneous and potentially fatal conclusions that a prisoner is feigning lack of responsiveness;
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and perform the safety officer role during restraint incidents
Wider context from the report “3. The role for a safety officer which is part of the College of Policing training in a situation such as this was not recognised . The Inquest heard evidence from an expert witness that a safety officer plays a key role in an incident such as the one involving Mr Moura and ensures key information is not lost/shared. This lack of an officer at his head taking on such a role emphasised the fact that although officers had attended the PST training key points had not been retained. Greater emphasis on this role in training would be beneficial in reducing the risk to prisoners being restrained;
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to use objective AVPU checks for unresponsiveness
Wider context from the report “4. Many of the officers who gave evidence indicated that they believed that Mr Moura was feigning his lack of responsiveness. This was despite the fact that there was very limited evidence of officers carrying out the recognised AVPU checks . Officers relied on their own perceptions rather than AVPU . An officer who did carry out AVPU did not clearly share his lack of responsiveness with other officers. The Inquest heard that there is no formal training on what officers should do if they believe a prisoner under arrest is feigning unresponsiveness. Clarification and enforcement of the need for objective use of AVPU may well prevent subjective assessments leading to erroneous and potentially fatal conclusions that a prisoner is feigning lack of responsiveness;
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal measurement of ABD training knowledge
Wider context from the report “2. The Inquest heard that the ABD training did not have any formal way of measuring/testing knowledge but was reliant of the perception of the trainer . A more formalised approach may have increased the ability of officers to recognise ABD;
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of ABD training to enable recognition in real-life settings
Wider context from the report “1. During the course of the Inquest, evidence was heard about the understanding and training in relation to Acute Behaviour Disturbance (ABD). All of the officers who had received their College of Policing Personal Safety Training had been trained on the ABD module within that package. However it was clear that the training package had not achieved the objective i.e. to recognise ABD in a real life setting . The Inquest heard that ABD is an umbrella term and not all of the symptoms need to be present for someone to be suffering from ABD. It was clear from the officers’ evidence that the videos played in the training particularly of extreme examples of ABD had led them to not consider or recognise ABD in this situation . The Inquest heard that it could be difficult to recognise ABD in a dynamic situation but the training was there to ensure officers considered it in situations where it was a possible explanation for behaviour seen by officers. An emphasis on the nuances and less on extreme examples may assist in improving the recognition of ABD;
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to require body worn video during prisoner escorts nationally
Wider context from the report “5. The officers escorting Mr Moura to the police station did not have their body worn cameras on. Greater Manchester Police (GMP) at the time did not have a policy at that time requiring escorting officers to switch on their Body Worn Video (BWV) cameras. GMP do now require that BWV cameras are on. This is an important change but it was not clear if all forces have implemented such a change . Given that the evidence before the inquest made it clear that the change in practice by GMP was important in allowing clarity around how a prisoner is behaving whilst being escorted to custody it is important that its use at all times should be promoted nationally .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and publish NPCC body-worn video guidance requiring recording during prisoner transport and addressing coverage, access and retention of journey footage.
Verbatim wording from the response “In relation to point 5, we are in the process of re-writing and revising the NPCC Body Worn Video (BWV) guidance and it has been agreed that we would include that BWV should be left running during periods of prisoner transport, due to the vulnerability of officers and subjects during that process, and to provide a documented account of that journey. This guidance will be published in October, and I share the relevant draft wording below:” Source location Response from National Police Chief's Council
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 College of Policing is responsible for addressing the four concerns concerning personal safety and Acute Behaviour Disturbance training.
Verbatim wording from the response “I note you set out five areas of concern, four of which focus on College of Policing Personal Safety Training, with particular focus on Acute Behaviour Disturbance (ABD). I am aware the College of Policing have written to you separately to address these points and have shared the timeframes for implementation of new Public and Personal Safety Training and revised ABD training.” Source location Response from National Police Chief's Council
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Chiefs’ Council; 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 Chiefs’ Council; 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 Chiefs’ Council; 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 Chiefs’ Council; 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 Chiefs’ Council; 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
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maxine Betty Davison and 4 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; 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 National Police Chiefs’ Council; 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 National Police Chiefs’ Council; 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
23 Feb 2023 Anthony John Raymond INGRAM · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Lack of standardised information-sharing requirements or protocols for cross-border missing-person investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony John Raymond INGRAM · 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
Anthony Ingram was found deceased at his second home in Suffolk on 29 March 2022, having died by hanging. The report identified poor communication between the Metropolitan Police and Suffolk Constabulary, including failure to share information that he had a rope and a collapsible bicycle, resulting in a missed opportunity to find him earlier. The principal concern was the lack of standardised information-sharing requirements or protocols for cross-border missing-person investigations, including cases involving suicidal missing people.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised information-sharing requirements or protocols for cross-border missing-person investigations
Wider context from the report “It was clear that crucial information (that Anthony had a rope in his possession, and a collapsible bicycle providing a secondary form of transport) was not passed between the Metropolitan Police and Suffolk Constabulary.
It was heard that there was no set format, or prescribed information requirements to be shared by officers reporting missing persons between one force and another . Investigating officers in the Metropolitan police spoke to the Suffolk Constabulary control room, whose staff logged what they were told onto the CAD record. This information was then relayed to the officers on the ground.
Witnesses in this case stated that there is no standardised information sharing requirement or protocol for cross border missing persons investigations (including missing persons with suicidal ideation) .
I am concerned that, as there is no standardised information sharing requirements or protocols in such cases, in the future a force receiving details of a suicidal missing person may also not be informed that an individual has taken a means of suicide with them. In addition, other important information that may assist in the search for that person may also not be passed .
” 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 Update the National Transfer form to capture requests for enquiries in another force, including direct telephone or video communication of risk and urgency.
Verbatim wording from the response “In addition to the above The National Transfer form is being updated to include a section to be used for requesting enquiries in another force. One of the new recommendations is to require the officer requesting the enquiries or transfer to contact by telephone or video call the key decision-maker in the other force so that the level of risk and urgency of enquiries can be effectively communicated, rather than rely on what is written on an email or the incident log. We are still waiting for the new form to be completed, but there is a working party completing that task and it is anticipated that it will be available in the next few weeks when the new processes will go live.” Source location Response from National Police Chiefs' Council
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 consult forces on NPCC advice for requesting missing-person enquiries in another force and transferring investigations.
Verbatim wording from the response “Further to the APP guidance a Task and Finishing Group has been initiated focusing on the very issue you have outlined. Draft NPCC advice on ‘Requesting Missing Person Enquiries in Another Force and Transfers of Investigations’ has been developed and has now been circulated to all forces for consultation.” Source location Response from National Police Chiefs' Council
Open published response
Concerns raised 2 Lack of formal guidance, training, and protocols for correlating COMPACT risk assessments with ACT stop priority instructions View source Mismatch between COMPACT risk assessments and ACT stop priority instructions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
HANNAH WARREN · 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
Hannah Warren was reported missing on 3 February 2016 after leaving London by car while expressing delusional thoughts, and her body was found in Port Talbot harbour the following morning. The inquest concluded that she died from drowning and a head injury. Concerns included shortcomings in the missing-person investigation, including delayed or insufficient use of the ANPR Bureau, communication failures, failure to contact family, and the use of a low-priority vehicle stop despite a medium risk assessment; the report also identified a lack of formal guidance, training, or protocols linking these systems.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formal guidance, training, and protocols for correlating COMPACT risk assessments with ACT stop priority instructions
Wider context from the report “(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling;
(2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle.
(3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems ; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all.
(4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT.
(5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.
(6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Mismatch between COMPACT risk assessments and ACT stop priority instructions
Wider context from the report “(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling;
(2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle.
(3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all.
(4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT.
(5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all.
(6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically.
” Open source report
19 Jan 2023 Nicholas Dumphreys · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 3 Absence of standards for police garages and mechanics allowing inadequate performance to go unnoticed View source Failure of the informal approach to ensure passage of safety-critical information to individual police forces View source Lack of policy or guidance preventing auction of known faulty equipment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicholas Dumphreys · 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
Nicholas Dumphreys, a 47-year-old serving police officer, died on 26 January 2020 after the engine of his police BMW failed catastrophically while he was responding to an emergency call on the M6. The vehicle veered across the carriageway, overturned and crashed, causing fatal head injuries. Concerns included the robustness of communication of safety-critical information, the lack of policy to prevent faulty vehicles being auctioned, and the absence of national standards for police garages and mechanics.
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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Absence of standards for police garages and mechanics allowing inadequate performance to go unnoticed
Wider context from the report “(3) The evidence that I heard indicated that there are no national standards for police garages and mechanics. I can understand that overly prescriptive guidelines might not be fit for purpose; the nature of different police areas may place very different demands on vehicles. A 'one size fits all' policy could be problematic. However, I am concerned that the absence of any standards risks inadequate performance going unnoticed.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the informal approach to ensure passage of safety-critical information to individual police forces
Wider context from the report “(1) In the course of the inquest I heard evidence about the role of the National Association of Police Fleet Managers ('NAPFM'). BMW UK made several presentations to NAPFM with a view to them publicising concerns about the N57 engine to their members. However, I heard evidence from the current chair of NAPFM and it is important to make two observations. First, NAPFM membership is not mandatory. There are police fleet managers who, for whatever reason, might not choose to join. Second, NAPFM has no official standing, status, or budget. It is largely reliant on the goodwill of its members to function. I am concerned that this informal approach may not be sufficiently robust. It may not ensure that safety critical information is passed to individual police forces.
” 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 Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or guidance preventing auction of known faulty equipment
Wider context from the report “(2) Evidence was given as to how 'end of life' police vehicles are disposed of. It was explained that quite frequently such vehicles are sold at auction. In relation to vehicles with N57 engines I heard that a particular effort was made to ensure that they were not auctioned but were destroyed. However, this appeared to me to be an ad hoc arrangement. I am concerned that there is no policy or guidance which ensures that equipment which is known to be faulty is not auctioned off and purchased by unsuspecting members of the public.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to each Chief Constable and reissue N57 disposal advice as clearly NPCC-branded guidance.
Verbatim wording from the response “Whilst the guidance was from both NPCC and NAPFM, it was issued on NAPFM headed paperwork. Therefore week commencing the 20th March 2023, I am going to write to each Chief Constable attaching this response to your regulation 28 notice in order to highlight the importance of the issues you raise and my response as NPCC lead. Within this correspondence I will also reissue the N57 disposal advice but put this clearly under NPCC branded guidance.” Source location Response from National Police Chief's Council
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 implement Blue Light-specific training and accreditation for technicians working on police vehicles.
Verbatim wording from the response “This will reference industry best practice and minimum standards relevant to operating police vehicles, alongside participation and awareness of emerging risks across sector and industry. This work includes the development and implementation of Blue Light specific training and accreditation for technicians working on police vehicles. I do not yet have an honest assessment on how long this will take to develop, or indeed if every Chief Constable will agree to it. However, my commitment is that the NPCC Fleet portfolio will deliver options for the Police Service within the initial priorities in the portfolio work plan.” Source location Response from National Police Chief's Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement national police vehicle servicing, operating standards and a code of practice for adoption by forces.
Verbatim wording from the response “When I took ownership of the NPCC Fleet portfolio in Summer 2022 I asked for consistency and standards for police garages to be considered as a workstream. Since that time this has been developed into a workstream under the revised NPCC Fleet portfolio and structure as detailed in point one above.” Source location Response from National Police Chief's Council
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 Issue NPCC Fleet direction and guidance to every NPCC police force and organisation.
Verbatim wording from the response “• This governance structure will issue direction and guidance concerning Police Fleet to every NPCC Police Force/Organisation. This will be issued by the NPCC and not from NAPFM.” Source location Response from National Police Chief's Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish the reorganised NPCC Fleet governance and delivery structure, including strategic and tactical groups.
Verbatim wording from the response “A reorganisation of the NPCC Fleet structure has taken place and a new NPCC led governance and delivery structure is currently being established. This will ensure NPCC ownership and direction of all Police Fleet issues including the dissemination of safety critical information.” Source location Response from National Police Chief's Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop National Police Fleet Standards defining a consistent approach to disposing of police vehicles that may pose a risk.
Verbatim wording from the response “Policy and guidance will be developed as part of the “National Police Fleet Standards”. This will define a consistent approach for the disposal of any police vehicles that may pose a risk, through a common standard, agreed and held by the NPCC. This policy will be delivered as a priority workstream.” Source location Response from National Police Chief's Council
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations