15 Sep 2022 Harper DENTON · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 4 Lack of an offender register or equivalent protection for children from people convicted of cruelty against a child View source Failure to require Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children View source Failure to adopt MOSOVO guidance for managing sexual and violent offenders, particularly PDPs View source Lack of proactive police information sharing to protect children from people convicted of violence or cruelty against a child View source See 1 more concern
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Harper DENTON · 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
Harper DENTON, aged one month, was unlawfully killed by her father, who had previously been convicted of violent offences against a two-year-old child. The inquest found that failures by state agencies to manage the continuing risk he posed contributed to her death. Concerns included police information-sharing and risk-management practices, the absence of an offender register for people convicted of cruelty offences against children, and the non-mandatory nature of full safeguarding assessments by health visitors.
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× 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 an offender register or equivalent protection for children from people convicted of cruelty against a child
Wider context from the report “3. There is nothing today, such as form of Offender Register, to protect children from an individual who has already been convicted of a cruelty offence against a child and served their sentence.
” 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 Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children
Wider context from the report “4.The need for a Health Visitor to carry out a full safeguarding assessment of a father’s/co-parent's potential risks to a child is currently only ‘best practice’ and not mandatory .
” 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 adopt MOSOVO guidance for managing sexual and violent offenders, particularly PDPs
Wider context from the report “1.The MPS does not appear to have adopted ACPO Guidance on Protecting the Public: Managing Sexual Offenders and Violent Offenders 2010 and subsequent APP College of Policing MOSOVO Guidance , particularly with respect to PDPs .
” 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 proactive police information sharing to protect children from people convicted of violence or cruelty against a child
Wider context from the report “2. There appears to be a lacuna in pro-active information sharing practices by Police (similar to those found under Clare’s Law and Sarah’s Law) in order to protect children from those who may present a threat to them as a result of having previous convictions for violence/cruelty offences against a child - this concern is directed to the CEO College of Policing and the Chair of the NPCC.
” Open source report
29 Jul 2022 Christopher Dominic Boughton · Prevention of Future Deaths report Surrey
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Concerns raised 1 Lack of requirements for direct discussion between police forces during investigation tasking and transfers View source
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AI-generated summary
Christopher Dominic Boughton · 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
Christopher Dominic Boughton left home on 3 November 2021 and was later found deceased in a wooded location in Oxshott, Surrey, after friends searched areas he was known to visit. The inquest found that he took his own life by hanging at some point between being dropped off by taxi on 3 November and being found on the morning of 5 November. The principal concern was insufficient direct communication and coordination between bordering police forces when tasking and transferring investigations, which could delay effective action and the sharing of relevant information.
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× 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 requirements for direct discussion between police forces during investigation tasking and transfers
Wider context from the report “The evidence of Detective Inspector ████████, Tactical and Policy Lead for MPS, highlighted a concern that in tasking and transferring investigations between bordering Police forces, there is a lack of ownership and discussion between officers at Inspector level or above between forces, which would ensure effective tasking and, when necessary, smooth transfer of investigations . Requests were made by email and CAD, without discussions between officers.
This was confirmed in the evidence of Detective Chief Constable ████████ of SP, who stated that from her perspective there was a lack of feedback from SP to manage MPS’ expectations regarding a search for Mr Boughton.
In respect of the initial search, this meant that SP did not advise MPS that they considered the search request unfeasible given the extent of land outlined and the limitations on searching wooded areas during winter night hours.
In respect of the request for a further search with more precise location detailed provided, MPS did not disclose all of the information available regarding Family and friends potentially being able to assist in finding the location based upon where Mr Boughton used to visit. There was no feedback from SP regarding when a search might take place, leading MPS to consider deploying its own search team.
Whilst contact telephone numbers for Officers at MPS and SP were provided on the CAD, there is no evidence that direct contact was made between the forces to discuss the investigation and how best to move this forward. A SP officer recorded on the CAD that until the transfer document was received from MPS, SP were unable to arrange a search or contact the specialist search team.
Whilst DI ████████ gave evidence that he is aware the NPCC is reviewing issuing guidance around tasking and transfers between bordering Police forces, at present there appears to be no requirement for appropriate Police Officers to make telephone contact between forces to ensure effective tasking and transferring, in addition to the required written requests. This means an opportunity to discuss and pass on all relevant information between forces may be lost.
1. The lack of any detailed requirement for telephone discussion between appropriate police officers on sending through written tasking requests and considering transfers of investigation means that an opportunity to discuss and ensure smooth transition and passing on of relevant information is lost. This may cause delay in effective action being taken by the tasked Force, or (in the case of transfers) by the Force to whom it is considered a transfer will be made.
Consideration should be given to whether any steps can be taken to address the above concerns.
” 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 Develop and circulate draft NPCC advice on requesting missing-person enquiries in another force and transferring investigations for comment before finalisation and wider circulation.
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 for comment prior to finalisation and wider circulation.” Source location 2022-0235 - Response from NPCC
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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 Initiate a Task and Finishing Group focused on cross-border missing-person investigations and investigation transfers.
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 for comment prior to finalisation and wider circulation.” Source location 2022-0235 - Response from NPCC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing APP guidance and information-transfer procedures address the concerns about cross-border investigation tasking and transfers.
Verbatim wording from the response “Difficulties can arise when a person reported missing resides outside the area where the report is being made, for example, a student in temporary accommodation or a day trip visitor. The police area that receives the report must record it and carry out all necessary initial actions. If the responsibility for a case is subsequently transferred to another force area, the rationale for doing so must be recorded. Written acknowledgement from the receiving force should be obtained.
When deciding where ownership of the investigation lies, the principal issue is to consider where the majority of the enquiries are and who has the greatest opportunity of locating the missing person. It is probable that the area where the person was last seen would generate the majority of the initial enquiries (although this is not always the case, see also Out-of-area placements).” Source location 2022-0235 - Response from NPCC
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29 Jun 2022 Louise Theresa Bailey · Prevention of Future Deaths report South London
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Concerns raised 2 Failure to provide drivers with information about whether other units are closer for emergency-call risk assessment View source Lack of training on when officers should assign themselves over the radio 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
Louise Theresa Bailey · 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
Louise Theresa Bailey died after being struck by a police car responding to an incident while she was running across the road to catch a bus. The concern was that the police system and training did not ensure responding drivers had information about whether other units were closer, preventing them from completing a full risk assessment.
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× 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 drivers with information about whether other units are closer for emergency-call risk assessment
Wider context from the report “Chapter 13 of Roadcraft, the Police Driver’s Handbook, provides that before officers begin their response to an emergency call, they should go through a process of risk assessment. That includes consideration of whether other units are closer. However, in this case the driver and operator did not know the answer to that question. In part that was due to the fact that officers are encouraged to avoid assigning themselves over the radio during an ongoing incident to prevent clogging up of airwaves. However, I heard evidence that several units did in fact assign themselves over the radio, though not all with their location, and that no training is provided as to when to assign over the radio and when not to. Moreover, there is an emergency button which allows the originating officer to override other broadcasts if needed mitigating any risk of clogging up airwaves. My concern is that the current system and training does not facilitate drivers being provided with the information they need to answer the question “are other units closer?” which means they are unable to complete a full risk assessment .
” 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 on when officers should assign themselves over the radio
Wider context from the report “Chapter 13 of Roadcraft, the Police Driver’s Handbook, provides that before officers begin their response to an emergency call, they should go through a process of risk assessment. That includes consideration of whether other units are closer. However, in this case the driver and operator did not know the answer to that question. In part that was due to the fact that officers are encouraged to avoid assigning themselves over the radio during an ongoing incident to prevent clogging up of airwaves. However, I heard evidence that several units did in fact assign themselves over the radio, though not all with their location, and that no training is provided as to when to assign over the radio and when not to . Moreover, there is an emergency button which allows the originating officer to override other broadcasts if needed mitigating any risk of clogging up airwaves. My concern is that the current system and training does not facilitate drivers being provided with the information they need to answer the question “are other units closer?” which means they are unable to complete a full risk assessment.
” Open source report
14 Mar 2022 Aliny Godinho · Prevention of Future Deaths report Surrey
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Concerns raised 6 Lack of accessible cultural risk information for domestic abuse risk assessment View source Lack of systematic monitoring and auditing of domestic abuse investigations View source Lack of call-handler training on managing reports relating to ongoing domestic abuse investigations View source Failure of the Officer in the Case to complete required DASH risk assessment and DA Matters training View source Lack of effective training on the Domestic Abuse Policy and Procedure View source Lack of timely effective supervision of domestic abuse investigations 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
Aliny Godinho · 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 8 February 2019, Aliny Godinho was attacked and repeatedly stabbed in Ewell, Surrey, and died at the scene despite emergency medical attention. The report states that Surrey Police’s handling of earlier and same-day domestic abuse reports included failures in risk assessment, safeguarding, investigation, supervision, monitoring, call-centre handling and consideration of cultural risk; the inquest found that her death was probably more than minimally contributed to by Surrey Police.
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× 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 accessible cultural risk information for domestic abuse risk assessment
Wider context from the report “CONCERN 6
Cultural Risk: I found that there was a failure to take account of the risk arising from the fact that the perpetrator was from Brazil , where there is a considerably higher incidence of domestic homicide than in the United Kingdom. I was told that no national source of information concerning such cultural risks exists for the benefit of officers investigating domestic abuse who are required to assess and manage the risks arising. Although steps are being taken in Surrey to build knowledge of relevant cultural norms for local communities, I was told that a national data base of relevant and evidenced cultural information, whether based on statistical incidence of domestic violence or homicide, or otherwise, would assist in ensuring cultural risk is not overlooked .
” 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 systematic monitoring and auditing of domestic abuse investigations
Wider context from the report “CONCERN 4
Monitoring and Auditing: I was told that there is no system in place to monitor and audit the performance and effectiveness of the Domestic Abuse Team . Data from the “PowerBI” system is used to monitor matters such as case load, but there is no systematic monitoring or auditing (whether by use of Key Performance Indicators or otherwise) of the conduct of the investigations , including (for example) whether and when safeguarding and investigation plans have been made and implemented.
” 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 call-handler training on managing reports relating to ongoing domestic abuse investigations
Wider context from the report “CONCERN 5
Call Centre Training: The evidence at the inquest revealed that, on three occasions, reports made to Surrey Police concerning the perpetrator’s conduct were incorrectly passed to the Metropolitan Police, and without sufficient information first being adduced and risk assessed. I found that, on the third occasion in particular, the error contributed to Aliny Godinho’s death. I was told by the Contact Centre Performance Manager for Surrey Police that these errors had not been appreciated until the inquest hearing and that there were important lessons to be learned concerning the proper management by the Call Centre of reports relating to an ongoing Surrey domestic abuse investigation, when the victim is currently living outside Surrey. It was acknowledged that training for call handlers in respect of this learning is required but has not yet been provided .
” 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 Officer in the Case to complete required DASH risk assessment and DA Matters training
Wider context from the report “CONCERN 2
Training of DC ████████: I found that failures by the Officer in the Case, to implement the Domestic Abuse Policy and Procedure in relation to the investigation of Aliny Godinho’s complaint, contributed to the death. The outcome of the officer’s misconduct meeting was a requirement for her to undertake DASH risk assessment and “DA Matters” training by March 2021. The officer is currently working in Surrey Police’s Domestic Abuse Team but has not yet undertaken the required training and I consider this presents an ongoing 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 effective training on the Domestic Abuse Policy and Procedure
Wider context from the report “CONCERN 1
Training of the Domestic Abuse Team: At the inquest I heard that, at the time of the death, not all members of the Surrey Police SIU were familiar with and were implementing the contents of its Domestic Abuse Policy and Procedure ; this led directly to a number of the failings which, I found, contributed to Aliny Godinho’s death.
I have been told that all members of its new Domestic Abuse Team have been required to read its amended Domestic Abuse Policy and Procedure, but that training on the same, which is still being written, has not yet been delivered . I am concerned that unless and until effective training is delivered, a risk will continue .
” 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 timely effective supervision of domestic abuse investigations
Wider context from the report “CONCERN 3
Supervision of the Domestic Abuse Team: I found that Aliny Godinho’s death was contributed to not only by the failures of the Officer in the Case, but also by those of her supervising sergeant. At that time, there was an expectation that the sergeant would ensure that safeguarding and investigation plans were in place and were implemented, but there was no system in place to ensure that happened and, in relation to the investigation of Aliny Godinho’s complaint, it did not happen.
There continues to be no system in place to ensure, through supervision, that the steps which the Officer in the Case must take from the start of the investigation, including in relation to the initial risk assessment and the setting of safeguarding and investigation plans, have been taken in a timely manner . I was told that a supervisory review every 28 days is now included on “niche” as a task for the sergeant but, in my view, this will not ensure that there is effective supervision at any earlier stage of the investigation .
” Open source report
21 Jan 2022 Anthony Walgate and 3 others · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Lack of clarity about specialist and forensic support available when BCU retains primacy View source Use of “unexplained” death categorisation distracting officers from treating sudden deaths as suspicious until investigation establishes otherwise View source Failure to carry out handwriting verification appropriately and sensitively View source Lack of ownership and responsibility among officers leading unexplained-death investigations View source Closure of CRIS investigations without completion review and critical assessment of non-suspicious classification View source Lack of identity verification for users engaging escorts through the Sleepyboy website View source Lack of clarity in the policy framework guiding primacy decisions View source Inaccessibility or poor understanding of the SCRG as a complex-investigation review resource View source Failure to record investigation lines, actions and outcomes View source See 6 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
Anthony Walgate and 3 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
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor were four young men who were drugged with GHB and murdered. The report raises concerns about serious investigative failings, including how sudden deaths were categorised, the allocation and support of homicide investigations, leadership, recording and review of investigative actions, handwriting verification, death notifications and the response to coroners’ concerns. It also identifies concern that users of the Sleepyboy website could engage escorts without verifying their identities.
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× 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 clarity about specialist and forensic support available when BCU retains primacy
Wider context from the report “It remains a matter of concern that there is a lack of clarity surrounding the levels of support that can be expected from the specialist homicide investigators and crime scene managers or other forensic practitioners in the investigation of deaths where primacy remains with the BCU (MC2B).
” 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 Use of “unexplained” death categorisation distracting officers from treating sudden deaths as suspicious until investigation establishes otherwise
Wider context from the report “It is a matter of concern that although the current MPS policy, the Death Investigation Policy, dated 24 May 2021, similarly stipulates that officers attending the scene of a sudden death should treat the scene and incident as suspicious until satisfied that it is not, the term “unexplained” as used in the current policy may once again distract officers from the correct and necessary approach , which is for the death to be treated as suspicious unless and until the police investigation has established that it is not (MC1).
” 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 carry out handwriting verification appropriately and sensitively
Wider context from the report “Therefore, although it may only very rarely be the case that the verification of a person’s handwriting might have a critical impact on future deaths, it is a matter of concern to me that this task be carried out appropriately and sensitively to afford the police the best opportunity of any identification being accurate (MC5).
” 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 ownership and responsibility among officers leading unexplained-death investigations
Wider context from the report “It is a matter of concern that despite the regularly refreshed training that is now in place for detective sergeants and detective inspectors, and the additional leadership training in which the MPS has invested, a lack of ownership and responsibility for the investigations of unexplained deaths may persist in officers who are supposed to be leading investigations into unexplained deaths (MC3A).
” 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 Closure of CRIS investigations without completion review and critical assessment of non-suspicious classification
Wider context from the report “A further, related, matter of concern is that the CRIS was closed by supervising officers without any review of whether the actions had been completed or any critical assessment at detective sergeant level or detective inspector level of whether the investigation had established that the death was non-suspicious (MC4B).
” 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 identity verification for users engaging escorts through the Sleepyboy website
Wider context from the report “It is a matter of concern that users of the Sleepyboy website can engage escorts without having to verify their identity (MC6).
” 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 clarity in the policy framework guiding primacy decisions
Wider context from the report “It is a matter of concern that the current policy framework guiding decisions on primacy still lacks clarity (MC2A).
” 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 or poor understanding of the SCRG as a complex-investigation review resource
Wider context from the report “It nevertheless remains a matter of concern that the SCRG, which DAC ████████ commended as an asset to assist in the process of review of complex investigations is not, in practice, accessible and/or properly understood as a resource (MC3B).
” 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 record investigation lines, actions and outcomes
Wider context from the report “It remains a matter of concern that whatever the system, CRIS or CONNECT, officers may not record lines of investigation, actions and outcomes (MC4A).
” Open source report
26 Nov 2021 Felicity Jane Clough · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of accessibility to records held by different healthcare trusts View source Failure of Emergency Department staff to access vital pre-admission and paramedic records View source Lack of access by other police forces to information held on individual police force systems 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
Felicity Jane Clough · 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
Felicity Jane Clough was taken to hospital on 24 November 2019 after being prescribed Tramadol, discharged during the early morning, and later found collapsed and unresponsive in a field. The concerns included limited information-sharing between healthcare trusts and police forces, and the failure to consistently review paramedic records containing potentially critical information at Yeovil District Hospital.
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× 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 accessibility to records held by different healthcare trusts
Wider context from the report “i. There could be future deaths nationally due to the lack of accessibility to records held by different healthcare trusts . I would request consideration is given to the sharing of records between healthcare trusts.
” 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 Emergency Department staff to access vital pre-admission and paramedic records
Wider context from the report “iii. I have concerns that future deaths could occur at Yeovil District hospital due to the missing of vital information within the pre admission documentation due to the fact that the staff within the Emergency Department at Yeovil District Hospital are not always accessing admission documentation, especially the paramedic records when a person is brought into the Accident and Emergency department. I request that consideration is given to issuing further guidance to remind staff of the need to review this documentation or amending the current policy in place.
” 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 access by other police forces to information held on individual police force systems
Wider context from the report “ii. I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces , especially neighbouring forces who may both have contact with individuals. Whilst I understand there is some work being done on a regional basis to address this, I would request that the issue is considered nationally as to how information held on all Police systems, not just the Police National Database, can be shared to assist in the management and assessment of individuals and the risk they pose to themselves or others.
” Open source report
26 Nov 2021 Gary Williams · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1 Lack of training on temporal lobe epilepsy-related ictal automatism during restraint 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
Gary Williams · 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
Gary Williams died on 28 July 2017 after a pulmonary thromboembolism and deep venous thrombosis, with ictal automatism due to temporal lobe epilepsy also recorded as a cause. The report describes concerns about the lack of detailed information passed during handovers, omissions in medical records concerning restraint, use of force and injuries, and inconsistent communication between hospital departments. It also notes that ictal automatism was not included in College of Policing training materials on restraint.
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× 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 on temporal lobe epilepsy-related ictal automatism during restraint
Wider context from the report “Gary Williams suffered from Temporal lobe epilepsy. He was a retired police officer who was a very friendly and polite gentleman, when not unwell. He had previously had absences. However, nothing that can compare with the events in the eleven days before his death on the 28th July 2017. On the 18th July 2017 he suffered from an extreme acute behavioural disturbance, described as what appeared to be a psychotic delusional state in which array and violence to life and property was demonstrated. This was Ictal automatism due to temporal lobe epilepsy. A neurologist explained at the inquest that he felt sorry for the police, as they did not know the patient or with what they were dealing. He explained that there was no way to rationalise with some in this state - they are like a zombie and though they do not feel pain the use of PAVA, baton strikes and restraint will be responded to by the person’s fight and flight instincts. It is important to approach such a person with calm. In a neurological ward, it can take four experience health care professional and a fifth to sedate to deal with such a presentation. There is no treatment as such for this presentation just sedation and if necessary critical care support until the person has recovered. This condition is not part of the college of policing training materials with regard to use of restraint. You may consider that it would be helpful to include it in the minimum of 12 hours future mandatory annual restraint refresher training undertaken by all officers. In this case, officers, members of the public and health care professionals were distressed and exhausted but fortunately officers, healthcare professionals and the public did not suffer permanent serious or fatal harm.
” 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 Update and circulate the ABD Training Package for UK police forces, directing immediate delivery of the revised package.
Verbatim wording from the response “Subsequently the ABD Training Package for UK Police Forces was updated and circulated in March 2021 with a direction for Forces to deliver the revised ABD package with immediate effect. Additionally, The Royal College of Emergency Medicine Best practice Guidelines: Guidelines for the Management of Excited Delirium/Acute Behaviour Disturbance (ABD) May 2016, was also circulated to forces in September 2021 which contains a section on ‘restraint’ in relation to medical settings.” Source location 2021-0401-Response-from-NPCC_Published
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 Circulate emergency medicine best-practice guidelines on excited delirium and acute behavioural disturbance to police forces.
Verbatim wording from the response “Subsequently the ABD Training Package for UK Police Forces was updated and circulated in March 2021 with a direction for Forces to deliver the revised ABD package with immediate effect. Additionally, The Royal College of Emergency Medicine Best practice Guidelines: Guidelines for the Management of Excited Delirium/Acute Behaviour Disturbance (ABD) May 2016, was also circulated to forces in September 2021 which contains a section on ‘restraint’ in relation to medical settings.” Source location 2021-0401-Response-from-NPCC_Published
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 Obtain specialist emergency and forensic medicine advice on ABD training materials and trainer guidance.
Verbatim wording from the response “Specialist advice was sought from experts in emergency and forensic medicine who provided expert advice to SDAR relating to the ABD PowerPoint, notes for trainers and the National Personal Safety Manual.” Source location 2021-0401-Response-from-NPCC_Published
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 Continue reviewing learning from coroners, oversight bodies, stakeholders and police forces to inform restraint and self-defence training.
Verbatim wording from the response “The Self Defence Arrest and Restraint (SDAR) working group led by DAC ████████, works closely with the College of Policing. This group reviews the learning from coroners, the Independent Office of Police Conduct (IOPC), Her Majesty’s Inspectorate of Constabularies and Fire and Rescue Services (HMICFRS), stakeholders and police forces.” Source location 2021-0401-Response-from-NPCC_Published
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 update the ABD PowerPoint and Personal Safety Training Manual with additional restraint training.
Verbatim wording from the response “Following the Oak inquest, the SDAR group immediately reviewed and updated the existing ABD power point and the PST Manual. This included incorporating additional training which was identified and documented within our response to the coroner overseeing the proceedings in this case.” Source location 2021-0401-Response-from-NPCC_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing ABD training materials and package updates address the concern, with the arrangements remaining subject to continual review.
Verbatim wording from the response “Following the Oak inquest, the SDAR group immediately reviewed and updated the existing ABD power point and the PST Manual. This included incorporating additional training which was identified and documented within our response to the coroner overseeing the proceedings in this case.” Source location 2021-0401-Response-from-NPCC_Published
Open published response
19 Oct 2021 Donna Constantine · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Unavailability of verbatim recording for calls received by officers View source Lack of a clear escalation policy for calls received by officers from members of the community View source Failure to monitor officers’ work mobile phones when they are off duty or on annual leave View source Lack of a clear policy for creating an audit trail of actions taken on received calls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Donna Constantine · 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
Donna Ann Constantine, a vulnerable adult known to multiple agencies, was found severely decomposed at her home on 21 September 2019 after neighbours raised concerns. The post-mortem examination could not establish a cause of death, and the inquest conclusion was open. Concerns included the use of unmonitored police work mobile phones for contact from vulnerable people, alongside the absence of clear escalation, audit-trail, and verbatim call-recording policies.
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 Unavailability of verbatim recording for calls received by officers
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately.
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team .
” 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 clear escalation policy for calls received by officers from members of the community
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately.
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team.
” 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 monitor officers’ work mobile phones when they are off duty or on annual leave
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave . This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately .
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team.
” 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 clear policy for creating an audit trail of actions taken on received calls
Wider context from the report “The inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did.
However the phones are not monitored when officers are off duty or on annual leave. This inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately.
The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk.
In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team.
” Open source report
4 Oct 2021 LEON BRIGGS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 3 Failure of local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions View source Failure to provide continuous monitoring and risk assessment of detainees subject to restraint View source Insufficient training of police, ambulance crew and other front-line responders on medical emergencies and restraint risks 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
LEON BRIGGS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Leon Briggs was experiencing a psychotic disorder associated with exceptionally high amphetamine use when he was detained under section 136 of the Mental Health Act. Following restraint and conveyance to Luton Police station, he suffered cardiac arrest in the custody suite and later died in hospital. The principal concerns included poor communication, inappropriate restraint and use of force, inadequate medical assessment, unsatisfactory conveyance and supervision, and failures in risk assessment and monitoring that delayed recognition of his need for urgent medical attention.
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 local S136 multi-agency guidance to provide clear, usable, standalone and chronologically structured instructions
Wider context from the report “1. Adequacy of the local S136 Multi-Agency Policy
Whilst the local S136 guidance has changed considerably since the death of Leon, in my view, it is still not fit for purpose for the following reasons:
(i) It requires streamlining and re-formatting (including the use of a larger font) to make it easier for all agencies to follow – it may assist to focus on multi-agency activities ONLY (leaving individual agencies to provide their own specific policies to support the multi-agency interaction)
(ii) Reference to other regulations might best be avoided (see for example 3.3) so that it can stand as freestanding guidance for those attending fast moving incidents to apply without delay ;
(iii) The guidance should closely follow the chronology of a relevant incident i.e. it should start with the decision to detain, followed by the relevant risk assessment, appropriate conveyance, place of safety etc. Information regarding permitted periods of detention and roles and responsibilities could be dealt with at the end.
N.B. Whilst it is reassuring to learn that a local ‘task and finish’ group has been set up within the Mental Health Crisis Concordat Strategic Group (MHCCG) to improve the current Policy and that reference is being made to College of Policing training packages, in effecting these improvements, the group might wish to consider engaging with a national expert in this field such as Inspector Michael Brown who provided expert evidence to the Inquest and has experience of effective mental health policy 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 Failure to provide continuous monitoring and risk assessment of detainees subject to restraint
Wider context from the report “3. Adequacy of Monitoring of Detainees Subject to Restraint
The expert evidence of Dr ████████ (Consultant Intensivist). Professor ████████ (Consultant Cardiologist) and Dr ████████ (Forensic Pathologist) highlighted the effect that restraint has on detainees – not only in terms of the potential stress to the heart if the detainee struggles against such restraint but also in view of the continuing metabolic disturbance it creates which continues long after any restraint ceases or is removed. Indeed, they all agreed that metabolic disturbance from the restraint was one of the factors in causing Leon’s cardiac arrest and subsequent death. The evidence of Dr ████████ confirmed that the effects of the restraint would, however, have been treatable and that, if appropriate action had been taken, his cardiac arrest would likely have been avoided; indeed, he explained that even if action only had been taken at the point that Leon had become unconscious, the relatively simple steps of placing him in the recovery position in the cell and starting CPR, whilst awaiting emergency help, on the balance of probabilities, would have resulted in his survival.
The Jury through their answers to Questions 33-34 of the Jury Questionnaire not only determined that a failure to monitor Leon appropriately in the cell on 4 November 2013 more than minimally caused or contributed to his death but also concluded, in Box 3 of the Record of the Inquest, that “The inadequate continuous risk assessments and monitoring of Leon resulting in a failure to recognise when Leon became in need of urgent medical attention in the cell ” was one of the most serious failings by emergency services to provide Leon with adequate support.
Since the carrying out of even relatively basic first aid could have made a significant difference to the outcome in this case, it seems critical that the close monitoring of a detainee who has been subject to restraint should be guaranteed in all cases . As the Jury found there were specific failures by the Custody team in this case, consideration could perhaps be given to having additional monitoring in respect of such detainees independent of the Custody team.
The NHS England Patient Safety Alert (2015) gives guidance to NHS staff on post-restraint observations: https://www.england.nhs.uk/wp-content/uploads/2015/12/psa-vital-signs-restrictive-interventions-031115.pdf. Although this has been circulated to some police, it may not be widely known about and even though it may not cover all of the situations which the police will encounter in their work, something similar could be of potential benefit to all police forces across the country.
” 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 training of police, ambulance crew and other front-line responders on medical emergencies and restraint risks
Wider context from the report “2. Lack of Sufficient Training for Police Officers, Ambulance Crew and other Front-Line Responders
Although, the MHCCG Strategic Group are progressing joint training for all first responders including hospital staff who might need to assess medical fitness and/or treat S136 detainees, it was clear from the evidence heard at the Inquest that there remains insufficient or inadequate instruction of both police and ambulance crew about the critical issues of recognising and responding to a medical emergency and the effects of restraint including positional asphyxia . Consideration, therefore, needs to be given by National and Local Police and Ambulance services as to whether the current individual service training (including refresher training) is adequate (and of similar level to that provided to those working in Mental Health Units pursuant to the Mental Health Units (Use of Force) Act 2018) to ensure the welfare and safety of S136 detainees.
” Open source report
23 Sep 2021 Hamish John Cameron HOWITT · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Absence of directives in police training material and national policy on referral of apparently intoxicated injured people View source Alcohol-appearing effects masking serious underlying medical conditions View source Insufficient police training to identify and refer apparently intoxicated people complaining of injury View source Failure to recommend hospital or ambulance assessment for apparently intoxicated people complaining of injury View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Hamish John Cameron HOWITT · 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
Hamish John Cameron HOWITT, a 20-year-old university student, died unexpectedly overnight in Frome on 1 July 2016 after an evening involving alcohol, a traumatic brain injury and self-administered ketamine. The concerns were that police did not recommend hospital assessment after he reported being injured, and that police training and national policy should address the risk of serious underlying conditions being masked by apparent intoxication.
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 directives in police training material and national policy on referral of apparently intoxicated injured people
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” 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 Alcohol-appearing effects masking serious underlying medical conditions
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” 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 training to identify and refer apparently intoxicated people complaining of injury
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” 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 recommend hospital or ambulance assessment for apparently intoxicated people complaining of injury
Wider context from the report “(1) it is highly unlikely that Hamish would have died had he gone to hospital when the police saw him after the incident. Police at the scene did not recommend or encourage this course of action.
(2) The apparent effects of alcohol when assessed by police (who are not medically qualified) can frequently mask serious underlying conditions such as traumatic brain injury (in this case) but also symptoms of post epileptic attack; diabetic high/low; and drug taking (either prescribed or illegally used).
(3) Police Officers who come into contact with the public are not medically qualified but must be trained at both a national and local level to take steps to ensure those who appear inebriated and are complaining of injury are taken to hospital/seen by ambulance services.
(4) Police training material and national policy setting should include directives to this effect.
” Open source report
23 Sep 2021 Anthony James Preston · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1 Uncertainty about whether the Police Missing Person Policy is fit for purpose 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
Anthony James Preston · 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 James Preston died at home on 16 November 2020 after being found suspended by a ligature. The report describes his attendance at A&E after an apparent attempted hanging, his disappearance before a mental health assessment, and his later discovery deceased at home. The substantive concern was whether the Police Missing Person Policy was fit for purpose.
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 Uncertainty about whether the Police Missing Person Policy is fit for purpose
Wider context from the report “That the Police Missing Person Policy should be looked at to see if it is fit for purpose.
” Open source report
4 Jun 2021 David Conway ORMESHER · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 4 Failure to retain the personal radio appropriately during police vehicle operations View source Failure to deploy the siren when required View source Failure to keep the in-car radio switched on View source Inadequate driver training on appropriate driving and journey planning View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
David Conway ORMESHER · 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
David Conway ORMESHER's death was investigated from 5 September 2017, with the investigation concluding at the end of an inquest on 17 May 2021. Concerns identified included the use of the in-car radio and siren, handling of the personal radio, excessive speed, and the need to reinforce driver-training requirements.
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 retain the personal radio appropriately during police vehicle operations
Wider context from the report “In the light of Inspector ████████ evidence and from the conclusions of the Jury, the following points were identified as being relevant:
(1) The in-car radio should be switched on at all times
(2) The siren should have been deployed
(3) The personal radio should not be handed to the passenger in the police vehicle and not returned immediately
(4) The speed was found to be excessive and drivers in training need reminding of the Regulations:
‘Drive appropriately and justify the manner of driving’
‘Plan the journey using all available information’
Perhaps this tragic case will prompt a review of the existing driver training.
” 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 deploy the siren when required
Wider context from the report “In the light of Inspector ████████ evidence and from the conclusions of the Jury, the following points were identified as being relevant:
(1) The in-car radio should be switched on at all times
(2) The siren should have been deployed
(3) The personal radio should not be handed to the passenger in the police vehicle and not returned immediately
(4) The speed was found to be excessive and drivers in training need reminding of the Regulations:
‘Drive appropriately and justify the manner of driving’
‘Plan the journey using all available information’
Perhaps this tragic case will prompt a review of the existing driver training.
” 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 keep the in-car radio switched on
Wider context from the report “In the light of Inspector ████████ evidence and from the conclusions of the Jury, the following points were identified as being relevant:
(1) The in-car radio should be switched on at all times
(2) The siren should have been deployed
(3) The personal radio should not be handed to the passenger in the police vehicle and not returned immediately
(4) The speed was found to be excessive and drivers in training need reminding of the Regulations:
‘Drive appropriately and justify the manner of driving’
‘Plan the journey using all available information’
Perhaps this tragic case will prompt a review of the existing driver training.
” 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 driver training on appropriate driving and journey planning
Wider context from the report “In the light of Inspector ████████ evidence and from the conclusions of the Jury, the following points were identified as being relevant:
(1) The in-car radio should be switched on at all times
(2) The siren should have been deployed
(3) The personal radio should not be handed to the passenger in the police vehicle and not returned immediately
(4) The speed was found to be excessive and drivers in training need reminding of the Regulations:
‘Drive appropriately and justify the manner of driving’
‘Plan the journey using all available information’
Perhaps this tragic case will prompt a review of the existing driver training.
” Open source report
Concerns raised 8 Failure of managerial policy-change controls to prevent recurrence of superseded-policy confusion View source Insufficient knowledge, guidance and supervision among education inclusion officers and social workers supporting adolescents at risk of self-harm or suicide View source Reluctance to use a Borderline Personality Disorder diagnosis View source Unavailability of in-area supported accommodation for adolescent mental health patients View source AWOL policy failing to provide concise and usable live-incident guidance View source Lack of an agreed pathway for securing overnight assistance for adolescent mental health patients cared for at home View source Lack of drills, training exercises and information packs for nurses managing AWOL incidents View source Conflicting or confusing AWOL policies View source See 5 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
SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · 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
Sam died by suicide from an overdose of prescribed medication on 2 September 2018, aged 16. Chris died by suicide after deliberately stepping in front of a passing train on 26 January 2019, aged 17. The principal concerns included insufficient overnight support for adolescents cared for at home, shortcomings in local authority support and coordination, reluctance to use a Borderline Personality Disorder diagnosis, and unclear and inadequately implemented procedures for patients absent without leave.
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 managerial policy-change controls to prevent recurrence of superseded-policy confusion
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 knowledge, guidance and supervision among education inclusion officers and social workers supporting adolescents at risk of self-harm or suicide
Wider context from the report “(2) Involvement of CCC alongside CPFT in complex adolescent mental health cases where the risk is of suicide / self-harm (For CCC). In some respects CCC’s involvement in Chris and Sam’s care (social care and education) lacked direction, focus, knowledge and efficiency. I heard evidence of improvements in training in the relevant education and social work teams, and concerning the new Strong Families, Strong Communities Securing Best Outcomes for Children Strategy (March 2021). Further, that CCC is restructuring all of its early help and adolescent services and will be implementing a formal contextual safeguarding framework and that these developments will be in place by the end of 2021. I am concerned that in the midst of restructuring and new guidance, there remains a risk that education inclusion officers and social workers on the ground may still not have sufficient knowledge, guidance and supervision to ensure that CCC give practical and robust support to parents and adolescent patients, alongside treating healthcare agencies, where the main risk of serious harm to the child is from self-harm or suicide arising from adolescent mental health disorders , rather than neglect of harm by a third party.
” 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 Reluctance to use a Borderline Personality Disorder diagnosis
Wider context from the report “(3) Diagnosis of Borderline Personality Disorder (For CPFT). I am concerned that the evidence in Chris’ case, in particular, suggested a degree of age-related reluctance consistently to use the terminology of Borderline Personality Disorder (or Emerging Personality Disorder or EUPD) , even when a highly specialist second opinion had supported this and appeared to have been accepted. There are risks associated with a reluctance to use a personality disorder diagnosis (c.f. Position Statement from the Royal College of Psychiatrists dated January 2020). I received evidence that there have already been some changes/improvements in the preparedness to recognise Borderline Personality Disorder and that further consideration will be given in the context of the new ICD 11.
” 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 in-area supported accommodation for adolescent mental health patients
Wider context from the report “(1) Overnight assistance for adolescent mental health patients being cared for at home but with high levels of need (For CPFT and CCC). I heard evidence of increased funding for CPFT being used to extend home treatment options, but that this would be unlikely to extend to a 24/7 service. I also heard evidence from CCC that available support would now be considered under s17 Children Act or s117 Mental Health Act or both but that this would need to be jointly funded between social care and health. I remain concerned that a clear pathway to securing overnight assistance (even if only on a respite basis) for similar cases of exceptional need has not yet been clearly agreed between CPFT and CCC. I am concerned that if alternative supported accommodation in the community were the best solution, there does not appear to be provision for it in-area , so that admission to a mental health unit becomes more likely.
” 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 AWOL policy failing to provide concise and usable live-incident guidance
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident . In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 an agreed pathway for securing overnight assistance for adolescent mental health patients cared for at home
Wider context from the report “(1) Overnight assistance for adolescent mental health patients being cared for at home but with high levels of need (For CPFT and CCC). I heard evidence of increased funding for CPFT being used to extend home treatment options, but that this would be unlikely to extend to a 24/7 service. I also heard evidence from CCC that available support would now be considered under s17 Children Act or s117 Mental Health Act or both but that this would need to be jointly funded between social care and health. I remain concerned that a clear pathway to securing overnight assistance (even if only on a respite basis) for similar cases of exceptional need has not yet been clearly agreed between CPFT and CCC . I am concerned that if alternative supported accommodation in the community were the best solution, there does not appear to be provision for it in-area, so that admission to a mental health unit becomes more likely.
” 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 drills, training exercises and information packs for nurses managing AWOL incidents
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” 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 Conflicting or confusing AWOL policies
Wider context from the report “(4) AWOL patients from Darwin Centre for Young People (For CPFT). I heard evidence that since Chris’ death, staff have been reminded of the applicable policies; and that an audit has shown good compliance with the provision for calling the local signallers. I heard evidence that there is to be a further review of CPFT’s own AWOL policy. I remain concerned that: (i) CPFT’s own policy is too lengthy and complex to serve as reference-guidance during a live AWOL incident. In particular the flow chart summary is unnecessarily complex and hard to follow (at least as a tool to consult during a stressful incident); (ii) there is a risk of confusion in having two policies both of which are meant to be followed ; (iii) there did not appear be desktop-drills / other training exercises / information grab-packs (etc.) to ensure that all nurses in charge are properly equipped and trained to deal with AWOL incidents effectively (iv) steps ought to be taken at managerial level to ensure that the confusion over the two policies and whether one had been superseded (evidence of which only emerged during the inquest) cannot recur in this, or other areas, when new policies are introduced.
” Open source report
27 May 2021 Zeyna Partington · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 4 Failure to implement the national system for automatic notification of medium ACT marker ANPR hits across all forces View source Lack of GMP Officers’ knowledge and understanding of ACT marker levels and their implications for missing from home investigations View source Inadequate resourcing and allocation of officers to grade 2 calls within an hour View source Delays in placing ACT markers on vehicles during missing from home investigations View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Zeyna Partington · 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
Zeyna Partington was reported missing on 8 August 2019 and was believed to be at risk of suicide. Her vehicle was detected by ANPR in Derbyshire, but GMP did not become aware of this until 10 August; she was then found deceased in a nearby field after taking an overdose of prescribed medication. The substantive concerns included inadequate understanding of ACT marker levels, delays or gaps in national ANPR notification, and the absence of a fully implemented national system across all forces.
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 implement the national system for automatic notification of medium ACT marker ANPR hits across all forces
Wider context from the report “3. Despite a new national system being available this has still not been implemented across all forces meaning a force is not automatically notified if a vehicle with a medium ACT marker hits an ANPR camera nationally .
” 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 GMP Officers’ knowledge and understanding of ACT marker levels and their implications for missing from home investigations
Wider context from the report “1. There is a lack of knowledge and understanding by GMP Officers as to the different level of ACT markers and the implications the varying levels may have on investigations particularly missing from home investigations .
” 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 resourcing and allocation of officers to grade 2 calls within an hour
Wider context from the report “2. If the policy is not to place an ACT marker on a vehicle until the missing from home report is completed then this can mean a delay of several hours, particularly as the court heard it is often difficult to resource and allocate officers to grade 2 calls within an hour . In this case if the radio operator had not acted outside of policy then the hits on the 8th August in both Rochdale and Derbyshire would not have been known at all.
” 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 placing ACT markers on vehicles during missing from home investigations
Wider context from the report “2. If the policy is not to place an ACT marker on a vehicle until the missing from home report is completed then this can mean a delay of several hours , particularly as the court heard it is often difficult to resource and allocate officers to grade 2 calls within an hour. In this case if the radio operator had not acted outside of policy then the hits on the 8th August in both Rochdale and Derbyshire would not have been known at all.
” Open source report
11 May 2021 Paul Steven Reynolds · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 13 Failure to place a person subjected to prone restraint in the recovery position View source Lack of accurate and clear guidance on information to share with police View source Failure to provide or arrange additional training for security staff View source Failure to control the scene to facilitate assessment of a person’s condition View source Lack of clarity about incident command and staff responsibilities View source Failure to closely and effectively monitor breathing during prone restraint View source Failure to restrict restraint participation to appropriately badged staff View source Physical intervention policy permitting ground restraint methods not taught in accredited courses View source Reduction in time allowed for officer training View source Officers’ misunderstanding of the circumstances in which pain or pressure testing is justifiable View source Insufficient officer skills in non-physical aspects of conflict management View source Lack of consistency in the training curriculum View source Failure to document staff induction and training View source See 10 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
Paul Steven Reynolds · 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
Paul Steven Reynolds died on 16 February 2017 after being restrained by the neck and placed in a prone position at Pontins Pakefield in Lowestoft. The principal concerns included inadequate monitoring of his breathing, failure to place him in the recovery position, insufficient staff training, unclear responsibilities, and poor sharing of information with 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 place a person subjected to prone restraint in the recovery position
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 accurate and clear guidance on information to share with police
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 or arrange additional training for security staff
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 control the scene to facilitate assessment of a person’s condition
Wider context from the report “(4) Officers did not control the scene by clearing the ballroom and switching off the music which would have improved their ability to assess Mr Reynolds’ condition .
” 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 clarity about incident command and staff responsibilities
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 closely and effectively monitor breathing during prone restraint
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 restrict restraint participation to appropriately badged staff
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 Physical intervention policy permitting ground restraint methods not taught in accredited courses
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses .
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 Reduction in time allowed for officer training
Wider context from the report “(2) The time allowed for training had been reduced from 12 to 4.25 hours. Positional asphyxia training had been reinforced, but there were questions about the impact of the reduction upon officers.
” 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 Officers’ misunderstanding of the circumstances in which pain or pressure testing is justifiable
Wider context from the report “(1) Officers appeared to be under the impression that pain/pressure testing to determine whether a person was unconscious or simply asleep was an assault rather than being justifiable in certain circumstances.
” 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 officer skills in non-physical aspects of conflict management
Wider context from the report “(3) The College of Policing and NPCC Officer and Staff safety Review made two recommendations to include revising the curriculum to ensure greater consistency, and to implement guidelines to ensure officers are sufficiently skilled in non-physical aspects of conflict management . The time scales for implementation were not stated.
” 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 consistency in the training curriculum
Wider context from the report “(3) The College of Policing and NPCC Officer and Staff safety Review made two recommendations to include revising the curriculum to ensure greater consistency , and to implement guidelines to ensure officers are sufficiently skilled in non-physical aspects of conflict management. The time scales for implementation were not stated.
” 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 document staff induction and training
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” Open source report
15 Mar 2021 Joe Peter Robinson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to share and embed lessons about policing plans across other Force Areas 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
Joe Peter Robinson · 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
Joe Peter Robinson became unwell and collapsed near Ashton Canal in the early hours of 14 June 2020, and attempts to resuscitate him were unsuccessful. The post-mortem examination found that he died from a combination of MDMA and ketamine. The concerns included the absence of first-aid or paramedic facilities at a large unlicensed gathering, and uncertainty about whether lessons concerning policing plans had been shared and embedded across other force areas.
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 share and embed lessons about policing plans across other Force Areas
Wider context from the report “The evidence before the inquest was that Greater Manchester Police became aware of the event but felt unable to prevent it from continuing. The inquest was told that at the time GMP did not have a clear plan to deal with such a situation. However, since this event at Daisy Nook and a similar one that same night also in South Manchester they have developed a robust plan and there have not been similar large scale illegal gatherings.
What was not clear from the inquest was whether the lessons learnt of the need for policing plans to prevent such events occurring and reduce the risk of future deaths occurring had been shared and embedded in other Force Areas.
” Open source report
3 Mar 2020 Katrina Margaret Mary O’Hara · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Failure to provide replacement phones when victims’ phones are seized during an investigation View source Failure to recognise the perpetrator’s suicide risk as a significant domestic abuse risk factor for the victim View source Failure to ensure that non-emergency 999 calls from victims are taken or followed up without requiring the victim to call back View source Failure to ensure police officers are trained to use Niche for linking events and notifying investigation leads View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Katrina Margaret Mary O’Hara · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Katrina Margaret Mary O’Hara was stabbed by her ex-partner outside her place of work on 7 January 2016 and was pronounced deceased at the scene. The report raises concerns about police handling of non-emergency domestic abuse calls, recognition of a perpetrator’s suicide risk, provision of replacement phones when victims’ phones are seized, and the use and training of the Niche police software system.
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 replacement phones when victims’ phones are seized during an investigation
Wider context from the report “iii. It is not unusual that the mobile phones of victims are seized by police as part of investigation into domestic abuse related allegations. Until the death of Miss O’Hara, Dorset Police did not provide replacement phones, leaving victims potentially without a means to communicate with others, including in an emergency . As stated above, Dorset Police now have a store of mobile phones available to supply to victims where their phones have been seized as evidence. I am concerned that this may not be in place across the police forces of England and Wales and that victims in some areas are being left without the means of contacting others, including the emergency services, when their phones have been seized by police during an investigation .
” 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 the perpetrator’s suicide risk as a significant domestic abuse risk factor for the victim
Wider context from the report “ii. Dorset Police have changed their Domestic Abuse Investigation Policy and Procedure to include the suicide risk of the perpetrator of domestic abuse as a significant risk factor for the victim of domestic abuse . This is a recent change and reflects the growing understanding that the perpetrator who has “nothing left to lose” poses a significant risk to his or her victim. I am concerned that this change in policy in Dorset may not be reflected nationwide .
” 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 that non-emergency 999 calls from victims are taken or followed up without requiring the victim to call back
Wider context from the report “i. I am concerned that Police Forces across England and Wales may still be employing a policy similar to that previously employed by Dorset Police, with regard to non-emergency calls made to 999 . Dorset Police have recognised the courage it takes a victim of domestic violence to make a call to the police so have now ensured that, depending on the risk level and whether police attendance will be required, the call will either be taken by the 999 call handler, or, where it is deemed that no police attendance at any time is likely required, the caller will be called back at a later convenient time. It is no longer left to the victim to make a subsequent call to the police in relation to the same complaint. The concern is that if similar policies are not in place across the police forces in England and Wales, victims of offences, who may have had to take a huge risk to themselves or others to make the call to the police, are being asked to call back on a different number if their call is not categorised as an emergency .
” 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 police officers are trained to use Niche for linking events and notifying investigation leads
Wider context from the report “iv. “Niche” is a software program used by, I understand, 23 police forces across England and Wales. I do not know if more forces are due to adopt Niche in the future. I am concerned that appropriate training needs to be provided to police officers to ensure they have a good understanding of Niche and how to “link” events to an occurrence and to ensure that the appropriate individuals, for example the officer leading an investigation, are notified of any developments in a case .
” 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 Implement revised national Principles and Practice for Contact Management covering the concern about redirecting non-emergency calls.
Verbatim wording from the response “Since 2015 there has been a major refresh of the National Contact Management Strategy. This has been undertaken under the auspices of the National Contact Management Steering Group and was approved by Chief Constable’s Council in January 2019. Following on from the approval of the strategy a corresponding, comprehensive, review of the Principles and Practice for Contact Management has also been undertaken.” Source location 2020-0051-Response-from-National-Police-Chiefs-Council_Redacted
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 revised national contact-management principles already cover the concern, so no further clarification or amendment is intended.
Verbatim wording from the response “Our revised principles and practice cover this issue.” Source location 2020-0051-Response-from-National-Police-Chiefs-Council_Redacted
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 incident appears to have involved inappropriate channel selection under the national 999 criteria.
Verbatim wording from the response “However, it should also be borne in mind that 999 is a national system with specific criteria, and it would appear that it was a case of inappropriate channel selection as outlined within those National criteria.” Source location 2020-0051-Response-from-National-Police-Chiefs-Council_Redacted
Open published response
8 Jan 2020 Anthony Carroll · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Lack of public information about the safe speed of police emergency vehicles responding to emergencies View source Lack of a visual indication of police emergency vehicle siren activation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony Carroll · 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 Carroll, aged 70, was struck by a police vehicle while crossing Scotland Road A59 in Liverpool on 25 December 2018 and was pronounced dead after being taken to hospital. The report raised concerns about public understanding of police emergency vehicle speed limits and the absence of a visual indicator showing whether the siren was activated.
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 public information about the safe speed of police emergency vehicles responding to emergencies
Wider context from the report “1. During the Course of evidence, it was apparent that the public might be under a misapprehension that police emergency vehicles responding to an emergency are limited to 20 mph above the designated speed limit for the Road has there been publicity that vehicles need to respond safely as quickly as possible . If not, is this under consideration?
” 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 visual indication of police emergency vehicle siren activation
Wider context from the report “2. During the Course of evidence, the police driver and the police passenger believed the sirens were activated and sounding . Analysis of the Siemens VDO Incident Data Recorder demonstrated that in the heat of the emergency both were mistaken and the sirens were not activated . Has a warning light in the cab been considered as a visual indicator or the lights and siren being activated been considered?
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing emergency-equipment indicators and siren controls are considered sufficient; additional cab indicators could distract officers during emergency driving.
Verbatim wording from the response “Although many police response vehicles are similar throughout the United Kingdom, not all of the emergency equipment or control units are standardised within these vehicles. They all have a control panel or switches to operate the emergency equipment and usually a corresponding light to indicate that the equipment has been activated. This is described as a warning light and serves in addition to the noise and pressure waves of the sirens themselves.” Source location 2020-0018-Response-from-NPCC_Redacted
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 No publicity about the speed exemption is currently planned because its lawful use depends on circumstances assessed by the driver at the time.
Verbatim wording from the response “As I refer to above, the lawfulness of the exemption is dependent upon the prevailing circumstances as the driver determines them to be at that time. For these reasons, the NPCC therefore has no plans currently to undertake any publicity around the exemption allowing police vehicles to safely exceed the speed limit.” Source location 2020-0018-Response-from-NPCC_Redacted
Open published response
24 Oct 2019 Douglas Paul Oak · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 9 Lack of general awareness of Acute Behavioural Disturbance View source Insufficient frequency and variety of ABD training View source Unsuitability of existing ABD training package for control-room staff View source Failure of Emergency Services to use mutually understood control-room terminology View source Insufficient ABD training for Police and Ambulance Service front-line and control-room staff View source Confusion over Police procedures for requesting Ambulance support View source Absence of Clinical Governance Boards in Police Forces View source Lack of cross-working within the emergency services View source Absence of joint national guidance on Police and Ambulance Service management of ABD View source See 6 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
Douglas Paul Oak · 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 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency 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 Lack of general awareness of Acute Behavioural Disturbance
Wider context from the report “i. There is a lack of awareness generally regarding ABD and I would request consideration is given to the inclusion of the signs, symptoms and management of ABD within the First Aid Manual so that all those trained in first aid are able to deal with a patient presenting with 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 Insufficient frequency and variety of ABD training
Wider context from the report “iv. I also have concerns in relation to the frequency of the delivery of the training referred to in (iii) and I therefore request consideration be given to that training being delivered regularly, at least on an annual basis and with a variety of training techniques, including simulation and role play scenarios.
” 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 Unsuitability of existing ABD training package for control-room staff
Wider context from the report “vii. In relation to the training package that has been provided by the College of Policing regarding ABD, although ████████ has recommended this could be rolled out to control room staff, the package is tailored for front-line staff . I would therefore request consideration is given to a specific training package on ABD being designed and rolled out to those working in the control room environment by the College of Policing together with the Association of Ambulance Chief Executives or the National Ambulance Service Medical Directors.
” 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 Emergency Services to use mutually understood control-room terminology
Wider context from the report “v. Given that the Police and Ambulance Services work very closely in treating and managing a patient with ABD, and other patients who present with life threatening conditions, it is important that they understand each other. It was clear from this Inquest that there is different terminology used by the different services, the meaning of which is not understood by the other Emergency Services . An example of this was the use of the phrase “on the hurry up”. Although the confusion regarding this terminology was not found to be causative or contributory to Doug’s death, it could be in respect of a future death. I therefore request that consideration is given to the joint national training packages for all Emergency Services, namely the Police Service, Ambulance Service and the Fire Service on the workings within each control room and around the language used in the control rooms.
” 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 ABD training for Police and Ambulance Service front-line and control-room staff
Wider context from the report “iii. I believe it is likely there are persons working within Ambulance Service Trusts and Police Forces, whether it be on the front line or in the control room who are not aware of ABD and the serious risk to life it presents . I therefore request that consideration is given to ensuring all those working on the front line, or in control rooms in Ambulance Service Trusts and Police Forces in England and Wales are trained in 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 Confusion over Police procedures for requesting Ambulance support
Wider context from the report “ix. It was clear from the evidence that there appears to be confusion of when Dorset Police Officers should call 999 directly and when they should request assistance through the Police control room . I would request that there is consideration of the redrafting of the current “Police Requesting Ambulance Support” policy within Dorset Police and specifically when Police Officers should dial 999. In addition, I would request consideration of training be provided by Dorset Police to all Police Officers regarding the use of dialling 999 when contacting other Emergency Services. In doing this I would ask that consideration is given to liaising with the other local emergency services regarding their expectations, especially SWAST.
” 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 Clinical Governance Boards in Police Forces
Wider context from the report “viii. Evidence was given that Dorset Police have established a Clinical Governance Board which helps to create an awareness of, and improvement in, medical care provided by those working in the Police Service. This is not something adopted by all Police Forces in England and Wales and I therefore request that consideration is given to setting up a Clinical Governance Board in every Police Force in England and Wales.
” 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 cross-working within the emergency services
Wider context from the report “vi. Extending this point further, evidence was given that there would be benefit in cross working within the emergency services , so for example an Ambulance Clinician working within the Police control room to provide advice. I would therefore request that consideration is given on a national level to cross working within the emergency services.
” 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 joint national guidance on Police and Ambulance Service management of ABD
Wider context from the report “ii. There is no joint national guidance on the management of ABD by those who work for the Police and Ambulance Services, both on the front-line and in the control rooms. They are the people most likely to encounter those suffering with ABD and in most cases work together in the management of these patients. Accordingly, I request consideration is given to providing joint national guidance on the management of ABD patients by the Police and Ambulance Services to include:
• the provision of chemical sedation in pre-hospital care
• the training of all paramedics in administering chemical sedation
• the categorisation of Emergency Service calls relating to ABD
• the transfer of an ABD patient to hospital
” Open source report
29 Aug 2019 Michael Hoolickin · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 15 Insufficient capacity to cross-reference offender intelligence across offenders and agencies View source Failure to require ACOs to access offender records View source Lack of formal information-sharing procedures for integrated teams View source Poor or absent records by SPOs and ACOs View source Failure to undertake multi-agency reviews after high-risk offenders under multi-agency management kill someone View source Lack of training on accessing drug test results View source Failure to update OASYS risk assessments View source Insufficient planning and preparation for service amalgamation View source N-Delius failing to provide timely access to current offender information View source Inadequate agenda, minutes, attendance records and meeting records for IOM cohort meetings View source Failure to accurately share information about offenders between police forces View source Lack of induction training and office procedures on local drug-testing practices View source Lack of clarity and specific instructions on ACO warnings View source Lack of clear arrangements for initiating police curfew checks View source Failure to record licence conditions on the Police National Computer View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Hoolickin · 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
Michael Hoolickin was attacked and stabbed in an unprovoked assault on 14 October 2016 and died at Manchester Royal Infirmary on 17 October 2016. The report identifies organisational and management failures in supervising the perpetrator, including failures concerning drug testing, information sharing and provision of relevant information, which resulted in a missed opportunity to initiate recall to prison. The Inquest found that this probably contributed to Michael Hoolickin’s death, although it was not causative of the attack.
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 capacity to cross-reference offender intelligence across offenders and agencies
Wider context from the report “During the course of the Inquest questions were raised around the ability of the NPS to cross reference intelligence received in respect of different offenders . In addition whether there was capacity to cross reference intelligence held by other agencies such as the Youth Offending Team .
” 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 ACOs to access offender records
Wider context from the report “There is no expectation for an ACO to access an offenders records on the case management system in order to inform themselves or to consider whether there is any further relevant 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 Lack of formal information-sharing procedures for integrated teams
Wider context from the report “The evidence before the Court was there are no Standard Operating procedures or formal processes in place for the sharing of information when teams are integrated .
” 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 Poor or absent records by SPOs and ACOs
Wider context from the report “The Court had serious concerns as to the poor records or complete lack of records particularly by SPOs and the ACOs.
” 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 multi-agency reviews after high-risk offenders under multi-agency management kill someone
Wider context from the report “The failure to undertake a multi-agency review in cases where a high risk offender subject to multi-agency management has gone on to take someone’s life means both organisational and individual failings are not identified and there is a missed opportunity to learn lessons in order to prevent 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 training on accessing drug test results
Wider context from the report “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results . As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices.
” 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 update OASYS risk assessments
Wider context from the report “At no stage after March 2016 was the offenders OASYS risk assessment updated . Moreover the lack of formal supervision meant this 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 Insufficient planning and preparation for service amalgamation
Wider context from the report “The Court has concerns as to the planning and preparation required for the amalgamation of any new service in order to alleviate the evidenced problems which occurred as a direct result of the previous Transforming Rehabilitation programme.
” 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 N-Delius failing to provide timely access to current offender information
Wider context from the report “Numerous witnesses gave evidence as to the difficulties in accessing this system , its design and the time it takes to access the different parts which hold pertinent information about an offender , describing this as prohibitive. For example for Offender managers trying to read through the file to obtain current information there is nowhere which would easily show the most up to date curfew or the most up to date position as to how often drug testing is being conducted .
” 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 agenda, minutes, attendance records and meeting records for IOM cohort meetings
Wider context from the report “The evidence before the Court was that in respect of the multi-agency IOM meetings there was no formal agenda, no formal minutes, no accurate record kept of these meetings by either GMP or the NPS and no way of ascertaining who had attended these meetings .
” 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 accurately share information about offenders between police forces
Wider context from the report “There was a complete breakdown of communication and information sharing between GMP and Lancashire Constabulary which lead to only information about one of the two offenders being passed on . More importantly there was confusion between the forces as to which offender was being discussed .
” 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 induction training and office procedures on local drug-testing practices
Wider context from the report “The Court found there was an ineffective national system in use in 2016 (N Delius) for which there had been no training on how to access Drug test results. As a result individual offices had implemented their own systems for storing drug test results. However there is no induction training, information available to staff in individual offices by way of office procedures which informs staff of local practices .
” 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 clarity and specific instructions on ACO warnings
Wider context from the report “The Court found there is a lack of clarity and specific instructions to the NPS on this point.
” 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 arrangements for initiating police curfew checks
Wider context from the report “The Court was satisfied from the evidence that there is no clear understanding as to the initiation of curfew checks . It was clear to the Court there was confusion as to whether an offender on a curfew will automatically be subject to curfew checks carried out by the Police or whether such checks will only be conducted following a specific request by the NPS .
” 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 record licence conditions on the Police National Computer
Wider context from the report “The Court heard that an offenders’ licence conditions are not held on the Police National Computer database . Hence if an offender is arrested by a different force they are unlikely to know whether the offender may be in breach of their licence.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing IOM guidance, alongside statutory MAPPA requirements, is considered sufficient to support forces.
Verbatim wording from the response “Being statutory in nature, MAPPA arrangements will always have primacy over IOM schemes although, as set out in the Key Principle documentation, IOM working can be useful in complementing the measures agreed in MAPPA.” Source location 2019-0292-Response-from-the-National-Police-Chiefs-Council-1
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 Operational matters within each force, including the concerns raised, are the responsibility of the respective chief constable.
Verbatim wording from the response “I was not previously aware of this incident, and I am very sorry to learn of the tragic circumstances surrounding the death of Mr Hoolickin. You will appreciate that I am unable to comment on the specific facts of this case, but I can address your concerns regarding policing practice more generally. I understand that you have made contact with the chief constables of Greater Manchester Police and Lancashire Constabulary, both whom will no doubt wish to respond separately in addressing the issues you have raised with specific reference to the actions of their respective forces.” Source location 2019-0292-Response-from-the-National-Police-Chiefs-Council-1
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 A full response to concerns about serious further offence reviews, curfews, and police records was delayed pending subject-matter expert consideration.
Verbatim wording from the response “In order to provide a useful response to the matters of concern you have raised, it has been necessary for me to consult with a number of national leads across several portfolios. I am unfortunately not able to provide you with a full response to all of your concerns today because some of those I have consulted with are still in the process of considering the matters of concern, and no doubt further consulting with subject matter experts. However, I hope you are willing to accept this letter in part response to the issues raised.” Source location 2019-0292-Response-from-the-National-Police-Chiefs-Council-1
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 lacks authority to direct chief constables to take or refrain from specific operational action.
Verbatim wording from the response “It is important to understand the distinct role of the National Police Chiefs’ Council (NPCC). As you know, each chief constable is ultimately responsible for operational matters within their own force area, which includes all of those issues referred to within the matters of concern you have raised. Whilst the NPCC seeks to encourage chief constables to work collaboratively in the national interest (for example, the way in which forces implement policies or practice), the NPCC does not have the authority to direct a chief constable to take (or not to take) a specific course of action. That said, we do recognise the need for consistency across forces whenever possible, which we know can lead to better outcomes for the public. The way the NPCC” Source location 2019-0292-Response-from-the-National-Police-Chiefs-Council-1
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 Nationally strict codification of IOM schemes and information-sharing arrangements is impractical because local partnerships, circumstances and priorities differ.
Verbatim wording from the response “I have discussed the matters of Integrated working (concern 4) and Integrated Offender Management (concern 5) with the national lead for this area, Deputy Chief Constable Jon Stratford of Gloucestershire Constabulary. DCC Stratford advises me that under the Multi-Agency Public Protection Arrangements (MAPPA), Integrated Offender Management (IOM) operates on a non-statutory basis. The agencies involved commit to joint working voluntarily in furtherance of their individual aims and because it is in the public interest for them to do so. This means that the precise nature of each IOM scheme is very much a function of the local partnership landscape, circumstances and priorities.” Source location 2019-0292-Response-from-the-National-Police-Chiefs-Council-1
Open published response
15 Jul 2019 Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Absence of a system providing firearms licensing departments with current medical fitness information View source Lack of skills and training for Firearms Enquiry Officers assessing applicants’ medical fitness View source Lack of mandatory comprehensive training for new Firearms Enquiry Officers View source Insufficient gathering of applicants’ relevant medical information before firearms certification decisions View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Christine Ann Lee and Lucy Daisy Lee · 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
Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The jury found that failures in Surrey Police’s firearms licensing decisions contributed more than minimally to the deaths. The report also raised concerns about insufficient mandatory training for firearms licensing officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.
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 a system providing firearms licensing departments with current medical fitness information
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application .
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm . These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” 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 skills and training for Firearms Enquiry Officers assessing applicants’ medical fitness
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably . I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation .
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” 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 mandatory comprehensive training for new Firearms Enquiry Officers
Wider context from the report “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”) . I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete.
Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so.
I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role, in the form of the South Yorkshire Training Course or equivalent , will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, 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 Insufficient gathering of applicants’ relevant medical information before firearms certification decisions
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant , and the lack of clarity as to what medical conditions may be relevant and must be disclosed , together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness .
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report
15 Jul 2019 Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Absence of mandatory comprehensive training for Firearms Enquiry Officers View source Lack of relevant training and competence among Firearms Enquiry Officers assessing medical fitness View source Absence of ongoing notification of relevant medical changes during firearms certificate validity View source Insufficient medical-condition disclosure and evidence gathering before firearms licensing decisions View source Absence of a required current GP medical report before firearms certificate applications 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
Christine Ann Lee and Lucy Daisy Lee · 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
Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The report identified failures by Surrey Police firearms licensing staff to sufficiently investigate and consider relevant information, apply the correct standard of proof, and ensure appropriate senior oversight before returning the perpetrator’s shotgun certificate and shotguns. It also raised concerns about insufficient mandatory training for firearms enquiry officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.
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 mandatory comprehensive training for Firearms Enquiry Officers
Wider context from the report “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”) . I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete.
Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so .
I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role , in the form of the South Yorkshire Training Course or equivalent, will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, 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 relevant training and competence among Firearms Enquiry Officers assessing medical fitness
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably . I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation .
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” 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 ongoing notification of relevant medical changes during firearms certificate validity
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes .”
I understand that this recommendation has not been implemented . This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” 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 medical-condition disclosure and evidence gathering before firearms licensing decisions
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant , and the lack of clarity as to what medical conditions may be relevant and must be disclosed , together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness .
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” 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 required current GP medical report before firearms certificate applications
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP , obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate , and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented . This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report
9 Jul 2019 Leroy Dacosta Junior Medford · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 7 Insufficient protected training time for police officers View source Failure of officers to know the drugs SOP requirement for an officer to be within the cell with the detained person View source Failure to safely prioritise the volume and frequency of police training updates View source Lack of easy digital access to, and efficient updating and storage of, police procedures and policies View source Failure to monitor whether police training has been taken up View source Failure to encourage officers to consult infrequently used SOPs and guidance View source Failure of the police training system to disseminate training effectively and safely 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
Leroy Dacosta Junior Medford · 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
Leroy Dacosta Junior Medford, referred to as Junior, was arrested by Thames Valley Police on 1 April 2017 and detained under the drugs SOP after being suspected of concealing drugs. His condition deteriorated in his cell, and resuscitation was unsuccessful; the recorded cause of death was heroin (diamorphine) toxicity. The principal concerns were that officers of all ranks involved did not know that the SOP required observation from inside the cell, and broader concerns about how police training is delivered, monitored, prioritised and taken up.
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 protected training time for police officers
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this . Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” 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 officers to know the drugs SOP requirement for an officer to be within the cell with the detained person
Wider context from the report “The Drugs SOP
One of the reasons that the drugs SOP was introduced by Thames Valley Police on 1st July 2016 was to prevent exactly what happened in this case. That is (one of) the reasons that the SOP requires an officer to observe from within the cell.
We heard that the SOP was circulated to all police officers in July 2016. Custody Sergeants were asked to carry out online training on this in the same month. Clearly no officer would be expected to know any SOP word for word, but these are available to be looked at on computers within the custody suite.
A key requirement of the drugs SOP is the requirement for an officer to be within the cell with the detained person.
What has concerned me in this case is that not 1 or 2 officers were unaware of this requirement. All officers – of all ranks – who were involved with Junior on the night of 1st April 2017 were unaware of this requirement.
I was however satisfied that additional training and awareness has now taken place around this particular SOP. It is a SOP that is used more frequently now.
” 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 safely prioritise the volume and frequency of police training updates
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised . There is perhaps a risk of lack of urgency if training updates are given too frequently .
” 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 easy digital access to, and efficient updating and storage of, police procedures and policies
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” 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 monitor whether police training has been taken up
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up , and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” 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 encourage officers to consult infrequently used SOPs and guidance
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly .
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” 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 police training system to disseminate training effectively and safely
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service . I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe .
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” 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 Share the prevention of future deaths report and response with chief constables across all forces.
Verbatim wording from the response “It appears from the response from the Chief Constable of Thames Valley Police that the force has taken the points you raise very seriously, and have taken steps locally to address your concerns. But this case has clearly highlighted the need to ensure that individual chief constables pay particular attention to the way in which training is delivered within their own force, its method, frequency and participation levels. I have therefore shared your report and this response with chief constable colleagues in all forces across the country, in case there are areas of practice within their own force which they feel may benefit from review.” Source location 2019-0233-Response-by-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 Participate in the College of Policing’s development of a national strategy for police learning.
Verbatim wording from the response “As Chair of the National Police Chiefs’ Council, it is my role to ensure that chief constables work together collaboratively in the national interest, although that does not extend to directing chief constables to take a specific course of action. I have, however, discussed this matter with the NPCC’s national lead for training and development, Mark Milton, Director of People and Organisational Development at Avon and Somerset Constabulary. Mark has carefully considered your recommendations, and reviewed the responses of both Thames Valley Police and the College of Policing. Mark has advised me that on behalf of the NPCC, he is closely involved in the College of Policing’s work on a national strategy for police learning, which I know the College of Policing have described to you in their response to your recommendations, so I won’t repeat the detail here.” Source location 2019-0233-Response-by-NPCC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Chief constables are responsible for deciding and delivering training volume, methods, prioritisation and participation within their own police forces.
Verbatim wording from the response “Each chief constable is therefore ultimately responsible for the delivery of training in their police force, which includes making decisions about the volume and method of training, the way in which different training is prioritised according to local need and any issues around levels of participation. This is by no means straightforward; you will appreciate the vast number of important areas of policing practice in which officers and staff require training, which is of course costly, and usually necessitates the abstraction of officers from their regular duties. Chief constables are therefore faced with many competing priorities which must all be carefully balanced so as not to adversely impact upon the service they provide.” Source location 2019-0233-Response-by-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 Chair’s role does not include directing chief constables to adopt a specific training course of action.
Verbatim wording from the response “As Chair of the National Police Chiefs’ Council, it is my role to ensure that chief constables work together collaboratively in the national interest, although that does not extend to directing chief constables to take a specific course of action. I have, however, discussed this matter with the NPCC’s national lead for training and development, Mark Milton, Director of People and Organisational Development at Avon and Somerset Constabulary. Mark has carefully considered your recommendations, and reviewed the responses of both Thames Valley Police and the College of Policing. Mark has advised me that on behalf of the NPCC, he is closely involved in the College of Policing’s work on a national strategy for police learning, which I know the College of Policing have described to you in their response to your recommendations, so I won’t repeat the detail here.” Source location 2019-0233-Response-by-NPCC
Open published response
Concerns raised 7 Insufficient training on atypical seizure and post-seizure behaviour View source Insufficient sharing and requesting of information needed to assess restraint safety View source Lack of guidance defining monitoring requirements for restrained detainees View source Reliance on breathing sounds as insufficient monitoring of prone restrained detainees View source Insufficient emphasis on heightened risks of prone restraint when multiple breathing-affecting factors are present View source Inconsistent understanding of when to commence CPR for abnormal or distressed breathing View source Failure to prioritise assessment of detainees after control is obtained over speedy removal from the scene View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Duncan Tomlin · 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
Duncan Tomlin died on 29 July 2014 after cardiac arrest following the use of drugs and police prone restraint, including handcuffs, leg restraints and incapacitant spray. The report identified concerns about insufficient emphasis on the heightened breathing risks of multiple factors, delayed opportunities to assess and reposition him, inadequate guidance on monitoring, the timing of CPR, and understanding atypical or post-seizure 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 Insufficient training on atypical seizure and post-seizure behaviour
Wider context from the report “Understanding aspects of Epilepsy and Seizures
5. The training material which has been provided to me on behalf of Sussex Police covers many aspects of epilepsy and seizure that were explored during the inquest. The training material indicates that if it is available to the trainer, participants will be shown a video which informs the viewer of the way in which a person may present post seizure, namely confused, vulnerable, perceiving aggression from others and at risk of lashing out due to misunderstanding. I have also been provided with a copy of a training manual provided by Epilepsy Action which was sent to ACPO in 2011. Aspects of the evidence from the family in this inquest were entirely consistent with the less common presentations of a person in an atypical or post seizure state.
Although epilepsy was not found to be causative in the death in this Inquest, in another situation with a similar set of circumstances, the reactions of a person suffering an atypical seizure or in a post seizure state, could be misconstrued as violence and resistance were officers not to appreciate that fact that their presentation may be part of a medical condition and restraint in such circumstances could have inherent and fatal risks. It is therefore of importance that training extends beyond the two more well known types of seizure and that post seizure behaviour is also understood in general terms .
” 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 sharing and requesting of information needed to assess restraint safety
Wider context from the report “Timing of decisions and opportunity to assess
2. A further concern relates to how officers are trained to prioritise options available to them and the timing of decisions in circumstances similar to those in this inquest. It is appreciated that officers are not medically trained, they do not make clinical decisions and more detailed history will be taken formally in custody suites. However, officers do need to be in a position to have sufficient information to enable them to assess the safety of the restraint situation in which they are involved, and this includes sharing information and requesting information when participants in the restraint may not have been present from the outset . These points are particularly so when medical evidence suggests fatal consequences can arise in a matter of minutes and that by the time a detainee is unresponsive, action may be too late. In this inquest a priority of the officers, said to be in line with their training, was to remove the restrained person from the scene as soon as practicable. The officers also gave evidence on the risks involved in turning the detainee on his side and the possible acts that a violent individual can take towards officers and themselves which raise other risks of harm. However my concern is that in future similar situations officers may prioritise the need to act speedily to remove a person from the scene, rather than, when a measure of control is obtained (such as by the use of handcuffs and limb restraints), taking an opportunity to take stock in order to assess the detainee they are dealing with and why they are struggling or resisting. Are they dealing with a person who is struggling because they are violent, or because they are confused, or psychotic, or in a post seizure state, or because they are in pain, uncomfortable or struggling to breathe?
Once a measure of control is obtained, the speed of the incident is dictated by the actions the officers decide to make and balancing the risks of harm which, in the case of positional asphyxia, are fatal and therefore must be a priority.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance defining monitoring requirements for restrained detainees
Wider context from the report “Monitoring
3. The training plans, manuals and policies considered in evidence in this inquest refer to monitoring in different ways, depending on the circumstance. Phrases such as close, constant, careful and regular monitoring are used. Guidance as to what constitutes monitoring does not appear to be included within the literature available to officers . A different type of monitoring may be required for, for example, a detainee who poses a suicide risk or who has a known medical condition, as compared to the type of monitoring required for a person restrained in the prone position, particularly when affected by other factors impacting on breathing. Listening to noises associated with breathing may be entirely insufficient, particularly when they can be hard to hear, mishear or misinterpreted.
” 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 Reliance on breathing sounds as insufficient monitoring of prone restrained detainees
Wider context from the report “Monitoring
3. The training plans, manuals and policies considered in evidence in this inquest refer to monitoring in different ways, depending on the circumstance. Phrases such as close, constant, careful and regular monitoring are used. Guidance as to what constitutes monitoring does not appear to be included within the literature available to officers. A different type of monitoring may be required for, for example, a detainee who poses a suicide risk or who has a known medical condition, as compared to the type of monitoring required for a person restrained in the prone position, particularly when affected by other factors impacting on breathing. Listening to noises associated with breathing may be entirely insufficient , particularly when they can be hard to hear, mishear or misinterpreted .
” 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 emphasis on heightened risks of prone restraint when multiple breathing-affecting factors are present
Wider context from the report “Importance of heightened risk of prone restraint when multiple factors affecting breathing are present
1. The current and earlier training plans, manuals and policies examined as part of the evidence in this inquest make clear references to risks associated with: (a) positional asphyxia; (b) handcuffs and limb restraints; (c) incapacitant spray; (d) acute behavioural disorder or symptoms thereof; (e) lack of oxygen due to physical exertion; (f) drug/alcohol intoxication; and (g) seizures.
Although there is some cross-referencing between the various risk factors, the heightened risk to a person in prone restraint when a number of these factors are present is not emphasised or sufficiently emphasised . The multifactorial matters that can impact on a person’s ability to breathe and the heightened risks to a person in a position of prone restraint when experiencing such multiple factors are critical to the assessment of 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 Inconsistent understanding of when to commence CPR for abnormal or distressed breathing
Wider context from the report “Commencing CPR
4. The evidence relating to current training and training at the time of the death concerned in this inquest indicates that CPR should commence when a person is not breathing normally (described as in 2-3 breaths in 10 seconds for an adult and 3-5 in 10 seconds for small children) or if breathing is distressed (snoring, rasping) known as agonal breathing.
The evidence in the inquest was that individual officers of some experience understood CPR should commence when breathing had stopped . Whilst that may be a misunderstanding on the part of individual officers, owing to the importance of commencing CPR at the earliest opportunity when time is critically of the essence, the timing of when CPR should start should be a central point of when training CPR and when reacting to situations akin to that seen in this inquest .
” 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 prioritise assessment of detainees after control is obtained over speedy removal from the scene
Wider context from the report “Timing of decisions and opportunity to assess
2. A further concern relates to how officers are trained to prioritise options available to them and the timing of decisions in circumstances similar to those in this inquest. It is appreciated that officers are not medically trained, they do not make clinical decisions and more detailed history will be taken formally in custody suites. However, officers do need to be in a position to have sufficient information to enable them to assess the safety of the restraint situation in which they are involved, and this includes sharing information and requesting information when participants in the restraint may not have been present from the outset. These points are particularly so when medical evidence suggests fatal consequences can arise in a matter of minutes and that by the time a detainee is unresponsive, action may be too late. In this inquest a priority of the officers, said to be in line with their training, was to remove the restrained person from the scene as soon as practicable. The officers also gave evidence on the risks involved in turning the detainee on his side and the possible acts that a violent individual can take towards officers and themselves which raise other risks of harm. However my concern is that in future similar situations officers may prioritise the need to act speedily to remove a person from the scene , rather than, when a measure of control is obtained (such as by the use of handcuffs and limb restraints), taking an opportunity to take stock in order to assess the detainee they are dealing with and why they are struggling or resisting . Are they dealing with a person who is struggling because they are violent, or because they are confused, or psychotic, or in a post seizure state, or because they are in pain, uncomfortable or struggling to breathe?
Once a measure of control is obtained, the speed of the incident is dictated by the actions the officers decide to make and balancing the risks of harm which, in the case of positional asphyxia, are fatal and therefore must be a priority.
” Open source report
27 Mar 2019 Ms Donna Williamson · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to assign responsibility for repairing and securing doors in privately rented accommodation View source Failure to inform victims promptly when suspects are released on bail View source Insufficient clarity and knowledge of professional and legal duties to disclose confidential information about victims at risk View source Failure to contact available support services for disabled private tenants View source Failure of the MARAC process to provide coordinated protection and support for chaotic non-engaging individuals 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
Ms Donna Williamson · 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
Donna Williamson, a 44-year-old woman with mental health, alcohol dependence, mobility and domestic abuse vulnerabilities, died from stab wounds to the chest after being assaulted with a knife by her ex-partner. The principal concerns included the failure to secure her insecure door, failure to inform her that the suspect had been released on bail, and weaknesses in the MARAC process for protecting chaotic and non-engaging individuals.
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 assign responsibility for repairing and securing doors in privately rented accommodation
Wider context from the report “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not . Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted. Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable tenants.
” 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 victims promptly when suspects are released on bail
Wider context from the report “2. There was a failure to inform the victim that the suspect had been released on bail. Whilst the Metropolitan Police Service have taken steps to address this risk, wider awareness amongst other police forces of the importance of this being completed in a timely manner may be of value.
” 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 clarity and knowledge of professional and legal duties to disclose confidential information about victims at risk
Wider context from the report “4. Key information about the risk to the victim was secured by the police from the suspect’s GP, who has commendably established new procedures for handling domestic abuse, but the GP was unable to articulate what were the criteria when a GP has a duty to disclose confidential information to the police in relation to a victim at risk. There is a risk that GPs in general may not have sufficient knowledge or awareness of their professional and legal duties of disclosure.
” 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 contact available support services for disabled private tenants
Wider context from the report “1. No one agency took responsibility for repairing and securing the door. The detailed evidence is attached in an Appendix. Additionally a local authority officer gave evidence that the local authority did not realize that they had a duty to repair it if the landlord did not. Additionally it was reported that there was a local scheme that provided a service for disabled people which was not contacted . Local authorities may need wider awareness of how to resolve such problems for privately renting vulnerable tenants.
” 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 MARAC process to provide coordinated protection and support for chaotic non-engaging individuals
Wider context from the report “3. The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. Lengthy evidence was heard from the independent chair of the Domestic Homicide Review, who had conducted 23 such reviews. She said that the MARAC system can be good depending on the priority given by each organization. In this case agencies should have worked together to address risks in the context of her life environment and network. Instead her needs were compartmentalised. Her evidence was clear that no MARAC can deliver the needs of chaotic non engaging individuals . She reported that there were arguments for MARAC and other bodies to be put on a statutory footing. Clearly there is an urgent need for national review how the system can afford protection and support for these particularly vulnerable complex individuals or whether changes need to be made to it.
” Open source report
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Addressed to Association of Chief Police Officers, now represented here by National Police Chiefs’ Council.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations