Concerns raised 4 Inadequate content of police training on dealing with restraint View source Inadequate content and frequency of police training on the status and responsibilities of an Appropriate Adult View source Inadequate criteria for identifying the most appropriate place of safety View source Unclear responsibilities for transporting someone detained under Section 136 MHA 1983 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
Meirion James · 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
Meirion James was arrested for assaulting his mother and later became agitated at Haverfordwest Police station. During restraint, he was placed prone, stopped breathing and died from positional asphyxia. The report raised concerns about police restraint training, arrangements for people detained under Section 136 of the Mental Health Act, and training concerning Appropriate Adults.
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 Inadequate content of police training on dealing with restraint
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” 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 content and frequency of police training on the status and responsibilities of an Appropriate Adult
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed .
” 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 criteria for identifying the most appropriate place of safety
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” 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 Unclear responsibilities for transporting someone detained under Section 136 MHA 1983
Wider context from the report “(1) Whether the content of police training in dealing with restraint should be addressed
(2) Whether the criteria for identifying the most appropriate place of safety and the responsibilities for transporting someone who is detained under Section 136 MHA 1983 should be reviewed
(3) Whether the content and frequency of police training on the status and responsibilities of an Appropriate Adult under the Police & Criminal Evidence Act should be reviewed.
” Open source report
Concerns raised 3 Defective and inappropriate mouth and face guards for high-risk suspects View source Lack of knowledge of choking risks during arrest or detention View source Failure to carry and use mouth and face guards in appropriate cases 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
KARL BRUNNER · 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
Karl Brunner died after choking on a package of drugs he swallowed while being arrested by police in Bedford on 11 May 2016. The report identified concerns that officers lacked knowledge of the risks of choking during arrest or detention and that the mouth and face guards provided to them were defective and inappropriate for high-risk suspects.
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 Defective and inappropriate mouth and face guards for high-risk suspects
Wider context from the report “Police Officers are provided with mouth and face guards which are so defective and inappropriate when dealing with high risk suspects who may have significant health issues that they are neither carried nor used in appropriate cases. This should be urgently addressed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of choking risks during arrest or detention
Wider context from the report “The evidence before me showed that police officers were trained to deal with suspects who had swallowed drugs. The evidence however disclosed a complete lack of knowledge of the risks of choking when suspects were either arrested or in the process of being detained . This should urgently be addressed in the Officers’ training and the appropriate medical procedures should be adopted.
” 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 and use mouth and face guards in appropriate cases
Wider context from the report “Police Officers are provided with mouth and face guards which are so defective and inappropriate when dealing with high risk suspects who may have significant health issues that they are neither carried nor used in appropriate cases . This should be urgently addressed.
” Open source report
Concerns raised 1 Inability to lock stationary ambulance doors to prevent egress 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
Trystan Bryant · 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
Trystan Bryant, who had a history of mental illness and had expressed suicide intent, fell from the Tamar Bridge after leaving an ambulance and crossing barriers, sustaining multiple injuries that resulted in his death on 12 May 2017. The report raised a concern that stationary ambulance doors cannot be locked to prevent egress, which may affect police containment when escorting individuals under Section 136 of the Mental Health Act.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Inability to lock stationary ambulance doors to prevent egress
Wider context from the report “Ambulance Doors
When ambulances are stationary ambulance doors cannot be locked to prevent egress from inside the vehicle.
This may affect police containment preparations when police officers are escorting individuals for the purposes of Section 136 of the Mental Health Act
” Open source report
13 Jun 2018 Keiron Christopher Bould · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to verbally confirm transfers of cases between police forces View source Failure to verbally confirm which force has primacy for an incident 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
Keiron Christopher Bould · 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
Keiron Christopher Bould left home on 17 September 2017 after taking his girlfriend’s morphine tablets and was later found in his parked vehicle. He was taken to hospital and pronounced deceased on 18 September 2017; the medical cause of death was recorded as a morphine overdose and the inquest concluded suicide. Concerns were raised about the lack of clear communication over which police force had primacy for the missing-person inquiry and about a four-hour delay in actioning the transfer email.
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 verbally confirm transfers of cases between police forces
Wider context from the report “2. When Warwickshire police decided to transfer the case to West Midlands police an email was sent at 01.53 to a generic email address . There was a 4 hour delay in this email being picked up and actioned . There should be a system in place to ensure verbal confirmation about a transfer so the receiving force is aware of the referral .
” 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 verbally confirm which force has primacy for an incident
Wider context from the report “1. When each force received a missing person report soon after 12 midnight on 18/09/17, there was no communication about who would take primacy of the inquiry . There should be a system in place to ensure verbal communication confirms who is dealing with any incident .
” Open source report
Concerns raised 3 Failure to retain proper records of decisions on operational ammunition View source Lack of a system ensuring alternative ammunition avoids excessive or unnecessary injury risks from bullet fragmentation View source Failure to treat NPCC/CAST ammunition recommendations as superseding previous recommendations 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
RICHARD THOMAS DAVIES · 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
Richard Thomas Davies was killed by a police firearms officer during an incident on 21 October 2015 after he threatened his children and fired a homemade firearm at armed police officers. The report raised concerns about the use of unbonded ammunition by the joint Bedfordshire, Cambridgeshire and Hertfordshire Armed Policing Unit, including the absence of safeguards against excessive injury from bullet fragmentation and inadequate records of ammunition decisions.
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 proper records of decisions on operational ammunition
Wider context from the report “17. Accordingly, I am concerned that the Armed Policing Unit of Bedfordshire, Cambridgeshire and Hertfordshire police forces:
• Is or may be treating NPCC (previously ACPO)/CAST ammunition recommendations as not superseding previous recommendations contrary to the wording of those recommendations.
• Does not have in place a system to ensure that if NPCC/CAST recommendations on ammunition are not followed, the ammunition it adopts avoids the risk of excessive / unnecessary injury identified in the Nordic studies.
• Has not retained proper records of decisions made in respect of operational ammunition when it has decided in the past not to follow non-binding national guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a system ensuring alternative ammunition avoids excessive or unnecessary injury risks from bullet fragmentation
Wider context from the report “17. Accordingly, I am concerned that the Armed Policing Unit of Bedfordshire, Cambridgeshire and Hertfordshire police forces:
• Is or may be treating NPCC (previously ACPO)/CAST ammunition recommendations as not superseding previous recommendations contrary to the wording of those recommendations.
• Does not have in place a system to ensure that if NPCC/CAST recommendations on ammunition are not followed, the ammunition it adopts avoids the risk of excessive / unnecessary injury identified in the Nordic studies.
• Has not retained proper records of decisions made in respect of operational ammunition when it has decided in the past not to follow non-binding national guidance.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to treat NPCC/CAST ammunition recommendations as superseding previous recommendations
Wider context from the report “17. Accordingly, I am concerned that the Armed Policing Unit of Bedfordshire, Cambridgeshire and Hertfordshire police forces:
• Is or may be treating NPCC (previously ACPO)/CAST ammunition recommendations as not superseding previous recommendations contrary to the wording of those recommendations.
• Does not have in place a system to ensure that if NPCC/CAST recommendations on ammunition are not followed, the ammunition it adopts avoids the risk of excessive / unnecessary injury identified in the Nordic studies.
• Has not retained proper records of decisions made in respect of operational ammunition when it has decided in the past not to follow non-binding national guidance.
” Open source report
Concerns raised 7 Inconsistent police guidance on the appropriateness and endorsement of forced searches of detainees’ mouths View source Inconsistent police training and adoption of forced-search-of-mouth procedures View source Lack of clear police training for situations involving potentially harmful substances or items in a detainee’s mouth View source Lack of police training in control and restraint when a detainee is seen to put something in their mouth View source Lack of guidance on deploying PAVA spray when a detainee is believed to have placed something in their mouth View source Shortcomings in cascading safety information across police forces View source Unclear operational scope of FFLM recommendations on managing choking in police care and custody 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
Darran Hunt · 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 2015, Darran Hunt was involved in a struggle with police after attempting to evade detention and placing a package in his mouth. He choked on the package and died despite efforts to clear his airway and provide life support. The report raises concerns about police training and guidance on using PAVA spray, forced searches of a detainee’s mouth, and control and restraint where a detainee has placed something in their mouth.
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 Inconsistent police guidance on the appropriateness and endorsement of forced searches of detainees’ mouths
Wider context from the report “2. Forced Search of mouth
Clarification is needed on the extent to which individual police forces are expected/mandated to adopt Module12 of the Personal Safety Manual and in particular the practical technique of undertaking a forced search of the mouth. It appears that Dyfed Powys Police have not been trained on the method of forcible search of the mouth whereas South Wales Police have. The concept of a forced search of a detainee’s mouth is in stark contrast to the guidance/direction given by Faculty of Forensic & Legal Medicine (FFLM) . Officers are, as part of their training, directed to the FFLM guidance for further reading which provides that a forced search of a detainee’s mouth “is not ever appropriate to prevent the swallowing of an object”. There is significant inconsistency in this area and consideration needs to be given to the status and endorsement that the Police give to the FFLM recommendations in its guidance entitled “Management of Choking in Police Care & Custody – Recommendations for Police Personnel”. Consideration should also be given to whether the FFLM recommendations apply in the context of just custody suites or more widely such as in the street (as in this case).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Inconsistent police training and adoption of forced-search-of-mouth procedures
Wider context from the report “2. Forced Search of mouth
Clarification is needed on the extent to which individual police forces are expected/mandated to adopt Module12 of the Personal Safety Manual and in particular the practical technique of undertaking a forced search of the mouth . It appears that Dyfed Powys Police have not been trained on the method of forcible search of the mouth whereas South Wales Police have . The concept of a forced search of a detainee’s mouth is in stark contrast to the guidance/direction given by Faculty of Forensic & Legal Medicine (FFLM). Officers are, as part of their training, directed to the FFLM guidance for further reading which provides that a forced search of a detainee’s mouth “is not ever appropriate to prevent the swallowing of an object”. There is significant inconsistency in this area and consideration needs to be given to the status and endorsement that the Police give to the FFLM recommendations in its guidance entitled “Management of Choking in Police Care & Custody – Recommendations for Police Personnel”. Consideration should also be given to whether the FFLM recommendations apply in the context of just custody suites or more widely such as in the street (as in this case).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear police training for situations involving potentially harmful substances or items in a detainee’s mouth
Wider context from the report “There appears to be an apparent lacuna or, at least, confusion in respect of training for Police in relation to situations where a detained person puts a potentially harmful substance or item in their mouth .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of police training in control and restraint when a detainee is seen to put something in their mouth
Wider context from the report “It is of concern that there is a 2006 case with no too dissimilar facts in the South Wales Police Force area. In that case, the lack of training in relation to the forced search of the mouth of a detainee and control and restrain where a detainee has been seen to put something in their mouth were issues highlighted by the Inquest. One of the recommendations of the Preventing Future Death’s Report in that case was that officers should be trained in the technique of forced searching of the mouth. There is an apparent shortcoming in the cascading of information across the different police forces.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on deploying PAVA spray when a detainee is believed to have placed something in their mouth
Wider context from the report “1. Use of PAVA Spray
It has been suggested by the expert during the course of the Inquest that “luck” will determine whether a person sprayed with PAVA spray will inhale or exhale at the point immediately after being sprayed. There is clearly a risk therefore that a person with an object in their mouth could choke on that item if they inhale immediately upon being sprayed. At present there does not appear to be any guidance for officers on whether they should use PAVA spray in the circumstances of this case . Consideration needs to be given to whether guidance/policy should be issued to officers about if and when PAVA spray should ever be deployed in respect of a detainee who is believed to have placed something in their mouth.
” 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 Shortcomings in cascading safety information across police forces
Wider context from the report “It is of concern that there is a 2006 case with no too dissimilar facts in the South Wales Police Force area. In that case, the lack of training in relation to the forced search of the mouth of a detainee and control and restrain where a detainee has been seen to put something in their mouth were issues highlighted by the Inquest. One of the recommendations of the Preventing Future Death’s Report in that case was that officers should be trained in the technique of forced searching of the mouth. There is an apparent shortcoming in the cascading of information across the different police forces .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Unclear operational scope of FFLM recommendations on managing choking in police care and custody
Wider context from the report “2. Forced Search of mouth
Clarification is needed on the extent to which individual police forces are expected/mandated to adopt Module12 of the Personal Safety Manual and in particular the practical technique of undertaking a forced search of the mouth. It appears that Dyfed Powys Police have not been trained on the method of forcible search of the mouth whereas South Wales Police have. The concept of a forced search of a detainee’s mouth is in stark contrast to the guidance/direction given by Faculty of Forensic & Legal Medicine (FFLM). Officers are, as part of their training, directed to the FFLM guidance for further reading which provides that a forced search of a detainee’s mouth “is not ever appropriate to prevent the swallowing of an object”. There is significant inconsistency in this area and consideration needs to be given to the status and endorsement that the Police give to the FFLM recommendations in its guidance entitled “Management of Choking in Police Care & Custody – Recommendations for Police Personnel”. Consideration should also be given to whether the FFLM recommendations apply in the context of just custody suites or more widely such as in the street (as in this case).
” Open source report
17 Mar 2016 Mr Philmore Leonard Mills · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 2 Lack of training on containment as a tactical option for subjects with suspected excited delirium View source Failure to train Police Officers about the risk of death from takedown procedures 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
Mr Philmore Leonard Mills · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Philmore Leonard Mills, a 55-year-old patient with significant comorbidities including terminal lung cancer, became confused and aggressive while in hospital and died after police attended and restrained him. The report notes concerns that police training did not identify containment as a tactical option for suspected excited delirium, and did not warn that the restraint manoeuvre could in certain circumstances be fatal.
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 training on containment as a tactical option for subjects with suspected excited delirium
Wider context from the report “(1) In the course of the evidence, the Jury heard from two independent experts on restraint techniques and Police training. They both had the opportunity to review the existing Thames Valley Police and ACPO Training in place at the time of Mr Mills’ death. This included training for Police Officers when dealing with a subject who may be suffering from excited delirium. Both Officers highlighted the fact that there is no reference to the option of containment as a tactic taught to Police Officers as part of their training in dealing with subjects with suspected excited delirium . In the evidence, containment was identified as one of the tactical options that Officers should carefully consider in any situation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to train Police Officers about the risk of death from takedown procedures
Wider context from the report “(2) The Jury heard from one of the two expert witnesses, ████████ that, while Police Officers are trained as to the medical consequences of the take down procedure in restraining a subject, those consequences do not include reference to the risk of death . While they described the risk of bruising, broken bones etc, they do not suggest that such an manoeuvre could, in certain circumstances, prove fatal to the subject involved .
(3) The evidence surrounding the circumstances of the death of Philmore Mills suggests that this is a potential outcome of which Officers should be made aware .
” Open source report
Concerns raised 6 Failure to make detailed notes in detainees’ custody medical records View source Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels View source Insufficient targeted training on drug and alcohol-related risks in custody View source Insufficient training emphasis on correct observation levels View source Lack of joint training exercises for medical practitioners, custody sergeants, custody detention officers and assistants View source Failure to specify detainee observation levels precisely View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Name not published · 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
The deceased was arrested on 2 October 2011 and held in custody, where he received prescribed methadone and medication for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on 3 October 2011; the recorded medical cause of death was methadone intoxication, with alcohol withdrawal in a chronic alcoholic also identified. Concerns included communication between medical practitioners and custody staff, inconsistent observation levels, joint training, and training on drug and alcohol-related risks.
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 make detailed notes in detainees’ custody medical records
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical record .
” 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 verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical record.
” 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 targeted training on drug and alcohol-related risks in custody
Wider context from the report “5. That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal , particularly if the detainee is likely to be in custody for upwards of 24 hours.
” 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 emphasis on correct observation levels
Wider context from the report “3. That training should provide targeted emphasis on the correct levels of observation .
” 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 joint training exercises for medical practitioners, custody sergeants, custody detention officers and assistants
Wider context from the report “2. That consideration be given to the provision of joint training exercises for medical practitioners, custody sergeants and custody detention officers and assistants .
” 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 specify detainee observation levels precisely
Wider context from the report “4. That consideration should be given to eliminating the phrase ‘continue observations at the current level’ and require that doctors and custody sergeants specify the level of observation precisely .
” Open source report
12 May 2015 Paul Mc Guigan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 16 Unavailability of enhanced criminal-record disclosures for overseas armed private security employment View source Lack of recording of pre-conviction disclosures View source Lack of understanding of overseas armed close protection work View source Lack of guidance and transfer arrangements for MAPPA-triggering offenders View source Lack of computer categorisation for close protection occupations View source Lack of clear procedure and funding responsibility for independent forensic psychiatric reports View source Lack of training for officers and civilian employees on disclosure procedures View source Failure to understand and operate the Notifiable Occupation Scheme View source Failure to consider disclosure to employers View source Inadequate and infrequent formal supervision of newly qualified offender managers View source Lack of a national system and contact point for obtaining military information View source Failure to record discussions among key professionals View source Failure of agencies to check and share available information before multi-agency meetings View source Incomplete and unclear procedure for the Common Law Police Disclosure Scheme View source Misunderstanding of residence conditions for offender monitoring View source Lack of recording of offenders' bail conditions View source See 13 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 Mc Guigan · 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 Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.
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 enhanced criminal-record disclosures for overseas armed private security employment
Wider context from the report “I also have a concern that an employer on a private security contract at home has regulated by the SIA and a private security employed overseas [unregulated save for voluntary schemes such as International Code of Conduct for Private Security Service Providers 2010 [ICoC] and accredited certification to the standard ANSI/ SSlS PSC. 1-2012] is not entitled or able to obtain an enhanced CRB and would only ever receive a Standard disclosure on a pre employment check.
It concerns me in particular that in respect of employing on individual on an armed contract then consideration should be given to enabling Private Security Companies a route to obtaining an enhanced 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 Lack of recording of pre-conviction disclosures
Wider context from the report “It is clear that within GMP there was no recording anywhere as to when / if any pre convictions disclosures were made . It is important that there is a system of recording in this scenario and also to whom the disclosure is made. At present no-one can provide any information as to the number of detail of pre-conviction disclosures. In addition this means that officers who may be dealing with someone who has been arrested have no way of knowing if such a pre-conviction disclosure has ever been made.
” 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 understanding of overseas armed close protection work
Wider context from the report “In addition I have a concern that there is a complete lack of understanding by the Police and Probation / NOMS as to what close protection work overseas involves and in particular when this involves work on armed contracts .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and transfer arrangements for MAPPA-triggering offenders
Wider context from the report “It concerns me to ensure that there is clear guidance given by NOMS to the private community rehabilitation companies [e.g. in Manchester Purple Futures] as to assessment of risk and for offenders who then do trigger MAPPA concerns that should be being supervised or assessed for eligibility under MAPPA to be transferred to be supervised by the National Probation Service.
” 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 computer categorisation for close protection occupations
Wider context from the report “In respect of the GMP computer system and in respect of occupations that are regulated and require licensing by the SIA, there is no categorisation on the computer for “CLOSE PROTECTION” . Indeed the Court heard that there was some confusion and lack of understanding from many people as to what this occupation actually meant. Close protection work is a separate category of employment within the UK that the SIA regulates and the police system should reflect the occupations subject to regulation. It is important that the police and NOMS have a clear understanding as to what close protection work is to inform risk and 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 clear procedure and funding responsibility for independent forensic psychiatric reports
Wider context from the report “It concerns me that there is not a clear practice and procedure operating within the Court or probation system, including funding responsibility, for obtaining an Independent Forensic Psychiatric Report , particularly in circumstances where a defendant is remanded on bail in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of training for officers and civilian employees on disclosure procedures
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees . The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” 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 understand and operate the Notifiable Occupation Scheme
Wider context from the report “In my judgment there was a complete misunderstanding by GMP in respect of the operation of the Notifiable Occupation Scheme HOC 6/2006 .
Of immense concern also the complete failure for a period of approximately 18 months to make any post conviction notifications under the Notifiable Occupation Scheme , which was it transpired, formally withdrawn by the Home Secretary Theresa May MP in March 2015.
I heard and received evidence from the SIA that they were not aware that a regulatory gap existed in respect of the Police’s understanding of the scheme and notifications to themselves . The evidence I heard suggests that such a gap exists at GMP and has done so for in excess of 18 months.
” 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 consider disclosure to employers
Wider context from the report “In respect of the period of time when Post conviction disclosures were made [before this “back office” function ceased 18 months ago] these were only ever disclosures made to the Regulatory body and consideration never appears to have been given within GMP to disclosure to employers . Given the lack of understanding as to whom some regulatory bodies have responsibility for, this is important.
” 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 and infrequent formal supervision of newly qualified offender managers
Wider context from the report “I heard evidence that the Offender Manager was newly qualified and her formal supervision was inadequate and infrequent . This concerns me. It is important that newly qualified offender managers receive appropriate formal supervision .
” 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 national system and contact point for obtaining military information
Wider context from the report “My concern is to ensure that there is a system, protocol and point of contact for every offender manager nationally [including the private rehabilitation companies now operating as offender managers] that is well known as to who to contact to within the Ministry of Defence to obtain military information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussions among key professionals
Wider context from the report “In addition I heard evidence and it concerns me that in advance of the Multi Agency meeting convened due to concerns as to the Offenders risk, key professionals had had discussions, telephone calls and meetings and I was concerned by the failure to record and document these important discussions , to ensure clarity, understanding and consistency. It is important when key professionals have discussions that these are documented and recorded .
” 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 agencies to check and share available information before multi-agency meetings
Wider context from the report “It is important irrespective of who is the lead agency at a Multi Agency Meeting that each agency invited to attend checks information held on systems and records to which they have access and provides all this information to a multi agency meeting to ensure that a full and informed assessment of risk takes place and the fullest possible informed information sharing.
” 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 Incomplete and unclear procedure for the Common Law Police Disclosure Scheme
Wider context from the report “At present in respect of a replacement scheme in respect of clarifying the Common Law Police Disclosure Scheme I heard evidence as to the process GMP are undergoing in respect of a revised Procedure relating to Notifiable Occupations but this is far from complete and less than clear as to how it will operate and the training that will be given to officers / GMP civilian employees. The Court was also advised that at no stage has legal advice been taken from the force in-house legal team on the proposed scheme, even though this is a difficult legal area.
It is important that GMP and all forces have a recognised procedure in respect of having a scheme but also training officers to operate that scheme. It is imperative also that the SIA understand how and when each police force will be making disclosures under the Common Law Police Disclosure Scheme.
” 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 Misunderstanding of residence conditions for offender monitoring
Wider context from the report “I also heard evidence that a GMP officer believed that Bail with a condition of residence was different to “bail live and sleep each night”. It is of concern that there is a misunderstanding within GMP as to what a condition of residence means and how this relates to the monitoring of offenders .
” 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 recording of offenders' bail conditions
Wider context from the report “I heard evidence that in respect of GMP systems and processes there was nowhere on the GMP computer system where bail conditions are recorded , although this used to be possible. It is of concern that there is no system of recording on the GMP computer of offenders bail conditions so that this information can be known by officers and appropriately shared.
” Open source report
Concerns raised 1 Lack of compulsory practical in-car training for police driving at night-time 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
Joshua Steven BROWN · 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
Joshua Brown died after being struck by a police vehicle on the A31 Hog’s Back shortly after 03.30 on 1 December 2012, in patchy dense fog and reduced visibility. The jury found that the police officer’s speed was inappropriate in the brief period between encountering the fog and the collision, and that Joshua Brown was walking in the carriageway with his back to traffic; both elements contributed to the collision. The report raised concern about the absence of compulsory practical in-car night-time training in national police 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 Lack of compulsory practical in-car training for police driving at night-time
Wider context from the report “Night-time driver training
Consideration should be given to amending the national requirement for police driver training so as to include a compulsory element of practical in-car training for driving at night-time .
” Open source report
16 Apr 2015 Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 28 Failure of the youth diversion project to provide diversion before criminal justice processing View source Failure to record and explain incomplete medical assessments View source Failure to return completed Appropriate Adult forms to Social Services View source Interagency confusion about safeguarding roles and access to information View source Failure to initiate youth offending and mental health monitoring after case transfer View source Failure to pass complete incident information to attending officers View source Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs View source Insufficient availability of accommodation for children under 17 View source Insufficient recording of safeguarding information by Appropriate Adults View source Failure of youth offending teams to transfer and oversee cases after relocation View source Failure to assess police information when selecting an Appropriate Adult View source Lack of legally required accommodation for 17-year-olds refused bail View source Failure to make safeguarding referrals from custody medical information View source Failure to record safeguarding intelligence on nominal profiles View source Failure to conduct police database checks on standard-risk DASH referrals View source Failure to route domestic violence cases involving 17-year-old children to child protection review View source Lack of shared understanding between police and MEDACS about requested medical assessments View source Lack of interagency understanding for sharing safeguarding information between police and CPS View source Failure to provide Appropriate Adults with relevant custody risk information View source Failure to provide differentiated mental health assessments for children in custody View source Failure to document information provided to MEDACS before medical assessments View source Failure to check and update Prisoner Escort Records before release View source Custody handovers dependent on officers’ and staff’s unpaid free time View source Lack of consistent child safeguarding coverage across Manchester local authorities View source Lack of clear officer guidance for raising safeguarding concerns View source Unclear referral routes for non-criminal safeguarding concerns View source Lack of a process for recording safeguarding concerns View source Lack of a non-criminal safeguarding policy View source See 25 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
Kesia Lena Mary Leatherbarrow · 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
Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the youth diversion project to provide diversion before criminal justice processing
Wider context from the report “The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway . There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme .
” 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 and explain incomplete medical assessments
Wider context from the report “It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred .
” 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 return completed Appropriate Adult forms to Social Services
Wider context from the report “Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any cases.
” 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 Interagency confusion about safeguarding roles and access to information
Wider context from the report “Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles , what they are able and not able to do and also where to access important and effective information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to initiate youth offending and mental health monitoring after case transfer
Wider context from the report “This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside . The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur .
” 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 pass complete incident information to attending officers
Wider context from the report “The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife . The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding.
” 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 safeguarding functions across Manchester Multi-Agency Safeguarding Hubs
Wider context from the report “This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children .
” 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 availability of accommodation for children under 17
Wider context from the report “The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available . Attempts are being made to address this issue but at present the figure remains approximately 20% and the Inquest heard evidence that this was, “not good enough”.
Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities . The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe to do so.
” 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 recording of safeguarding information by Appropriate Adults
Wider context from the report “The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form
” 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 youth offending teams to transfer and oversee cases after relocation
Wider context from the report “There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess police information when selecting an Appropriate Adult
Wider context from the report “It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker.
” 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 legally required accommodation for 17-year-olds refused bail
Wider context from the report “There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to.
” 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 make safeguarding referrals from custody medical information
Wider context from the report “Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record safeguarding intelligence on nominal profiles
Wider context from the report “No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers . It is a core function of the police to submit such intelligence.
” 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 conduct police database checks on standard-risk DASH referrals
Wider context from the report “when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out . The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender .
” 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 route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report “For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between police and MEDACS about requested medical assessments
Wider context from the report “It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS .
” 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 interagency understanding for sharing safeguarding information between police and CPS
Wider context from the report “There was a lack of understanding between GMP and the CPS as to how such important information should be shared between agencies .
” 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 Appropriate Adults with relevant custody risk information
Wider context from the report “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS , nor that she had threatened to jump off a bridge on her release.
” 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 differentiated mental health assessments for children in custody
Wider context from the report “The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document information provided to MEDACS before medical assessments
Wider context from the report “there was no clarity as to whether this included previous risk assessments , whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure to check and update Prisoner Escort Records before release
Wider context from the report “The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge.
” 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 Custody handovers dependent on officers’ and staff’s unpaid free time
Wider context from the report “The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and 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 consistent child safeguarding coverage across Manchester local authorities
Wider context from the report “This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children
” 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 officer guidance for raising safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 Unclear referral routes for non-criminal safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for recording safeguarding concerns
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns . There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” 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 non-criminal safeguarding policy
Wider context from the report “Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal . There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded.
” Open source report
Concerns raised 3 Failure to implement nationally a policy limiting police attendance at mental health wards to threats to staff or disorder View source Absence of a national multi-agency crisis team system for people in mental health crisis View source Lack of national training and understanding of how best to treat acute behavioural disturbance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kingsley Burrell · 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
Kingsley Burrell died on 31 March 2011 after being restrained and transported between mental health and hospital settings following an acute mental health disturbance. The inquest found that the covering over his head, unreasonable periods of restraint, delay in resuscitation and neglect contributed to his death. Concerns included inconsistent national understanding of acute behavioural disturbance, the absence of a nationally implemented crisis-team system, and non-nationally consistent policies for managing patients between services during a crisis.
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 nationally a policy limiting police attendance at mental health wards to threats to staff or disorder
Wider context from the report “(3) This case has resulted in a multi-agency review of how patients are managed between the services when crisis occurs. A new conveying of patients policy has been devised. Critically police now only attend a mental health ward if there was a patient who is threatening staff or there is disorder on the ward. My concern is that this is not reflected nationally . Chief Inspector ███████ at West Midlands Police can provide full details of the policy.
” 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 national multi-agency crisis team system for people in mental health crisis
Wider context from the report “(2) The West Midlands area now have a crisis team that works with people who are in a mental health crisis . This involves a mental health worker and ambulance crew working together with the Police to try to help patients with acute mental health disorders . My concern is that this is not a national system . Chief Inspector ███████ at West Midlands Police can provide full details of the scheme.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Lack of national training and understanding of how best to treat acute behavioural disturbance
Wider context from the report “(1) Medical evidence at the inquest confirmed that Mr Burrell was suffering from acute behaviour disturbance. As a result he continued to struggle against restraint. Patients with this condition are at risk of death through prolonged restraint and struggle against restraint. Most training in relation to restraint deaths focuses on positional asphyxia. Position in this case was not a major consideration. It was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance . Minimising the period of restraint is key. West Midlands Police have undertaken considerable work and training of staff concerning this condition. My concern is that this has not been rolled out nationally and therefore many other forces will not understand the implications of this condition and how best to treat it . I suggest contact is made with Chief Inspector Russell at WMP for full information on the changes made in the West Midlands area.
” 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 Issue national instructions requiring monitoring and review of police requests to mental health environments, with escalation and supervisory involvement whenever restraint occurs.
Verbatim wording from the response “Chief Inspector Russell has cited my own national instruction to Chief Officers in respect of the monitoring and reviewing of all service requests to mental health environments, and for escalation and supervisory involvement on every occasion where police are requested to, or effect, restraint in a health environment whatever the circumstances.” Source location 2015-0472-Response-by-Metropolitan-Police
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 Report the expert reference group’s initial findings on the role of police in mental health settings by the end of the calendar year.
Verbatim wording from the response “Chief Inspector Russell has cited my own national instruction to Chief Officers in respect of the monitoring and reviewing of all service requests to mental health environments, and for escalation and supervisory involvement on every occasion where police are requested to, or effect, restraint in a health environment whatever the circumstances.” Source location 2015-0472-Response-by-Metropolitan-Police
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 Examine the role, legal basis, responsibility and safe practice for police involvement in mental health restraint through an expert reference group.
Verbatim wording from the response “In this tragic case, police officers were called in to a mental health environment to effect restraint upon a patient. Aside from the moral and ethical issues pertaining to police officers entering into a care environment to affect this type of force, I am examining the whole issue of the role of police in these types of circumstances and indeed whether this is simply an issue of a lack of capability, capacity and training for health practitioners rather than that it is and should be presumed a police matter. I hope you will be reassured to know that to this end I have been working with the College of Policing and have instigated an expert reference group, chaired by Lord Alex Carlile, to ascertain not only the legal platform upon which activities should sit, but further who should effect them and what is defined as safe practice across all public service disciplines.” Source location 2015-0472-Response-by-Metropolitan-Police
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 National police forces had already received guidance and training addressing acute behavioural disorder risks, with overall compliance considered to meet the standard.
Verbatim wording from the response “Whilst it is helpful that West Midlands have cited their activity in respect of positional asphyxia and other risks associated with restraint, it is not accurate to suggest that the force has implemented safe practice independent of all forces nationally. Indeed, Acute Behavioural Disorder (ABD) and Excited Delirium were specifically highlighted in a 2010 Guidance Document issued by the former National Policing Improvement Agency (now renamed The College of Policing). The NPIA then ran a series of national events throughout 2010/2011 where every single force in the country was briefed and provided with training materials to address this specific set of risks.” Source location 2015-0472-Response-by-Metropolitan-Police
Open published response
Concerns raised 10 Lack of fully independent control over fatal shooting scenes during investigation View source Failure to video record fatal police shooting scenes View source Failure to consider pursuing a planned weapons-seizure operation after a fatal shooting View source Failure to record armed police operations after State Red View source Lack of access to all relevant intelligence for fatal-operation investigations View source Failure to review operational strategy in response to developing events View source Failure to devise a coordinated strategy capable of seizing guns before collection View source Failure to develop and share operational intelligence between the MPS and SOCA View source Failure to obtain prompt comprehensive statements from all police witnesses to fatal shootings View source Lack of an agreed protocol between the IPCC, coronial and prosecution bodies View source See 7 more concerns
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
Mark Duggan · 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 4 August 2011, Mark Duggan was shot by an armed police officer during an enforced vehicle stop in London and was pronounced dead at the scene. The report raises concerns about intelligence sharing and operational decisions before the shooting, the investigation and preservation of evidence at the scene, the recording of the operation, and the coordination and access to intelligence during the investigation and inquest.
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 fully independent control over fatal shooting scenes during investigation
Wider context from the report “Concern 3: The IPCC had primacy at the scene but did not have the resources to conduct all relevant activities there
I am concerned that no scene of a fatal shooting should be the subject of any confusion about the purpose of the investigation, or about what should be done to further that investigation. There is a tension, in a case such as this, between the duty of the MPS to obtain and secure evidence at the scene, its position as being under investigation, and the IPCC’s obligation to investigate independently. The pragmatic approach adopted of the MPS consulting the IPCC about what should happen may not always resolve that tension. My primary concern is whether that position should persist. If it does then I am concerned that the police service has the practical control of many aspects of the scene and what happens there despite being under investigation , without the public realising that the investigation does not have full independence which the IPCC’s role appears to safeguard . This concern is addressed to the IPCC, the Home Secretary and the MPS.
” 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 video record fatal police shooting scenes
Wider context from the report “Concern 4: The scene of the fatal police shooting was not video recorded
I believe that it is important to minimise distrust in the police in connection with fatal shootings, as that distrust can then permeate the entire investigation which follows and may mean that civilian witnesses will not come forward. That plainly has the capacity to prevent lessons being learned which could prevent deaths in the future. This concern is addressed to the MPS, the IPCC and ACPO.
” 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 consider pursuing a planned weapons-seizure operation after a fatal shooting
Wider context from the report “Concern 5: The planned operation to seize weapons was not pursued after the fatal shot was fired
My concern is that no consideration appears to have been given to the prospect . A starting point should have been that one of the Trident officers saw the minicab turn into Burchell Road for the handover, and that was a short cul-de-sac. This concern is addressed to the MPS, the IPCC and ACPO.
” 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 armed police operations after State Red
Wider context from the report “Concern 6: The armed police operation was not recorded after State Red was called
I am therefore concerned that the cars involved in stopping the minicab containing Mr Duggan had data available to be downloaded or that the technology was not as effective in 2011 as it was in 2005. I expect to be told the actual position. In the circumstances I address these concerns to the MPS and ACPO.
” 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 to all relevant intelligence for fatal-operation investigations
Wider context from the report “Concern 8: The IPCC and Counsel to an inquest do not have access to all intelligence
These limitations not only give rise to understandable suspicions in the minds of those not party to the intelligence but also plainly create a risk that an intelligence-led operation which results in death will not be fully investigated so that lessons may be learned. This concern is addressed to the Home Secretary.
” 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 review operational strategy in response to developing events
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA, and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so, in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him . The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan. This concern is directed to the MPS and NCA.
” 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 devise a coordinated strategy capable of seizing guns before collection
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA, and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so, in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him. The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan . This concern is directed to the MPS and NCA.
” 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 develop and share operational intelligence between the MPS and SOCA
Wider context from the report “Concern 1: The MPS and SOCA could have reacted better to developing events and used their joint intelligence resources better.
I am therefore concerned that there may have been the opportunity for better liaison between the MPS and SOCA , and for more focus on intelligence about Mr Hutchinson-Foster, with a view to locating the guns prior to Mr Duggan collecting one. I am left with the clear concern that SOCA did no more than pass on the intelligence it received and did not develop it or suggest ways in which the MPS could do so , in order to get guns from the girlfriend’s address in Burchell Road. The MPS did not react to the unfolding situation so as to review their strategy of waiting for Mark Duggan to obtain a gun before stopping him. The MPS and SOCA did not devise a strategy which focussed on Mr Hutchinson-Foster and the guns and which was capable of leading to them being seized before one was collected by Mark Duggan. This concern is directed to the MPS and NCA.
” 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 obtain prompt comprehensive statements from all police witnesses to fatal shootings
Wider context from the report “Concern 2: Comprehensive accounts were not taken from police witnesses at the first possible opportunity
I am concerned that fatal police shootings are not as rigorously examined as they could be and that doubts about the accuracy of police accounts are not minimised. Lessons learned after a death should be as complete as possible. My concern is that not all witnesses to a fatal shooting are asked to give full statements as soon as possible after the event, giving a detailed account of what they saw . I am also concerned about whether there is any purpose in seeking to distinguish between “principal officers” and other police officers save that, where there is any reason to caution an officer, then of course that must be done. I am concerned that witnesses who perceived a threat from the person who was shot did not set that out in their statements . I therefore invite ACPO and the MPS to deal with what I have said when they respond to the IPCC consultation.
” 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 protocol between the IPCC, coronial and prosecution bodies
Wider context from the report “Concern 7: The IPCC does not have a protocol agreed with the Chief Coroner, ACP and the CPS
With a view to coroners holding effective inquests as soon as practicable I address this concern to the IPCC and ask it to consider approaching the Crown Prosecution Service, the Association of Chief Police Officers, the Chief Coroner and the Coroner’s Society with a view to integrating its memorandum with theirs.
” 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 Ensure a senior officer is present while officers prepare initial accounts after a death or serious injury incident.
Verbatim wording from the response “The National Policing portfolios are currently undertaking a further review of these procedures, in part at least as a direct result of the issues arising from the death of Mark Duggan. We have already taken steps to ensure that as part of immediate post incident procedures, a senior officer is present when officers are preparing initial accounts. This senior officer will be in a position to confirm and reassure that either conferring did not take place or, if it did, it was for a necessary purpose as provided by the APP, which sets out in clear terms that an officer should not confer about any honestly held belief relating to the use of force. In addition, we have made clear the post incident process can and should be more transparent to both a host force’s initial investigating officers and to the IPCC’s investigators.” Source location 2014-0182-Response-by-ACPO
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 Revise the APP to restrict staff association representatives’ pre-account intervention to welfare considerations, working with the College of Policing.
Verbatim wording from the response “Many police forces in England and Wales quite properly and responsibly ensure staff association representatives receive accredited training in post incident management. Whilst such representative play a crucial part in these post incident procedures under the direction and control of the post incident manager, it is equally important that such representatives do not duplicate or intrude into the provision of legal advice.” Source location 2014-0182-Response-by-ACPO
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 Review post-incident procedures in light of issues arising from Mark Duggan’s death.
Verbatim wording from the response “The National Policing portfolios are currently undertaking a further review of these procedures, in part at least as a direct result of the issues arising from the death of Mark Duggan. We have already taken steps to ensure that as part of immediate post incident procedures, a senior officer is present when officers are preparing initial accounts. This senior officer will be in a position to confirm and reassure that either conferring did not take place or, if it did, it was for a necessary purpose as provided by the APP, which sets out in clear terms that an officer should not confer about any honestly held belief relating to the use of force. In addition, we have made clear the post incident process can and should be more transparent to both a host force’s initial investigating officers and to the IPCC’s investigators.” Source location 2014-0182-Response-by-ACPO
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 Commission an expert review of research underpinning delayed formal accounts after traumatic firearms incidents.
Verbatim wording from the response “In paragraph 66 you make specific reference to the apparent inconsistencies in findings between earlier Home Office Study Papers (which lends some support to the practice of allowing a period between a traumatic event and a statement being given) and a more recent paper by Dr William Lewinski. As part of the National Policing response to the earlier IPCC consultation, we recently commissioned Professor Gudjonsson, Emeritus Professor of Forensic Psychology at King’s College, London to conduct a review of the conclusions of Home Office Study Papers of 1986 and 1993, taking into account subsequent relevant studies.” Source location 2014-0182-Response-by-ACPO
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 Liaise with the College of Policing to incorporate weapons-seizure procedures into operational training.
Verbatim wording from the response “The issue you set out in paragraphs 84 to 86 is one for wider operational policing and for senior investigating officer and operational commander and the National Policing portfolios will ensure liaison with the College of Policing to incorporate, reiterate and reflect in its operational training.” Source location 2014-0182-Response-by-ACPO
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 Determine whether body-worn video should be introduced into armed policing operations and develop pilot initiatives to assess feasibility and validity.
Verbatim wording from the response “The National Armed Policing Portfolio has already commenced work to determine whether the introduction of body worn video (BWV), recently trialled in a number of forces in England and Wales might be included in armed policing operations. This work is progressing and is likely to lead to some pilot initiatives later in 2014 to assess its validity and feasibility. The Portfolio is keen to establish an evidence based approach upon which BWV might provide best evidence, and as importantly public confidence and reassurance in such operations.” Source location 2014-0182-Response-by-ACPO
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 Consider how to reflect earliest-possible scene video recording in College of Policing APP post-incident procedures.
Verbatim wording from the response “The National Policing portfolios concur with your view that is important to minimise distrust in the police in connection with fatal shootings, and notwithstanding any development over the use of body worn video (BWV), will consider how best to reflect changes in the College of Policing’s APP on post incident procedures to ensure standard operational procedures encompass the benefits of the earliest possible commencement of the video recording of scenes, subject of course to ongoing operational imperatives to protect public and individual safety and to continue to mitigate any risk of harm.” Source location 2014-0182-Response-by-ACPO
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 Weapons-seizure procedures fall to wider operational policing, the senior investigating officer and the operational commander.
Verbatim wording from the response “The issue you set out in paragraphs 84 to 86 is one for wider operational policing and for senior investigating officer and operational commander and the National Policing portfolios will ensure liaison with the College of Policing to incorporate, reiterate and reflect in its operational training.” Source location 2014-0182-Response-by-ACPO
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 Data recording and tracking on covert vehicles is under consideration, so no more definitive response can currently be provided.
Verbatim wording from the response “The wider issues of data recording and tracking on covert police vehicles likely to be used in armed policing operations is currently being considered by the National Police Interoperability Working Group and at present I am unable to provide any more definitive response. I will of course ensure you are appraised of any progress or developments.” Source location 2014-0182-Response-by-ACPO
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 Separating officers may be operationally, logistically and practically impractical, particularly where numerous witnesses and operational imperatives are involved.
Verbatim wording from the response “Seeking to ensure the separation of officers engaged and involved in a critical incident for what may prove to be a significant period of time before an opportunity to rationally collect thoughts and compose an initial account – no matter how brief - is of course a legitimate and laudable aim but one that has to be set into context. Where officers have been together at the time of such an incident, as is in the case of many armed policing operations, the separation of officers may prove operationally or logistically impractical, as there are often large numbers of officers who will fall into the definition of a key policing witness. Such officers may have been together for a substantial period of time before it is practical to separate them, negating the rationale for separation.” Source location 2014-0182-Response-by-ACPO
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 The existing APP’s flexible, balanced approach is considered sufficient; wholesale separation of officers is not supported as fit for purpose.
Verbatim wording from the response “The IPCC’s draft guidance promotes the third factor at the expense of the first, second and fourth factors. The National Policing portfolios’ view is that post incident procedures should strike an appropriate balance between all four factors, a position that Module 7 of the APP seeks to achieve.” Source location 2014-0182-Response-by-ACPO
Open published response
Concerns raised 3 Lack of arrangements enabling doctors to report relevant information during firearms licence terms View source Failure to enable General Practitioners to share public-safety information with relevant authorities View source Lack of independent and transparent firearms licensing decisions for current or former police employees 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
William Howard DOWLING and Victoria Elaine ROSE · 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 2 March 2013, William Howard Dowling shot Victoria Elaine Rose twice in the head before shooting himself in the head. The report raised concerns about information sharing between general practitioners and firearms licensing authorities, the wider public-safety implications of confidentiality, and the independence and transparency of firearms licensing decisions involving current or former police employees.
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 arrangements enabling doctors to report relevant information during firearms licence terms
Wider context from the report “(1) During the course of the hearing I heard evidence from ███████ Wiltshire Police Firearms Licensing Manager, who indicated to me that at the present moment in time aside from a letter (copy attached marked A – since July 2011) which is sent to General Practitioners when firearms licence applications are successful or where they are renewed, giving a doctor the opportunity to relay relevant information in relation to their patient within 14 days, there is currently no memorandum of understanding or legislation that allows doctors the ability during the duration of the term of a firearms license, which stands at 5 years, to report matters which may have a bearing on that patient’s suitability to hold a firearms license and possess firearms . Doctors of course are bound at the present moment in time by patient confidentiality. I am concerned that this restriction may impede the firearms authority from making crucial decisions as regards individuals possessing firearms and continuing to hold a firearms licence in circumstances which, at present, may not come before the attention of the Firearms Authority unless the matter has ordinarily come before the police’s attention as a consequence of other aspects of their duties.
In evidence from ███████ she made me aware that Wiltshire Police through the cooperation of NHS Wiltshire Clinical Commissioning Group and two Doctor’s Surgeries were piloting a scheme (directly prompted Victoria’s two sons as a result of his tragedy) effective from September 2013, to allow an increase in the sharing of information in particular having a bearing on the suitability of an individual to hold a firearms licence. She indicated that as a result of this pilot scheme an individual’s firearms were taken away at short notice as a result of the information received from the General Practitioner. This pilot scheme seems to me to be an utterly sensible idea although at present it is a pilot scheme and is not a national concept . This ought to be urgently reviewed.
” 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 enable General Practitioners to share public-safety information with relevant authorities
Wider context from the report “(2) I am also concerned that any review arising out of this letter should not be singularly restricted as regards sharing information solely related to the suitability of somebody to hold a firearms licence. Information sharing with a view to public safety should be a reason for General Practitioners to make relevant authority(s) aware and I have in mind here the example of a driver whose eyesight is failing and where advice given from a GP to inform the DVLA, however that driver chooses not to do so as it will mean their licence may be revoked. If it is a matter of public safety then I am concerned at present moment in time that confidentiality appears to outweigh the concept of public safety .
” 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 independent and transparent firearms licensing decisions for current or former police employees
Wider context from the report “(3) I am also concerned as regards decisions being made relating to firearms licensing in respect of current employees within that licensing organisation’s (ie the Police) employment or even former employees . Licensing and the determination of such matters should be seen to be transparent and independent . In evidence although relating to matters some 16 years previously there were issues raised by family concerning complaints by Mr Dowling’s ex wife at the time they were getting divorced that appeared to have been “brushed under the carpet” by the police in respect of which Bill was a serving officer. In any event those concerns were not dealt with satisfactorily from the complainant’s perspective. I am concerned that to have a firearms licensing authority dealing with applications from existing police employees or even former employees of that police force is open to possible abuse . Bill Dowling was an exceptionally well known and respected former police employee and my concern is that such matters relative to firearms are so serious that consideration ought to be given to introducing an independent layer so as to ensure independence and transparency .
” Open source report
Concerns raised 3 Unavailability of specially trained nursing staff for hospital patients with substance misuse View source Unavailability of a dedicated substance misuse team in police custody suites View source Failure of SERCO handcuffing policy to align with ACPO guidance for seriously ill detainees 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
Wayne Spencer Malcolm Broad · 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
Wayne Spencer Malcolm Broad was arrested while under the influence of alcohol and became unwell during transfer between police custody, court and hospital. He later developed delirium tremens, collapsed despite resuscitation and died after suffering a hypoxic injury. Concerns included the lack of a dedicated substance misuse team in police custody, the need for alignment of handcuffing procedures with guidance for seriously ill detainees, and the availability of specially trained nursing staff for patients with substance misuse.
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 specially trained nursing staff for hospital patients with substance misuse
Wider context from the report “(3) Specially trained nursing staff should be available at hospitals for dealing with patients with substance misuse .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a dedicated substance misuse team in police custody suites
Wider context from the report “(1) That was no dedicated substance misuse team available to look after Mr Broad when he was in the custody suite at Hatfield Police Station , as there would have been had Mr Broad been detained in prison.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to National Police Chiefs’ Council; that does not assign responsibility.
PFD Monitor interpretation Failure of SERCO handcuffing policy to align with ACPO guidance for seriously ill detainees
Wider context from the report “(2) Police are required to make risk assessments and have requirements when dealing with the handcuffing of seriously ill detainees. There should be alignment with particular regard to those who are seriously ill and in general SERCO policy should come into alignment with ACPO guidance on the use of handcuffs .
” Open source report
Concerns raised 1 Failure to exchange relevant information between Police and Mental Health Services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rachael Claire Slack and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 2 June 2010, Andrew David Cairns entered Rachael Claire Slack’s home, stabbed their son Auden George Slack and Rachael Slack to death, and then stabbed himself to death. The principal concerns were failures in information-sharing between Police and Mental Health Services, and failures to communicate the assessed risk and safety measures to Rachael regarding the threat posed by Andrew.
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 exchange relevant information between Police and Mental Health Services
Wider context from the report “1. At the time of arrest of Mr Cairns, the Police were aware of his assessment under Section 136 of the Mental Health Act the previous day. The Custody Nurse had contacted the Crisis Team to obtain information regarding the 136 assessment which was duly given by the Mental Health Team. However, there was no reciprocal exchange of information and the Mental Health Team were not informed that Mr Cairns had been arrested with regards to Threats to Kill his partner.
2. At the conclusion of the Inquest and after all the evidence was heard, it came to light that there was in existence a policy for mutual sharing of information between the Police and Mental Health Services if each respective organisation requested information from the other.
3. This document was not disclosed prior to the Inquest or during the Inquest itself and it would have been critical to ask witnesses from the Police and Mental Health Services about their knowledge of this document.
” 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