Newcastle Upon Tyne City Council

Local government · English metropolitan district council

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First report 9 Aug 2019•Latest report 26 Jan 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 3
Published responses: 33%
Concerns addressed: 2
Stated actions: 5

Concerns and recipient responses

Statements from Newcastle Upon Tyne City Council linked to the concerns in each report. Select any concern, action or position to view the source wording.

26 Jan2024
Newcastle and North Tyneside
Concerns raised2
1. Lack of an appropriate structure to educate and manage people diagnosed with allergies and anaphylaxis
2. Failure to provide regular review of allergy, anaphylaxis risk and the benefits of automatic adrenaline injectors
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

James Stuart Atkinson · 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

James Stuart Atkinson, who had a known peanut allergy and asthma, died of anaphylaxis after eating a Chicken Tikka Masala pizza containing peanuts from Dadyal Takeaway Restaurant on 10 July 2020. The report identified concerns about the lack of allergen information from the takeaway, the absence of regular allergy reviews, and the failure to locate his Epi-pen during the reaction.

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 Newcastle Upon Tyne City Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of an appropriate structure to educate and manage people diagnosed with allergies and anaphylaxis
Wider context from the report
“The evidence in this case unequivocally established that James was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenaline injectors. The report of ████████ (attached) identifies the need for wider consideration of a systematic approach to improving anaphylaxis awareness and management. The risk of future deaths in the context of allergy/anaphylaxis remains in the absence of an appropriate structure to educate, review and manage those who are diagnosed allergies. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Newcastle Upon Tyne City Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide regular review of allergy, anaphylaxis risk and the benefits of automatic adrenaline injectors
Wider context from the report
“The evidence in this case unequivocally established that James was not under regular review for his allergy, risk of anaphylaxis and the benefits of automatic adrenaline injectors. The report of ████████ (attached) identifies the need for wider consideration of a systematic approach to improving anaphylaxis awareness and management. The risk of future deaths in the context of allergy/anaphylaxis remains in the absence of an appropriate structure to educate, review and manage those who are diagnosed allergies. ”
Open source report
10 Nov2020
Newcastle upon Tyne and North Tyneside
Concerns raised5
1. Lack of mandatory refresher training for police officers on mental health, learning disability and autistic spectrum disorder
2. Failure to allocate a police point of contact for the family of a medium-risk missing person
3. Lack of cross-agency awareness and training on requesting and sharing confidential medical information about missing persons
1. Lack of a multiagency meeting structure for reported missing persons
2. Lack of a joint police-health policy for sharing information about vulnerable missing persons with mental health difficulties
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Ewan Nathanial 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

Ewan Nathanial Brown was found dead on 30 April 2019 after absconding while awaiting mental health assessment, following concerns about his behaviour and mental health. The inquest concluded that he died by accidental drowning while experiencing an unassessed and untreated psychotic illness. Concerns included gaps in police and health-service information sharing, multiagency coordination, mental health training, and family contact during the missing-person search.

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 Newcastle Upon Tyne City Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of mandatory refresher training for police officers on mental health, learning disability and autistic spectrum disorder
Wider context from the report
“3. There is no mandatory refresher training for Police Officers in relation to mental health issues, learning disability and autistic spectrum disorder. After their initial training, when officers join the Police Force, such further training is optional but not compulsory. Given the prevalence of mental health issues in society and the complexities of dealing with such issues for officers of all ranks and across all areas of policing, this is an issue that all officers would benefit from at regular intervals. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Newcastle Upon Tyne City Council; that does not assign responsibility.
PFD Monitor interpretation
Failure to allocate a police point of contact for the family of a medium-risk missing person
Wider context from the report
“5. Northumbria Police accepted that during the period of time that Ewan was classed as a Medium Risk missing person, no officer was allocated as a point of contact for the family. This prevented information being given by the family that could have better informed the progress of the search and Ewan’s risk assessment as a missing person. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Newcastle Upon Tyne City Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of cross-agency awareness and training on requesting and sharing confidential medical information about missing persons
Wider context from the report
“4. I heard evidence from police officers and mental health professionals that indicated a clear lack of awareness that confidential medical information could be requested and shared with police by General Practitioners and Mental Health Professionals when a person is missing. There is a need for training in respect of this across both 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 Newcastle Upon Tyne City Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of a multiagency meeting structure for reported missing persons
Wider context from the report
“2. There is currently no structure in place at a local or national level to allow for a multiagency meeting or meetings to take place when an adult or child is reported missing to the Police. Such a meeting would be a vital source of information to inform missing person risk assessments and to gather intelligence about where the missing person may be. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Newcastle Upon Tyne City Council; that does not assign responsibility.
PFD Monitor interpretation
Lack of a joint police-health policy for sharing information about vulnerable missing persons with mental health difficulties
Wider context from the report
“1. There is no joint policy in place to give guidance to Northumbria Police officers and health professionals in order to enable them to work together and share information about an individual when reported missing, who is classed as vulnerable and is potentially a risk to themselves or others, as a consequence of a mental health difficulty or mental illness. I heard evidence that 30% of missing persons suffer from some form of mental health difficulty. The mental health of a missing person is a crucial aspect of any risk assessment, both in assessing the level of risk they pose to themselves and to others. ”
Open source report
9 Aug2019
Newcastle upon Tyne
Concerns raised2
1. Junction and crossing design allowing no margin for pedestrian or driver error
2. Foreseeable risk of pedestrian error at the crossing
Actions described in response 3
1. Action
  Revise light phasing, install detection sensors, relocate the primary traffic signal head, and raise pedestrian repeater signals.
2. Action
  Install “Look both ways” text on kerb edges at pedestrian crossing points.
3. Action
  Commissioned and completed two independent Stage 4 road safety audits of the junction layout and signal phasing.
AI-generated summary

Pauline Howell · 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 5 February 2018, Pauline Howell was struck by a bus while crossing Newbridge Street West at the junction with John Dobson Street in Newcastle upon Tyne, sustaining injuries that resulted in her death. The principal concerns were the crossing’s proximity to the junction, its location on a busy bus route, the tight junction design, and the lack of margin for error, with a similar previous pedestrian death reported at the junction.

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 Newcastle Upon Tyne City Council; that does not assign responsibility.
PFD Monitor interpretation
Junction and crossing design allowing no margin for pedestrian or driver error
Wider context from the report
“(1) The risk of pedestrian error at the John Dobson Street crossing is foreseeable. (2) The crossing is situated close to the junction. (3) The crossing is situated on a busy bus route. (4) The Junction is “tight” and challenging for public service vehicle drivers to negotiate. (5) The design/layout of the junction/crossing allow no margin for error by either or both pedestrian and driver. (6) The deaths of two pedestrians resulted from injuries sustained whilst crossing this junction in similar circumstances and the risk of future deaths continues. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Newcastle Upon Tyne City Council; that does not assign responsibility.
PFD Monitor interpretation
Foreseeable risk of pedestrian error at the crossing
Wider context from the report
“(1) The risk of pedestrian error at the John Dobson Street crossing is foreseeable. (2) The crossing is situated close to the junction. (3) The crossing is situated on a busy bus route. (4) The Junction is “tight” and challenging for public service vehicle drivers to negotiate. (5) The design/layout of the junction/crossing allow no margin for error by either or both pedestrian and driver. (6) The deaths of two pedestrians resulted from injuries sustained whilst crossing this junction in similar circumstances and the risk of future deaths continues. ”
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
Revise light phasing, install detection sensors, relocate the primary traffic signal head, and raise pedestrian repeater signals.

Verbatim wording from the response
“Other minor scheme improvements will include:”

Source location
2019-0498-Response-from-Newcastle-City-Council-Redacted-1
Page 2 · response
Published 9 August 2019
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
Install “Look both ways” text on kerb edges at pedestrian crossing points.

Verbatim wording from the response
“Potential confusion over road layout as the segregated cycle lane could be mistaken as southbound carriageway – there had been an original suggestion to install text on the kerb edge at pedestrian crossing points to state ‘Look both ways’ which was discounted at the time as not permitted under the regulations. This is now permitted by the Traffic Signs Regulations and General Directions and will be installed.”

Source location
2019-0498-Response-from-Newcastle-City-Council-Redacted-1
Page 2 · response
Published 9 August 2019
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
Commissioned and completed two independent Stage 4 road safety audits of the junction layout and signal phasing.

Verbatim wording from the response
“In order to give full consideration to the issues you raised, we commissioned two independent Stage 4 Road Safety Audits by different experienced Civil Engineers to review the current junction layout and signal phasing. Should you wish to see copies of the independent road safety audits we will make them available to you.”

Source location
2019-0498-Response-from-Newcastle-City-Council-Redacted-1
Page 1 · response
Published 9 August 2019
Open published response

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Lack of an appropriate structure to educate and manage people diagnosed with allergies and anaphylaxis

Failure to provide regular review of allergy, anaphylaxis risk and the benefits of automatic adrenaline injectors

Concerns raised5

Lack of mandatory refresher training for police officers on mental health, learning disability and autistic spectrum disorder

Failure to allocate a police point of contact for the family of a medium-risk missing person

Lack of cross-agency awareness and training on requesting and sharing confidential medical information about missing persons

Lack of a multiagency meeting structure for reported missing persons

Lack of a joint police-health policy for sharing information about vulnerable missing persons with mental health difficulties

Concerns raised2

Junction and crossing design allowing no margin for pedestrian or driver error

Foreseeable risk of pedestrian error at the crossing

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3

Actions described in response 3