Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maxine Betty Davison and 4 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to condition firearms licensing delegation on adequate training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training .
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training .
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Absence of a mandatory requirement for role-specific firearms licensing training
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training . I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff.
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists.
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular .
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff ;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally accredited training for firearms licensing staff
Wider context from the report “I am concerned that there is an urgent need to develop a national accredited training for FELU staff that covers how to apply the relevant Home Office Guidance on firearms licencing including, in particular, training in assessing the suitability of applicants to be granted a licence. The development of such accredited training is vitally important to achieve consistency and drive up standards.
I am concerned that there is currently no requirement or guidance that FELU staff should undergo mandatory training. I am also concerned that there is currently no requirement that Chief Officers of Police may only delegate decision making authority regarding issuing firearms licences to a person who has undergone adequate training.
Whilst I acknowledged that the current NPCC lead for firearms licencing is now working with the College of Policing and others to develop the required training, I am concerned to ensure that the momentum to effect change after the horrific tragedy in Keyham should not be lost, as it has been in respect of lessons and recommendations over the past 27 years.
I am therefore reporting the matters above to:
The NPCC lead for firearms licencing and all other Chief Constables in England and Wales
So that each Chief Constable is made aware of my concern that, that despite the many recommendations made over the past 27 years, there continues to be a lack of nationally accredited training for their FELU staff .
I also report my concern that in the absence of such the training there is a risk that the Statutory Guidance is not being appropriately applied by FELU staff today, and so each Chief Constable may need to take steps to satisfy themselves that (i) adequate local training, of a satisfactory standard has been universally delivered to all their FELU staff and supervisors in applying the Home Office Guidance on Firearms Licencing Law (published in November 2022) and the revised Statutory Guidance for Chief officers of Police (published in February 2023) and (ii) they have only delegated decision making to persons who have undergone adequate training in firearms licencing and in applying that recent Guidance.
The College of Policing (CoP)
So that the College of Policing is made aware of my concern that
(1) despite the repeated recommendations being made over the past 27 years, and the earlier requests made specifically to the College of Policing asking for such training to be developed, no accredited training as yet exists .
(2) neither the current CoP APP guidance on firearms nor the proposed update (which I am assured is still under consultation) includes any requirement that FELU staff are trained in firearms licencing generally or trained in conducting suitability assessments in particular.
The Home Secretary and The Minister of State for Crime, Policing and Fire
So that they may be made aware of my concern that despite the repeated recommendations being made over the past 27 years, beginning with the Cullen report in 1996:
(i) successive governments appear to have failed to ensure that any guidance is produced that makes having training in firearms licencing generally (and in conducting suitability assessments in particular) mandatory for all FELU staff;
(ii) there appears to be no requirement that Chief Officers of Police should only delegate authority to issue and revoke licences to officers and staff who have completed adequate (and preferably nationally accredited) training.
I am concerned that the lack of accredited training combined with the absence of a mandatory requirement for all those making firearms licensing decisions to undertake adequate training for their role increases the risk of incorrect decision making and, consequently, increases the risk of future deaths.
” Open source report
Concerns raised 2 Failure to record a safety and welfare resolution before closing a Concern for Safety event View source Ineffective training for police officers to accurately identify mental health issues View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 11
Action
Adapt the College of Policing vulnerable-person Taser package for personal-safety training and deliver it to all officers with auditable attendance.
Stated plannedThe respondent said that this action was planned when they made their response on 11 February 2018. View source
Action
Require supervisors to review every event before closure to ensure threats, risks and vulnerabilities are managed.
Stated completedThe respondent said that this action was complete when they made their response on 11 February 2018. View source
Action
Continue liaison with other forces and the local health board to improve mental-health training and share best practice.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018. View source
Action
Deliver mental-health training webinars covering mental-health conditions, places of safety, support, suicide, self-harm and learning disabilities.
Stated completedThe respondent said that this action was complete when they made their response on 11 February 2018. View source
Action
Seek mental-health team input to identify improvements to training delivery.
Stated plannedThe respondent said that this action was planned when they made their response on 11 February 2018. View source
Action
Develop a mental-health training package using learning from other forces and national working groups.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018. View source
Action
Incorporate coordination and incident close-out guidance into personal-safety training for all officers.
Stated plannedThe respondent said that this action was planned when they made their response on 11 February 2018. View source
Action
Embed early-intervention vulnerability training, including signposting to external support, within the vulnerability course.
Stated completedThe respondent said that this action was complete when they made their response on 11 February 2018. View source
Action
Convert the mental-health webinar package into an auditable classroom package and deliver it to officers.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018. View source
Action
Deliver Acute Behavioural Disorder training within mandatory personal-safety training for all officers.
Stated completedThe respondent said that this action was complete when they made their response on 11 February 2018. View source
Action
Deliver enhanced Vulnerable Person training, including a mental-health scenario and health-board advice, on Taser courses.
Stated completedThe respondent said that this action was complete when they made their response on 11 February 2018. View source See 8 more actions
×
AI-generated summary
Joshua James Alexander Hamill · 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 James Alexander Hamill, who was known to mental health services and had previously self-harmed, was reported as threatening to kill himself in the early hours of 5 June 2016. Police re-categorised the matter as a domestic incident and left him alone; he was later found dead at Flint Castle as a result of hanging. The concerns were that police training was ineffective in identifying mental health issues and that a “Concern for Safety” could be closed as a domestic incident without a recorded resolution regarding the safety and welfare of the person at risk.
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 North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record a safety and welfare resolution before closing a Concern for Safety event
Wider context from the report “2. That when an event was opened as a “Concern for Safety” it was closed down as domestic incident without there being a recorded resolution as to safety and welfare of the person originally at risk of harm .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Ineffective training for police officers to accurately identify mental health issues
Wider context from the report “1. That the current training afforded to police officers in North Wales was ineffective in ensuring that they were able to accurately identify mental health issues in persons they were attending .
” 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 Adapt the College of Policing vulnerable-person Taser package for personal-safety training and deliver it to all officers with auditable attendance.
Verbatim wording from the response “5. The College of Policing vulnerable person Taser package be adapted and extended into personal safety training. All officers will receive the package. This also ensures the training is auditable. This will be ready in the near future.” Source location 2017-0351-Response-by-North-Wales-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 Require supervisors to review every event before closure to ensure threats, risks and vulnerabilities are managed.
Verbatim wording from the response “In addition, since 1st March 2017, supervisors now review every event prior to closure to ensure any threat, risk or vulnerability is appropriately managed.” Source location 2017-0351-Response-by-North-Wales-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 Continue liaison with other forces and the local health board to improve mental-health training and share best practice.
Verbatim wording from the response “The North Wales Police training department are liaising with other forces and the local health board to improve the training.” Source location 2017-0351-Response-by-North-Wales-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 Deliver mental-health training webinars covering mental-health conditions, places of safety, support, suicide, self-harm and learning disabilities.
Verbatim wording from the response “A mental health training package was developed by the Training Department and delivered as a webinar package. This detailed different types of mental health issues, places of safety, support/advice contacts, suicide, self-harm and learning disabilities. Due to the way in which it was delivered it is not auditable. I can confirm that this was delivered on 10th May 2017 and 16th August 2017 but I cannot identify which officers received the input. I trust that this information assists in demonstrating that the training provided in relation to mental health issues has developed since the death of Joshua Hamill on 5th June 2016.” Source location 2017-0351-Response-by-North-Wales-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 Seek mental-health team input to identify improvements to training delivery.
Verbatim wording from the response “The training department will also contact the BCUHB mental health team to seek an input from them for Force trainers to identify any areas where we could improve delivery.” Source location 2017-0351-Response-by-North-Wales-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 Develop a mental-health training package using learning from other forces and national working groups.
Verbatim wording from the response “The Training Department are currently developing a mental health training package. Other Forces have been contacted in relation to their mental health training. The Training Department will be following this up through roles on the national working groups for personal safety training and Taser training as they bring trainers into contact with all forces. This will provide a definitive idea of what other forces are already doing and assist in developing best practice.” Source location 2017-0351-Response-by-North-Wales-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 Incorporate coordination and incident close-out guidance into personal-safety training for all officers.
Verbatim wording from the response “This is a challenge when numerous officers attend a spontaneous incident but the developments identified in the section relating to incident closure should improve the matter. All officers will also receive an input on this which will be incorporated into the Personal Safety Training.” Source location 2017-0351-Response-by-North-Wales-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 Embed early-intervention vulnerability training, including signposting to external support, within the vulnerability course.
Verbatim wording from the response “An early intervention training package was developed in force and delivered between November 2016 and July 2017. This package addressed concerns around dealing with vulnerable persons including those with mental health issues. As part of this package officers were provided with details of external partners that persons they were dealing could be signposted to. Although this package does not continue to be delivered as a stand-alone it does continue to be delivered as part of the vulnerability course. This is auditable through officer training records.” Source location 2017-0351-Response-by-North-Wales-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 Convert the mental-health webinar package into an auditable classroom package and deliver it to officers.
Verbatim wording from the response “6. The webinar package will be adapted and delivered as a classroom package. This will take time to develop and implement but officers attendance can be audited. Whilst this is still being developed it should be available to go live post April 2018.” Source location 2017-0351-Response-by-North-Wales-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 Deliver Acute Behavioural Disorder training within mandatory personal-safety training for all officers.
Verbatim wording from the response “During August 2016 the Acute Behavioural Disorder (ABD) package developed by the College of Policing was introduced to the classroom session of personal safety training. Although dealing primarily with persons suffering from ABD, it followed the same principles for dealing with persons suffering mental health problems. All officers in North Wales Police are required to undergo personal safety training; therefore every officer will receive this package. This package is still being delivered and some officers have now received it more than once. This is auditable through changes made to lesson plans and officer training records.” Source location 2017-0351-Response-by-North-Wales-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 Deliver enhanced Vulnerable Person training, including a mental-health scenario and health-board advice, on Taser courses.
Verbatim wording from the response “During April 2015 the “Vulnerable Person” package was introduced by the College of Policing, National Taser Course that all Taser officers have to complete. This package dealt with identifying and dealing with persons suffering mental health issues. This was implemented straight away by North Wales Police in both the initial and refresher training.” Source location 2017-0351-Response-by-North-Wales-Police
Open published response
Concerns raised 4 Inaccurate information in the Transfer of Care Form View source Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse View source Failure to ensure completion of the Transfer of Care Form by the examining doctor View source Delays in completing the Transfer of Care Form at the time of examination 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
Andrew Selwyn Roberts · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Selwyn Roberts was arrested on 24 December 2011, after being tasered and having taken an overdose, and was taken to hospital before being assessed as fit to return to custody. The transfer of care form inaccurately stated that he had been assessed by psychiatric liaison, although he had not been seen by that team. The substantive concerns were that the form was completed by a nurse rather than the examining doctor, contained inaccurate information, and was not completed and provided to police at the time of examination.
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 North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Inaccurate information in the Transfer of Care Form
Wider context from the report “1. That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequently found to be inaccurate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse
Wider context from the report “2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure completion of the Transfer of Care Form by the examining doctor
Wider context from the report “1. That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequently found to be inaccurate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Delays in completing the Transfer of Care Form at the time of examination
Wider context from the report “2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse.
” Open source report
2 Jul 2014 Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 11 Lack of required training or knowledge on restraint and asphyxia dangers View source Failure to audit accredited door-supervisor training on restraint and asphyxia View source Deaths related to or following restraint by door supervisors View source Failure to review restraint-related deaths for licensing and responsibility lessons View source Failure of existing bubble-car design to enable easy monitoring of rear-seat detainees View source Failure to integrate asphyxia training into restraint training View source Failure of new bubble-car design to enable officers to hear detainees’ breathing difficulties View source Repeated coronial concern about door-supervisor training on restraint and asphyxia View source Uncertainty about completion of physical intervention training by licensed door supervisors View source Lack of police training guidance on the significance of snoring during positional asphyxia View source Lack of a first-aid qualification requirement for door-supervisor licensing View source See 8 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
Mr Hywel Llewelyn Hughes · 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 Hywel Llewelyn Hughes was forcibly removed from a nightclub, restrained face down by door staff, and later declared deceased in hospital on 3 May 2003. The inquest concluded that the medical cause of death was traumatic asphyxia and that police actions were inappropriate and more probably than not contributed more than minimally to his death. Concerns included training and monitoring of detainees during restraint and transport, and shortcomings in the licensing, training, auditing and review of door supervisors.
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 North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Lack of required training or knowledge on restraint and asphyxia dangers
Wider context from the report “(6) The SIA’s standards of conduct, training and levels of supervision issued pursuant to their statutory responsibilities under section 1(2)(e) of the 2001 Act, namely the “Specification for Learning and Qualifications for Door Supervisors” (Feb 2010) and the “Specifications for Learning and Qualifications for Physical Intervention Skills” (Aug 2010), do not include a requirement for training or knowledge on the dangers inherent in restraint, specific modes of restraint, positional asphyxia or traumatic asphyxia .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to audit accredited door-supervisor training on restraint and asphyxia
Wider context from the report “(7) The SIA does not audit the training provided to door supervisors by accredited training providers , particularly on issues of restraint and asphyxia (traumatic and positional).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Deaths related to or following restraint by door supervisors
Wider context from the report “(4) Twenty deaths apparently related to and/or following restraint by door supervisors have occurred since the introduction in 2004 of (rolled out) compulsory licensing of door supervisors, by the Security Industry Authority (“SIA”) (established by the Private Security Act 2001, in 2003). There have been four restraint related deaths involving twelve door supervisors (all of whom have been charged with either murder or manslaughter) since April 2013, that is, following the introduction (in February 2013) of mandatory training as a condition for the awarding (or renewal) of a licence to work as a door supervisor anywhere in the UK.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to review restraint-related deaths for licensing and responsibility lessons
Wider context from the report “(5) The SIA does not undertake any review or inquiry into those deaths indicated by Inquest or criminal findings to be related to restraint by door supervisors to determine whether there are any lessons to be learnt in so far as their licensing or other responsibilities are concerned.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure of existing bubble-car design to enable easy monitoring of rear-seat detainees
Wider context from the report “(2) The design of the ‘bubble cars’ in existence at the time of Mr Hughes’ death and apparently still in use pending their phasing out, is such that the condition of a detainee held in the rear of the vehicle may not be easily monitored (because of the presence of a Perspex screen that may affect the ability to see and hear a detainee ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure to integrate asphyxia training into restraint training
Wider context from the report “(8) The mandatory training that door supervisors are required to undertake as a condition of the award of a licence by the SIA does not integrate training on asphyxia into the training on restraint (it is addressed by a limited and discrete element ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Failure of new bubble-car design to enable officers to hear detainees’ breathing difficulties
Wider context from the report “(3) The design of the new ‘bubble cars’ may impede an officer’s ability to hear a detainee (and thus identify irregularities or difficulties in breathing ) because of the presence of a (albeit smaller) Perspex screen .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Repeated coronial concern about door-supervisor training on restraint and asphyxia
Wider context from the report “(11) There have already been four ‘Rule 43’ reports to the SIA by Coroners concerning the training of door supervisors on restraint and asphyxia .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about completion of physical intervention training by licensed door supervisors
Wider context from the report “(10) It is not clear that all persons presently working as door supervisors have yet undertaken physical intervention training (it appears that those who already have a licence will only be required to undertake ‘top training’ when they seek renewal of a licence ).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police training guidance on the significance of snoring during positional asphyxia
Wider context from the report “(1) The training on positional asphyxia presently provided to police officers by the North Wales Police Force does not include guidance on the significance of ‘snoring’ and in particular that it is not inconsistent with deep unconsciousness and obstruction to breathing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Wales Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a first-aid qualification requirement for door-supervisor licensing
Wider context from the report “(9) The licensing requirements for door supervisors do not include a requirement for a first aid qualification .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations