19 Oct 2025 Alexander Philip MCCORMACK · Prevention of Future Deaths report Northamptonshire
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Concerns raised 3 Delays in completing the transfer of missing persons case information between forces View source Failure of the case-importing process to provide reliable guidance during competing high-risk priorities View source Lack of induction training for transferees from other forces on COMPACT case importing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alexander Philip MCCORMACK · 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
Alexander Philip McCormack was found deceased in a tent at Fermyn Woods Country Park on 27 February 2023 after expressing suicidal thoughts and plans and contacting mental health services with an intention to end his life. The inquest concluded that his death was suicide. Concerns were raised that delays in transferring missing-persons information between police forces could affect risk assessment and the formulation of lines of inquiry, particularly where officers lacked training in importing cases onto the COMPACT system.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Police; that does not assign responsibility.
PFD Monitor interpretation Delays in completing the transfer of missing persons case information between forces
Wider context from the report “The court heard evidence that when transferring missing persons cases between forces, the transfer is accepted by completion of a signed transfer document. Assuming primacy of an investigation does not depend on the importing of a COMPACT file. However, the court also heard that until a transfer of information is complete, the receiving force may not be able to accurately assess the risk and fully take ownership of the investigation . This gives rise to a concern that this could lead to delay in formulating lines of inquiry .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the case-importing process to provide reliable guidance during competing high-risk priorities
Wider context from the report “The court heard evidence that whilst new recruits to the force, and those promoted internally, are trained on COMPACT and importing cases, this is not covered on the induction training for transferees from other forces at a particular rank. Guidance on how to transfer / import cases is available on the force intranet but this would need to be accessed and followed by the relevant officer at the time of importing the information ; essentially leaning through experience. This gives rise to a concern as it could be during a busy night shift where a Reactive Inspector has competing high risk priorities .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of induction training for transferees from other forces on COMPACT case importing
Wider context from the report “The court heard evidence that whilst new recruits to the force, and those promoted internally, are trained on COMPACT and importing cases, this is not covered on the induction training for transferees from other forces at a particular rank . Guidance on how to transfer / import cases is available on the force intranet but this would need to be accessed and followed by the relevant officer at the time of importing the information; essentially leaning through experience . This gives rise to a concern as it could be during a busy night shift where a Reactive Inspector has competing high risk priorities.
” 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 Conduct direct discussions with other forces about missing-person transfer requests and obtain the National Transfer Form to support decisions.
Verbatim wording from the response “The process involves both the National Requesting Enquiries/Transfer Form and direct communication between operational supervisors. This dual approach ensures transparency, accountability and timely decision making. Our Duty Response Inspectors actively engage in these conversations to avoid unnecessary delays and to prioritise the safety and wellbeing of those involved.” Source location Response from Northamptonshire Police
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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 Make missing-person transfer decisions within two hours, sooner for high-risk cases.
Verbatim wording from the response “Decisions should be made within two hours” Source location Response from Northamptonshire 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 Provide COMPACT transfer training to future transferee inspectors and refresher training to existing staff.
Verbatim wording from the response “We recognise the importance of equipping officers with the right knowledge and tools. While Inspectors currently hold responsibility for COMPACT transfers, we are enhancing training across all relevant ranks. Updated training packages are being developed to ensure consistency and confidence in handling these sensitive cases. This includes future transferee Inspectors and ongoing refresher sessions for existing staff.” Source location Response from Northamptonshire 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 Develop updated COMPACT transfer training packages for relevant ranks, including Cadre, control-room and detective inspectors.
Verbatim wording from the response “We recognise the importance of equipping officers with the right knowledge and tools. While Inspectors currently hold responsibility for COMPACT transfers, we are enhancing training across all relevant ranks. Updated training packages are being developed to ensure consistency and confidence in handling these sensitive cases. This includes future transferee Inspectors and ongoing refresher sessions for existing staff.” Source location Response from Northamptonshire 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 Existing transfer procedures, National Transfer Forms and Inspector oversight are relied upon to manage missing-person investigation transfers.
Verbatim wording from the response “In Northamptonshire Police, our Duty Response Cadre Inspectors will have phone calls and discussions with other forces looking to transfer a missing person. There is then a reliance on the National Transfer Form (NTF) being sent to corroborate the information indicating that the missing person is most likely in the Northamptonshire area.” Source location Response from Northamptonshire 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 Acceptance of transfer primacy may be delayed when insufficient information is provided to assess risk accurately and take ownership.
Verbatim wording from the response “Once the National Transfer Form has been accepted and signed by the Inspector, that is when the missing case becomes the responsibility of the accepting force. It is no different to accepting a missing person from a member of the public, so as soon as we accept it, the investigation becomes our responsibility. We can commence actions based on information on the National Transfer Form.” Source location Response from Northamptonshire 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 The incident appears isolated rather than evidence of a systemic issue requiring wider remedial action.
Verbatim wording from the response “From my review, this appears to be an isolated incident rather than a systemic issue. Nevertheless, we remain committed to learning from every case and improving wherever possible. Please be” Source location Response from Northamptonshire Police
Open published response
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.
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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 Northamptonshire 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 Northamptonshire 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 Northamptonshire 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
27 Nov 2017 Jason Basalat · Prevention of Future Deaths report Milton Keynes
View report summary
Concerns raised 3 Unavailability of mental health assessment for defendants appearing before magistrates on Saturday mornings View source Failure of the court to inform the prison about a defendant's mental illness and related problems View source Failure to provide the prison with sufficient information about a vulnerable prisoner's behaviour, mental state and custody circumstances View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jason Basalat · 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
Jason Basalat was arrested after grabbing the steering wheel of a bus, causing it to crash into road barriers, and was remanded to HMP Woodhill. He was found hanging in his cell the following day and later pronounced dead at hospital. Concerns included inadequate sharing of information about his behaviour and mental state with the prison, and the lack of a mental health assessment or appropriate placement consideration before his transfer.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health assessment for defendants appearing before magistrates on Saturday mornings
Wider context from the report “(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state. The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture.
(2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted . The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness. Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment.
(3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the court to inform the prison about a defendant's mental illness and related problems
Wider context from the report “(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state. The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture.
(2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted. The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness . Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment.
(3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the prison with sufficient information about a vulnerable prisoner's behaviour, mental state and custody circumstances
Wider context from the report “(1) The deceased had been arrested for Dangerous Driving when, on the 9th December 2016, he tried to grab the steering wheel of a bus travelling on the M1 motorway forcing it to collide with the barriers in the roadworks. Whilst in police custody the deceased was behaving in a bizarre manner and was assessed by a medical practitioner at the custody centre. When eventually transferred to Woodhill Prison after appearing on a Saturday Morning at Wellingborough Magistrates Court the warrant simply stated that the offence was “Dangerous Driving.” Which did not in any way give a true picture of the offence and very little information was provided to the prison as to his behaviour or mental state . The prison informed me that it would have been helpful for them to receive a copy of the deceased’s custody record that gave the full picture .
(2) When the deceased appeared before the magistrates his solicitor was informed that it was not possible on a Saturday morning for a mental health assessment to be conducted. The court did not attempt to contact the prison to inform the prison of the problems being experienced by him due to his mental illness. Consideration should have been given as to the most appropriate place for the deceased to be held or to receive a mental health assessment.
(3) There needs to be an urgent review by both the Northamptonshire Police and the Northamptonshire Magistrates Court as to their procedures for sharing information with the prison when it is known in advance that the prison will receive a vulnerable prisoner .
” 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 Contact the national police lead on custody to suggest reviewing the Person Escort form against Authorised Professional Practice guidance.
Verbatim wording from the response “4.17 Further, contact will be made with the national police lead on Custody to suggest a review of the PER form to ensure it reflects the guidance in the Authorised Professional Practice.” Source location 2017-0423-Response-by-Northampton-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 Remind custody officers and staff to follow guidance on completing Person Escort Records and attaching relevant documentation.
Verbatim wording from the response “4.16 However, the Chief Constable confirms that Custody officers and staff have been reminded of the guidance in relation to the completion of PER forms and in respect of ensuring any relevant additional documentation accompanies them.” Source location 2017-0423-Response-by-Northampton-Police
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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 Person Escort Form and round-the-clock switchboard provided sufficient risk information and a route for receiving staff to seek clarification.
Verbatim wording from the response “The PER form provides staff transporting and receiving detainees with all necessary information. This includes any risks or vulnerabilities that the person may present.” Source location 2017-0423-Response-by-Northampton-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 A custody record is intended to document treatment in police custody, not provide a full picture of the investigation, evidence or detainee’s circumstances.
Verbatim wording from the response “4.7 The Custody Record is a document which the police are required to maintain to record certain decisions made pursuant to section 37 of the Police and Criminal Evidence Act 1984 and paragraph 2.1 of Code of Practice C referred to above.” Source location 2017-0423-Response-by-Northampton-Police
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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 concern about Magistrates’ Court procedure falls outside the matters addressed in this response.
Verbatim wording from the response “2.1.2 Point (2) appears to relate solely to the procedure before the Magistrates’ Court and is not addressed in this response.” Source location 2017-0423-Response-by-Northampton-Police
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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 format of the Warrant of Remand is not a police matter, so no comment is made on it.
Verbatim wording from the response “4.6 The format of the Warrant of Remand is not a matter for the police and the Chief Constable makes no comment on that issue.” Source location 2017-0423-Response-by-Northampton-Police
Open published response
19 Nov 2014 Leanne Carmen Gower · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 3 Failure to routinely check provided damage-only incident data View source Displaced road bollard View source Failure to record damage-only incidents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Leanne Carmen Gower · 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
Leanne Carmen Gower was a passenger in a car that lost control and collided with an oncoming vehicle; she died at the scene. The report raised concerns that damage-only road collision data was not routinely checked or recorded and may not have been considered when assessing whether highway works were needed.
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 Northamptonshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check provided damage-only incident data
Wider context from the report “It emerged in evidence that the police do not routinely check all provided data in relation to damage only incidents to the Council, MGWSP or any other party responsible for the maintenance of roads .
It was the evidence of PC ████████ that such damage only incidents stopped being recorded in January 2011, although the reason for that decision was unclear. In this particular case, the damage only collisions data was as follows:-
2010 – 5
2011 – 7
2012 – 3
2013 – 8
2014 – 13 to date
Although there were no reported incidents since the returturing of the relevant stretch of road, there is evidence of further incidents as one of the bollards has been displaced since.
████████ of the Police’s Safer roads team agreed in evidence that damage only collisions that are reported should be taken into consideration when determining whether any works are required to a particular stretch of highway.
████████ Principal Asset Engineer at Northamptonshire County Council also believed that collision only data would be helpful.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Police; that does not assign responsibility.
PFD Monitor interpretation Displaced road bollard
Wider context from the report “It emerged in evidence that the police do not routinely check all provided data in relation to damage only incidents to the Council, MGWSP or any other party responsible for the maintenance of roads.
It was the evidence of PC ████████ that such damage only incidents stopped being recorded in January 2011, although the reason for that decision was unclear. In this particular case, the damage only collisions data was as follows:-
2010 – 5
2011 – 7
2012 – 3
2013 – 8
2014 – 13 to date
Although there were no reported incidents since the returturing of the relevant stretch of road, there is evidence of further incidents as one of the bollards has been displaced since .
████████ of the Police’s Safer roads team agreed in evidence that damage only collisions that are reported should be taken into consideration when determining whether any works are required to a particular stretch of highway.
████████ Principal Asset Engineer at Northamptonshire County Council also believed that collision only data would be helpful.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northamptonshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record damage-only incidents
Wider context from the report “It emerged in evidence that the police do not routinely check all provided data in relation to damage only incidents to the Council, MGWSP or any other party responsible for the maintenance of roads.
It was the evidence of PC ████████ that such damage only incidents stopped being recorded in January 2011 , although the reason for that decision was unclear. In this particular case, the damage only collisions data was as follows:-
2010 – 5
2011 – 7
2012 – 3
2013 – 8
2014 – 13 to date
Although there were no reported incidents since the returturing of the relevant stretch of road, there is evidence of further incidents as one of the bollards has been displaced since.
████████ of the Police’s Safer roads team agreed in evidence that damage only collisions that are reported should be taken into consideration when determining whether any works are required to a particular stretch of highway.
████████ Principal Asset Engineer at Northamptonshire County Council also believed that collision only data would be helpful.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Financial pressures and required savings make allocating staff time to collate and analyse damage-only collision data difficult to justify.
Verbatim wording from the response “There is no statutory requirement to collect, collate and analyse damage only data. If this activity were to be graded in terms of necessity and weighed against policing priorities, then it would likely be given a very low priority. Current financial conditions and the requirement to make significant savings would also make the need to fund staff time to deal with damage only data difficult to justify. Consequently I would not recommend that formal steps be taken to collate and analyse damage only data within this organisation. My conclusion supports the decision of Chief Officers taken in September 2011.” Source location 2014-0567-Response-by-Northamptonshire-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 Damage-only collision data is too limited, unreliable and insufficiently rigorous to determine meaningful road-safety interventions safely.
Verbatim wording from the response “Where non-injury collisions are recorded by the police, details are again very brief and held in their administrative system for reference purposes. Reports are not forwarded to Northamptonshire Highways and we do not have the resource capacity to input the detail on our database.” Source location 2014-0567-Response-by-Northamptonshire-Police
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formal collation and analysis of damage-only collision data is not considered necessary because there is no statutory requirement and it has low priority.
Verbatim wording from the response “There is no statutory requirement to collect, collate and analyse damage only data. If this activity were to be graded in terms of necessity and weighed against policing priorities, then it would likely be given a very low priority. Current financial conditions and the requirement to make significant savings would also make the need to fund staff time to deal with damage only data difficult to justify. Consequently I would not recommend that formal steps be taken to collate and analyse damage only data within this organisation. My conclusion supports the decision of Chief Officers taken in September 2011.” Source location 2014-0567-Response-by-Northamptonshire-Police
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations