23 Oct 2024 John Paul Hurst · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Failure to record detailed information about detained persons’ mental health concerns View source Failure to provide detailed analysis and comprehensive reasoning for CJLD assessment conclusions 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
John Paul Hurst · 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
John Paul Hurst, who had a history of paranoid schizophrenia and previous suicide attempts, was released from custody on 13 September 2021 after concerns had been raised about his mental health and risk of suicide. He was found near train tracks on 15 September 2021 and died from haemorrhage associated with severe injury to his right leg, consistent with impact with a train. The principal concern was that the electronic custody record inadequately documented the mental-health and suicide-risk concerns, and lacked detailed analysis and reasoning for the CJLD assessment conclusion.
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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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record detailed information about detained persons’ mental health concerns
Wider context from the report “At the Inquest I heard evidence that, following John’s arrest, concerns were expressed by police officers involved in the investigation as to his mental health, and by John’s sister as to his risk of ending his own life. These concerns were repeated by John’s sister to the Criminal Justice Liaison and Diversion Service (CJLD) prior to his assessment. The evidence was that when completing the release risk assessment, the custody sergeant had been greatly assisted by the information recorded on the electronic custody record regarding the concerns that led to the mental health assessment and the assessment itself, in addition to the custody sergeant’s own observations. The evidence highlighted that the electronic custody record contained limited information about the concerns of police officers and John’s sister , and there was a distinct lack of detail about the assessment itself and very little analysis of the concerns and reasoning for the CJLD conclusion.
I am concerned that the information on the electronic custody record was inadequate and lacked detail regarding the concerns for the detained person’s mental health, as identified by police officers and family, including the risk of suicide, the content of notes found and the detained persons history of suicidal ideation and previous engagement with mental health services . In addition, I am concerned that the record also lacked a detailed analysis of those concerns by CJLD and comprehensive reasoning for the assessment conclusion.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide detailed analysis and comprehensive reasoning for CJLD assessment conclusions
Wider context from the report “At the Inquest I heard evidence that, following John’s arrest, concerns were expressed by police officers involved in the investigation as to his mental health, and by John’s sister as to his risk of ending his own life. These concerns were repeated by John’s sister to the Criminal Justice Liaison and Diversion Service (CJLD) prior to his assessment. The evidence was that when completing the release risk assessment, the custody sergeant had been greatly assisted by the information recorded on the electronic custody record regarding the concerns that led to the mental health assessment and the assessment itself, in addition to the custody sergeant’s own observations. The evidence highlighted that the electronic custody record contained limited information about the concerns of police officers and John’s sister, and there was a distinct lack of detail about the assessment itself and very little analysis of the concerns and reasoning for the CJLD conclusion .
I am concerned that the information on the electronic custody record was inadequate and lacked detail regarding the concerns for the detained person’s mental health, as identified by police officers and family, including the risk of suicide, the content of notes found and the detained persons history of suicidal ideation and previous engagement with mental health services. In addition, I am concerned that the record also lacked a detailed analysis of those concerns by CJLD and comprehensive reasoning for the assessment conclusion .
” 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 Provide custody staff with instruction and learning on recording detainees’ mental-health concerns through the Custody Newsletter, Custody Compendium and direct reminders to Custody Sergeants.
Verbatim wording from the response “I agree that it is important that custody officers record all relevant information and concerns expressed in relation to the mental health of a detainee. This is something which all custody officers should be aware of. In order to ensure that custody staff are aware of their obligations in this respect, following receipt of your report appropriate instruction and learning from this Inquest has been provided to custody staff via:” Source location Response from Northumbria Police
Open published response
Concerns raised 5 Failure to grade vulnerable incidents at the appropriate level View source Failure to provide timely oversight of incidents View source Insufficient police resources causing delays in attendance View source Failure to pursue alternative attendance options when resources are unavailable View source Failure to provide comprehensive and interpretable assurance of improvements to incident management and grading View source See 2 more concerns
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. 10
Action
Implement an enhanced process for delayed Grade 2 incidents, including escalation, caller re-contact, renewed risk assessment and safeguarding consideration.
Stated completedThe respondent said that this action was complete when they made their response on 29 April 2024. View source
Action
Modify the Storm incident management system with call scripts to support Communications staff decision-making on Right Care, Right Person cases.
Stated completedThe respondent said that this action was complete when they made their response on 29 April 2024. View source
Action
Provide each Response Team with a dedicated Sergeant to review incidents and assist Communications staff with resource allocation.
Stated completedThe respondent said that this action was complete when they made their response on 29 April 2024. View source
Action
Introduce a Grade 3 response with dedicated resources, 24-hour deployment, victim-availability scheduling and single-crewed officers.
Stated plannedThe respondent said that this action was planned when they made their response on 29 April 2024. View source
Action
Train all Communications staff in the Right Care, Right Person process.
Stated completedThe respondent said that this action was complete when they made their response on 29 April 2024. View source
Action
Conduct daily Pacesetter meetings chaired by the Force Gold Commander to oversee and scrutinise response times.
Stated completedThe respondent said that this action was complete when they made their response on 29 April 2024. View source
Action
Implement the Right Care, Right Person process, supported by THRIVE risk assessment and secondary review of uncertain cases.
Stated completedThe respondent said that this action was complete when they made their response on 29 April 2024. View source
Action
Embed THRIVE assessment and related best-practice learning as a standing item in Communications staff Protected Learning Days.
Stated completedThe respondent said that this action was complete when they made their response on 29 April 2024. View source
Action
Implement the new Operating Model, including staff realignment, enhanced area leadership and increased response-policing officer numbers.
Stated completedThe respondent said that this action was complete when they made their response on 29 April 2024. View source
Action
Establish a full-time Risk Management Desk to reassess risks and grading for vulnerable Grade 2 incidents delayed beyond one hour.
Stated completedThe respondent said that this action was complete when they made their response on 29 April 2024. View source See 7 more actions
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AI-generated summary
Stevyn Carr · 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
Stevyn Carr was found dead at his home on 16 November 2021 after contacting Northumbria Police the previous evening and requesting help. Police did not attend until more than 16 hours after his first contact, following a further call from his family. The principal concerns were the grading and delayed handling of the incident, lack of oversight and alternatives when resources were unavailable, and uncertainty about whether Northumbria Police’s subsequent changes had improved the timeliness of responses.
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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to grade vulnerable incidents at the appropriate level
Wider context from the report “(1) The evidence I heard at inquest indicated the level of police response should have been classed as a Grade 2 Vulnerable to ensure a more timely response.
(2) No oversight of the incident took place for over 9 hours and at that a comment was made that there were no resources able to attend, but no other options/alternatives were pursued.
(3) The family of Stevyn Carr contacted police some 15 hours after the first call to the police and after this a further 1 hour and 23 minutes elapsed before police went to his address and found him.
(4) I heard evidence at inquest that a number of incidents were ‘delayed’ for a significant period for lack of police resources and this position was common place at that time.
(5) I have asked for evidence to satisfy me that the position in terms of police attendance has improved both within the area Stevyn Carr died, but across the Northumbria Police force area. The evidence I have received is difficult to interpret and not comprehensive. I am concerned whether the changes to the management of incidents and/or training in relation to the grading of incidents by Northumbria Police has improved since Stevyn Carr’s death, to the extent that the timeliness of police response to requests from the public for assistance is improved and is improving.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely oversight of incidents
Wider context from the report “(1) The evidence I heard at inquest indicated the level of police response should have been classed as a Grade 2 Vulnerable to ensure a more timely response.
(2) No oversight of the incident took place for over 9 hours and at that a comment was made that there were no resources able to attend, but no other options/alternatives were pursued.
(3) The family of Stevyn Carr contacted police some 15 hours after the first call to the police and after this a further 1 hour and 23 minutes elapsed before police went to his address and found him.
(4) I heard evidence at inquest that a number of incidents were ‘delayed’ for a significant period for lack of police resources and this position was common place at that time.
(5) I have asked for evidence to satisfy me that the position in terms of police attendance has improved both within the area Stevyn Carr died, but across the Northumbria Police force area. The evidence I have received is difficult to interpret and not comprehensive. I am concerned whether the changes to the management of incidents and/or training in relation to the grading of incidents by Northumbria Police has improved since Stevyn Carr’s death, to the extent that the timeliness of police response to requests from the public for assistance is improved and is improving.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient police resources causing delays in attendance
Wider context from the report “(1) The evidence I heard at inquest indicated the level of police response should have been classed as a Grade 2 Vulnerable to ensure a more timely response.
(2) No oversight of the incident took place for over 9 hours and at that a comment was made that there were no resources able to attend, but no other options/alternatives were pursued.
(3) The family of Stevyn Carr contacted police some 15 hours after the first call to the police and after this a further 1 hour and 23 minutes elapsed before police went to his address and found him.
(4) I heard evidence at inquest that a number of incidents were ‘delayed’ for a significant period for lack of police resources and this position was common place at that time .
(5) I have asked for evidence to satisfy me that the position in terms of police attendance has improved both within the area Stevyn Carr died, but across the Northumbria Police force area. The evidence I have received is difficult to interpret and not comprehensive. I am concerned whether the changes to the management of incidents and/or training in relation to the grading of incidents by Northumbria Police has improved since Stevyn Carr’s death, to the extent that the timeliness of police response to requests from the public for assistance is improved and is improving.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to pursue alternative attendance options when resources are unavailable
Wider context from the report “(1) The evidence I heard at inquest indicated the level of police response should have been classed as a Grade 2 Vulnerable to ensure a more timely response.
(2) No oversight of the incident took place for over 9 hours and at that a comment was made that there were no resources able to attend, but no other options/alternatives were pursued .
(3) The family of Stevyn Carr contacted police some 15 hours after the first call to the police and after this a further 1 hour and 23 minutes elapsed before police went to his address and found him.
(4) I heard evidence at inquest that a number of incidents were ‘delayed’ for a significant period for lack of police resources and this position was common place at that time.
(5) I have asked for evidence to satisfy me that the position in terms of police attendance has improved both within the area Stevyn Carr died, but across the Northumbria Police force area. The evidence I have received is difficult to interpret and not comprehensive. I am concerned whether the changes to the management of incidents and/or training in relation to the grading of incidents by Northumbria Police has improved since Stevyn Carr’s death, to the extent that the timeliness of police response to requests from the public for assistance is improved and is improving.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide comprehensive and interpretable assurance of improvements to incident management and grading
Wider context from the report “(1) The evidence I heard at inquest indicated the level of police response should have been classed as a Grade 2 Vulnerable to ensure a more timely response.
(2) No oversight of the incident took place for over 9 hours and at that a comment was made that there were no resources able to attend, but no other options/alternatives were pursued.
(3) The family of Stevyn Carr contacted police some 15 hours after the first call to the police and after this a further 1 hour and 23 minutes elapsed before police went to his address and found him.
(4) I heard evidence at inquest that a number of incidents were ‘delayed’ for a significant period for lack of police resources and this position was common place at that time.
(5) I have asked for evidence to satisfy me that the position in terms of police attendance has improved both within the area Stevyn Carr died, but across the Northumbria Police force area. The evidence I have received is difficult to interpret and not comprehensive. I am concerned whether the changes to the management of incidents and/or training in relation to the grading of incidents by Northumbria Police has improved since Stevyn Carr’s death , to the extent that the timeliness of police response to requests from the public for assistance is improved and is improving.
” 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 Implement an enhanced process for delayed Grade 2 incidents, including escalation, caller re-contact, renewed risk assessment and safeguarding consideration.
Verbatim wording from the response “In relation to the actual incident, it is believed this would now be identified as a vulnerable incident but a definitive response to this cannot be provided as each assessment is a subjective assessment made by an individual. We have however implemented an enhanced process for Grade 2 incidents that were not attended within SLA to ensure a continued assessment of the risk.” Source location Response from Northumbria 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 Modify the Storm incident management system with call scripts to support Communications staff decision-making on Right Care, Right Person cases.
Verbatim wording from the response “Since this incident the “Right Care, Right Person” (RCRP) process is also now live within Northumbria Police. RCRP is an initiative which has been implemented nationally within policing and seeks to ensure that the most appropriate agency responds to requests for assistance from members of the public. Incidents for RCRP are still risk assessed using THRIVE, but the most appropriate agency to engage with the caller may not always be the police. All Communications staff have received training in RCRP. The force incident management system (Storm) has been altered so that Communications Department staff may use call scripts to assist in their decision making. The Risk Management Desk, which is staffed with experienced police officers, conduct a secondary review for incidents where the Call Handler is uncertain if an incident fits the criteria for RCRP.” Source location Response from Northumbria 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 Provide each Response Team with a dedicated Sergeant to review incidents and assist Communications staff with resource allocation.
Verbatim wording from the response “In addition, since the incident each Response Team now has a dedicated Sergeant who reviews incidents and assists the Communications Department in assigning resources. This ensures a swifter level of service.” Source location Response from Northumbria 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 Introduce a Grade 3 response with dedicated resources, 24-hour deployment, victim-availability scheduling and single-crewed officers.
Verbatim wording from the response “Recognising that our performance for non-emergency incidents could be improved, a review of the deployment model has been completed. This review has led to the introduction of a Grade 3 response which will have dedicated resources to deploy to the incidents within 24 hours of the caller contacting the police. The response will be diarised in accordance with victim availability and will be serviced by single crewed officers. Incidents which will remain graded as G2 incidents will be those with elements of vulnerability or other time critical issues. This change to the grading structure enables Communications staff and frontline officers to identify which non-emergency incidents require a timelier response, to enable them to deploy resources more appropriately.” Source location Response from Northumbria 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 Train all Communications staff in the Right Care, Right Person process.
Verbatim wording from the response “Since this incident the “Right Care, Right Person” (RCRP) process is also now live within Northumbria Police. RCRP is an initiative which has been implemented nationally within policing and seeks to ensure that the most appropriate agency responds to requests for assistance from members of the public. Incidents for RCRP are still risk assessed using THRIVE, but the most appropriate agency to engage with the caller may not always be the police. All Communications staff have received training in RCRP. The force incident management system (Storm) has been altered so that Communications Department staff may use call scripts to assist in their decision making. The Risk Management Desk, which is staffed with experienced police officers, conduct a secondary review for incidents where the Call Handler is uncertain if an incident fits the criteria for RCRP.” Source location Response from Northumbria 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 Conduct daily Pacesetter meetings chaired by the Force Gold Commander to oversee and scrutinise response times.
Verbatim wording from the response “a 15.1% improvement in vulnerable grade 2 incidents against the year before. There is also high-level oversight and scrutiny of response times during the daily Pacesetter meeting, which is chaired by the Force Gold Commander. We expect still further improvement in our response times as we embed this new force operating model.” Source location Response from Northumbria 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 Implement the Right Care, Right Person process, supported by THRIVE risk assessment and secondary review of uncertain cases.
Verbatim wording from the response “Since this incident the “Right Care, Right Person” (RCRP) process is also now live within Northumbria Police. RCRP is an initiative which has been implemented nationally within policing and seeks to ensure that the most appropriate agency responds to requests for assistance from members of the public. Incidents for RCRP are still risk assessed using THRIVE, but the most appropriate agency to engage with the caller may not always be the police. All Communications staff have received training in RCRP. The force incident management system (Storm) has been altered so that Communications Department staff may use call scripts to assist in their decision making. The Risk Management Desk, which is staffed with experienced police officers, conduct a secondary review for incidents where the Call Handler is uncertain if an incident fits the criteria for RCRP.” Source location Response from Northumbria 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 THRIVE assessment and related best-practice learning as a standing item in Communications staff Protected Learning Days.
Verbatim wording from the response “There have been improvements across the department in terms of the identification of vulnerable victims and incidents which have centred around the THRIVE assessment made by the contact handler, which looks to identify threat, harm risk, investigative opportunities, vulnerability and level of engagement at the first point of contact, but also through the life of the incident with further THRIVE assessments completed when required. THRIVE has become a standing agenda item on the Protected Learning Days for Communications staff which includes best practice alongside areas of learning.” Source location Response from Northumbria 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 Implement the new Operating Model, including staff realignment, enhanced area leadership and increased response-policing officer numbers.
Verbatim wording from the response “The Force moved to a new Operating Model on the 4th March this year which included a re-alignment of staff to each of the 6 area commands and a more enhanced leadership structure for each area. This means that there are increased officer numbers working in response policing giving us a better ability to meet calls for service in a timely manner aligned to more focussed leadership and accountability. Although the model has only been running for a short period of time it is evident this has had a positive impact with improvements in the percentage of incidents attended within our stated times, a 13.3% improvement in grade 2 incidents and” Source location Response from Northumbria 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 Establish a full-time Risk Management Desk to reassess risks and grading for vulnerable Grade 2 incidents delayed beyond one hour.
Verbatim wording from the response “There is now a full time Risk Management Desk in place, whose responsibility is the ongoing assessment and mitigation of risk within vulnerable incidents. If a caller is classified as Vulnerable from their initial Grade 2 (G2V) call then in the event the incident is not responded to within one hour the Risk Management Desk will re-contact the caller and undertake a full review of their risks and vulnerabilities and assess if the incident requires a change of grading.” Source location Response from Northumbria Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some public assistance requests are assigned to the most appropriate agency rather than the police following risk assessment.
Verbatim wording from the response “Since this incident the “Right Care, Right Person” (RCRP) process is also now live within Northumbria Police. RCRP is an initiative which has been implemented nationally within policing and seeks to ensure that the most appropriate agency responds to requests for assistance from members of the public. Incidents for RCRP are still risk assessed using THRIVE, but the most appropriate agency to engage with the caller may not always be the police. All Communications staff have received training in RCRP. The force incident management system (Storm) has been altered so that Communications Department staff may use call scripts to assist in their decision making. The Risk Management Desk, which is staffed with experienced police officers, conduct a secondary review for incidents where the Call Handler is uncertain if an incident fits the criteria for RCRP.” Source location Response from Northumbria 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.
×
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 Northumbria 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 Northumbria 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 Northumbria 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 5 Lack of mandatory refresher training for police officers on mental health, learning disability and autistic spectrum disorder View source Failure to allocate a police point of contact for the family of a medium-risk missing person View source Lack of cross-agency awareness and training on requesting and sharing confidential medical information about missing persons View source Lack of a multiagency meeting structure for reported missing persons View source Lack of a joint police-health policy for sharing information about vulnerable missing persons with mental health difficulties View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
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 Northumbria Police; 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 Northumbria Police; 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 Northumbria Police; 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 Northumbria Police; 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 Northumbria Police; 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
Concerns raised 6 Lack of a robust working arrangement between Emergency Services to obtain timely support from other agencies View source Failure to identify familial or social support for the patient View source Delays in reacting meaningfully and promptly to presenting danger View source Lack of a protocol enabling personnel to initiate responses beyond ambulance allocation View source Failure to accurately evaluate and grade the presenting danger View source Failure to enquire about the patient’s location and immediately available support View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
MAUREEN WHARTON · 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
Maureen Wharton contacted ambulance services after stating that she had taken several medications and wanted to end her life. An ambulance arrived at her flat several hours after her first call, by which time she was deceased; a post-mortem attributed her death to the combined effects of Tramadol, Venlafaxine, Zopiclone and alcohol. Concerns focused on the delayed response, the assessment and grading of the calls, and missed opportunities to arrange timely support or assistance from family, other agencies, or emergency services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust working arrangement between Emergency Services to obtain timely support from other agencies
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to identify familial or social support for the patient
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Delays in reacting meaningfully and promptly to presenting danger
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat . Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol enabling personnel to initiate responses beyond ambulance allocation
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately evaluate and grade the presenting danger
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to enquire about the patient’s location and immediately available support
Wider context from the report “The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process.
It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls.
Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented.
An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious
a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise.
b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger
c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation
d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger.
There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.
” Open source report
12 Jun 2019 Miss Nguyen Ngoc Quyen · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 9 Probation staffing and accommodation deficiencies View source Lack of integrated information technology View source Insufficient time and unsuitable environment for meaningful probation engagement View source Lack of contemporaneous probation computer records View source Over-reliance on offender self-reporting and ineffective challenge of accounts View source Failure to complete timely OASys risk and needs assessments View source Failure to share relevant police information with Probation View source Failures of communication across relevant sources View source Failure to monitor and actively manage Category 2 Level 1 offenders View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Miss Nguyen Ngoc Quyen · 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
Miss Nguyen Ngoc Quyen died on 15 August 2017 at Success Road, Shiney Row, Houghton Le Spring; her death was consistent with the effects of fire. The report identified concerns about failures to act sufficiently, promptly and in a coordinated manner on known breaches of life licence conditions, including failures in information sharing between the Police and Probation Service, alongside wider organisational and supervision failings.
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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Probation staffing and accommodation deficiencies
Wider context from the report “The Inquest highlighted many other issues: -
• The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East.
• The time spent with ████████ was short and in a working environment not conducive to meaningful engagement.
• Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017.
• There were no contemporaneous computer records from 13th December 2016 until 18th August 2017, the day before ████████ appeared in Court for murder.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Lack of integrated information technology
Wider context from the report “However, I remain concerned. For example, Probation were of the view that the present solution was an interim one, whereas the Police thought it was finalised.
There were further issues considered, such as the lack of integrated IT , failures of communication from a number of sources, supervision, issues of risk management and staff turnover, and pressures upon staff performance and the ability to investigate self-report.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient time and unsuitable environment for meaningful probation engagement
Wider context from the report “The Inquest highlighted many other issues: -
• The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East.
• The time spent with ████████ was short and in a working environment not conducive to meaningful engagement.
• Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017.
• There were no contemporaneous computer records from 13th December 2016 until 18th August 2017, the day before ████████ appeared in Court for murder.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Lack of contemporaneous probation computer records
Wider context from the report “The Inquest highlighted many other issues: -
• The Probation Service in Sunderland had staffing and accommodation problems. Operations and efficiency appeared to be in stark contrast between North West and North East.
• The time spent with ████████ was short and in a working environment not conducive to meaningful engagement.
• Unwin undermined the supervisory process by attending appointments with his child and not progressing in a more timely way the request to create a portfolio of his employment, culminating in an unsigned reference dated 25th July 2017.
• There were no contemporaneous computer records from 13th December 2016 until 18th August 2017 , the day before ████████ appeared in Court for murder.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on offender self-reporting and ineffective challenge of accounts
Wider context from the report “There was an over reliance on self-reporting by the offenders. The evidence exposed a system for the protection of the public, which was at times dysfunctional, contributed to by human factors.
Evidence heard during the hearings demonstrated that there was a disconnect between the reality on the ground and, in particular, ████████’s accounts to his Probation Officer. Although inevitably he would minimise his actions, there was little or no evidence that he was challenged effectively .
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to complete timely OASys risk and needs assessments
Wider context from the report “On the evidence, there were multiple occasions when information about ████████ could and should have been shared between the Police and Probation, and for him to be challenged in a more meaningful way than he was.
A Probation expert gave evidence about:
• the limitations of what can be achieved through the supervisory process;
• the frequency of the assessments in relation to ████████ appear to “have fallen below good practice standards” but had further reviews taken place, the risk assessments would not have changed;
• the absence of an Offender Assessment System (OASys) assessment on ████████ for over 3 years fell below good practice . Such an assessment would have assessed the risks and needs of an Offender;
• if Northumbria Police had passed on information to Probation about 2 incidents involving ████████ there would have been enforcement action, but short of recall as the threshold criteria had not been met.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to share relevant police information with Probation
Wider context from the report “In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log. As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders. The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated , and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer .
The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failures of communication across relevant sources
Wider context from the report “However, I remain concerned. For example, Probation were of the view that the present solution was an interim one, whereas the Police thought it was finalised.
There were further issues considered, such as the lack of integrated IT, failures of communication from a number of sources , supervision, issues of risk management and staff turnover, and pressures upon staff performance and the ability to investigate self-report.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and actively manage Category 2 Level 1 offenders
Wider context from the report “In April 2015 due to high operational demand there was a direction from the senior management team of Northumbria Police to stop monitoring Category 2 Level 1 offenders and to remove the markers on the log . As a result, the Multi Agency Public Protection Arrangements (MAPPA) department were no longer actively managing Category 2 Level 1 offenders . The responsibility for sharing information was solely with the sourcing officer. With ████████ his Police computer record was not updated, and attending Police Officers for incidents in 2015 and 2017 did not pass information to the relevant Probation Officer.
The responsibility goes wider though to Control Room Staff, Patrol Sergeants, Patrol Constables and Supervising Sergeants too, when markers, flags and warnings were evident.
” 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 Disseminate force-wide bulletins informing and reinforcing officers’ responsibility to share relevant information with NPS.
Verbatim wording from the response “To ensure staff were aware of this change, a force wide bulletin was sent to officers and staff informing them of the process and that it was their responsibility to share any relevant information/intelligence with NPS.” Source location 2019-0194-Response-by-Northumbria-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 Update Category 2 Level 1 offender warning screens with instructions requiring officers to share risk-relevant information with the relevant probation area.
Verbatim wording from the response “Included within the process implemented in December 2018 was that all Category 2 Level 1 offenders would also have an NPICCS warning marker updated with a new instruction on the IS record for that offender. This will highlight the requirement for any officer who is in possession of relevant information to inform the relevant probation area.” Source location 2019-0194-Response-by-Northumbria-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 Add newly notified Category 2 Level 1 offenders to Northumbria Police systems immediately upon notification from NPS.
Verbatim wording from the response “In relation to new Category 2 Level 1 offenders, when we receive notification from NPS to the MOSOVO Department, they will be added to Northumbria Police systems immediately.” Source location 2019-0194-Response-by-Northumbria-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 Operate the MK-flag and MASH process to queue relevant offender-record changes, share information with NPS, and retain emails for audit.
Verbatim wording from the response “In December 2018 Northumbria Police devised a process to ensure compliance for the purpose of information/intelligence sharing on every record for a Category 2 (violent) Level 1 MAPPA offender.” Source location 2019-0194-Response-by-Northumbria-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The agreed police and probation information-sharing process is considered definitive and sufficient, although it may evolve with future IT development.
Verbatim wording from the response “The final point in relation to the current process was your concern that the Police were of the view this was a permanent solution to this issue, whereas NPS were viewing it as an interim solution. This concern may have emerged because of the way the evidence came out at the inquest. We have contacted NPS with regards to the content of this letter and they confirm that they agree this process is definitive going forward. It may of course evolve in the future as IT systems are further developed and the two organisations co-operate to further improve the system but at present the system outlined above is agreed as the operating model going forward.” Source location 2019-0194-Response-by-Northumbria-Police
Open published response
4 Apr 2019 Lesley Ann Armstrong · Prevention of Future Deaths report North Northumberland
View report summary
Concerns raised 1 Failure to communicate completion of Police investigations to the Local Safeguarding Adults Board and care home owners 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
Lesley Ann Armstrong · 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
Lesley Ann Armstrong died at home on 20 July 2016 after taking her own life by hanging. She had believed she remained under suspicion of assault because Northumbria Police did not inform her that its investigation had been discontinued, and the report identified concerns about communication between the police, safeguarding authorities and her employer regarding the investigation’s status.
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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate completion of Police investigations to the Local Safeguarding Adults Board and care home owners
Wider context from the report “It is recognised that employers have a duty of care to their employees to investigate allegations against them promptly and keep them reasonably informed about the progress of investigation of misconduct. On this occasion the employers Akari Care Limited could not properly inform Mrs Armstrong about the status of their investigation because they were not formally told when the Section 47 investigation by Northumbria Police had been discontinued. Northumbria Police acknowledged at the Inquest that there were procedural errors by two of their Officers, that the procedures themselves required improvement and that they had taken steps to address these. It was not clear that any practical steps had been taken to improve communication with the Local Safeguarding Adults Board or the owners of the Care Home both of whom needed to know when the Police investigations were completed so that the Safeguarding Board could if necessary progress an investigation under the Care Act 2014, and the Care Home could keep Mrs Armstrong informed about progress and her employment position. That lack of information or progress caused Mrs Armstrong to believe she was still under suspicion for an offence of assault.
” 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 Investigation outcomes should normally be communicated directly to the suspect or legal representative by the investigating officer, not through an employer.
Verbatim wording from the response “The purpose of information sharing between agencies, particularly in the care context, is to safeguard care users. It is this purpose which potentially enables disclosure of information relating to allegations of criminal conduct to be disclosed to an employer. The purpose of such information sharing is not to enable the employer to keep its employee updated as to the progress of the criminal investigation against that employee. Disclosure for that reason would be unlawful, unless the employee provided his or her consent and if the employee provided such consent, there would of course be no need to notify the employer. If the employee requires an update as to progress then it is clearly most appropriate that contact should be sought directly with the police, or via the employee’s legal representative.” Source location 2019-0136-Response-by-Northumbria-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 Routine employer updates about criminal investigations are inappropriate and unlawful without the employee’s consent, subject to case-by-case disclosure decisions.
Verbatim wording from the response “Sharing of criminal conviction data, or of information relating to allegations of criminal conduct, is subject to the provisions of the General Data Protection Regulation (GDPR) and the Data Protection Act 2018 (the Act). Such information is defined as “special category data” (analogous to sensitive personal data under the earlier Data Protection Act 1998). The legislation restricts the sharing of such information save in clearly defined circumstances.” Source location 2019-0136-Response-by-Northumbria-Police
Open published response
2 Dec 2016 Joshua Harry Smith · Prevention of Future Deaths report North Northumberland
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Concerns raised 7 Searches being stood down without confirming reported safety information View source Delay in deploying the Hazardous Area Response Team to a hazardous-area incident View source Failure to recognise location information from 999 calls View source Unclear multi-agency command control and co-ordination View source Failure to identify location from mobile 999 calls View source Failure to immediately alert police and other emergency services from 999 call information View source Failure to provide police control with essential incident information View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Joshua Harry Smith · 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 Harry Smith, aged 16, fell from cliffs near Spittal Beach and was later swept out to sea while clinging to a rock. He was rescued unconscious and died at Wansbeck General Hospital. The report identified delays in locating him, unclear overall command and coordination, and failure to follow JESIP principles.
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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Searches being stood down without confirming reported safety information
Wider context from the report “The search for Joshua was briefly stood down after a North East Ambulance call to Joshua’s father indicated that Joshua was at home in his bedroom, without waiting for ████████ to check and confirm whether Joshua was in fact in his bedroom.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Delay in deploying the Hazardous Area Response Team to a hazardous-area incident
Wider context from the report “Joshua had explained in his 999 call that he was below cliffs having fallen, was injured and that an ambulance would not be able to reach him. The Hazardous Area Response Team of North East Ambulance was not deployed to the incident until approximately 3 a.m. arriving at the scene under an hour later and were 1.5 miles away from the incident at the time Joshua was swept out to sea by action of the waves.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise location information from 999 calls
Wider context from the report “The search for Joshua continued at Berwick Holiday Park (on the north side of the River Tweed and the town of Berwick-upon-Tweed) as a result of his location at Spittal Beach not being recognised from his 999 call .
After Joshua’s phone call was ‘listened back’ it was observed that he had described his location as Spittal, at the bottom of a cliff, near Spittal beach.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Unclear multi-agency command control and co-ordination
Wider context from the report “The circumstances of the death showed that although there were examples of good co-operation and effort among the emergency services, overall command, control and co-ordination were unclear and JESIP was not followed.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to identify location from mobile 999 calls
Wider context from the report “At 2.15 a.m. when Joshua made his 999 call he stated to Ambulance control that he had fallen from a cliff near Spittal Beach (which is on the south side of the River Tweed) and injured himself, that he was alone and was unable to walk.
Police and other emergency services were not immediately alerted from the outset of the information provided in Joshua’s telephone call to 999. Joshua’s location could not be identified from the mobile phone call made to 999.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to immediately alert police and other emergency services from 999 call information
Wider context from the report “At 2.15 a.m. when Joshua made his 999 call he stated to Ambulance control that he had fallen from a cliff near Spittal Beach (which is on the south side of the River Tweed) and injured himself, that he was alone and was unable to walk.
Police and other emergency services were not immediately alerted from the outset of the information provided in Joshua’s telephone call to 999. Joshua’s location could not be identified from the mobile phone call made to 999.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide police control with essential incident information
Wider context from the report “Two Police Officers on Berwick Town Centre duties (which is north of the River Tweed) were asked in the street by paramedics for assistance in locating Joshua, and while paramedics went to look for Joshua on the north side of Berwick near the Holiday Park and cliffs, the police officers travelled to Spittal looking for Joshua although they had no name or further details at that time . A brief search of Spittal beach near to the cliffs by Police Officers was unsuccessful, before they returned to Town Centre duties. A report to Police Control was not made at that time.
” Open source report
Concerns raised 10 Lack of effective Police Service practice for transparent internal review of incidents View source Failure to provide integrated electronic aids for location, route planning and safe passage View source Failure to communicate continuing caller contact to incident managers View source Failure to plan and evaluate resource allocation for critical incidents View source Lack of clear protocols, communication lines and incident command identification View source Failure to define incident management roles View source Failure to review incident grading and allocate resources using essential information View source Lack of co-ordinated management, monitoring and control of serious incidents View source Lack of clear training and understanding of graded-incident response times View source Over-reliance on presumed training and experience instead of individual incident control View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Vincent Gibson · 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
Vincent Gibson was fatally injured while crossing Whiteleas Way, South Shields, when he was struck by a police vehicle travelling at speed in response to a Grade 1 emergency call. The principal concerns related to inadequate coordination, management, monitoring and control of the incident, including the failure to communicate that the caller remained in contact with the call taker, unclear roles, insufficiently informed risk assessment, resource allocation, route planning and uncertainty about response speed.
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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Lack of effective Police Service practice for transparent internal review of incidents
Wider context from the report “It is a matter of some concern that this is not an apparent practice of the Police Service even though they have a Professional Standards Department, which is clearly designed to address and respond to issues around Professional Standards and that not only in an objective but effective way .
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide integrated electronic aids for location, route planning and safe passage
Wider context from the report “Electronic aids are a benefit not only to Central Control but also to responders and such electronic aids should eliminate any issue or debate around the fact as to route and leave the crew speculating as to the position, route or speed.
10. Electronic aids should (a) readily identify the location (b) pre-plan the route (c) determine a safe and where appropriate speedy passage . In any event, any electronic aids and/or systems must be fully integrated being identified for the purpose they are intended to serve.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate continuing caller contact to incident managers
Wider context from the report “Much more significant than all the other facts which appeared on this log directly was the omission of the fact at any stage before the incident of the collision that ████████ was in continued conversation with the caller .
7. ████████ was in the same room as ████████ and it had known of the continuing conversation one assumes, she could have planned accordingly. ████████ clearly appreciated that contact with the caller was an essential way of trying to find out more positive information about him and effectively plan for his help and support.
8. As the Resource Controller and the recipient of the initial log and graded incident she is the obvious point of direct contact for such essential detail. She is also the obvious conduit for not only the fact that the caller is still talking to the Call Taker but to understand the tone and content of that conversation and analyse the level of distress if any, the caller is continuing to demonstrate.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to plan and evaluate resource allocation for critical incidents
Wider context from the report “Identifying an allocation of resource should not be a spontaneous response to a demand but a reasoned and considered response to effective planning and to positive resource evaluation.
a. Self-selection borne of enthusiasm and worse, boredom does not make for a balanced plan and safe approach to a critical incident . Officers in this case were able simply to call in, identify themselves as available and willing.
b. The resource controller although she had an electronic map which could identify the whereabouts of resource did not use that map it falling out of favour and being judged not fit for purpose. Accordingly, at no stage was any resource identified even if it was available at a closer proximity .
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clear protocols, communication lines and incident command identification
Wider context from the report “Rules of practice, ie protocols need to be clear and unequivocal identifying robust rules of procedure identifiable lines of communication where appropriate but at all stages in the identifying of the individual in the management, monitoring and control of an incident who can be properly identified as in charge of the incident in hand.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to define incident management roles
Wider context from the report “It is not clear that either ████████ or Acting Sergeant Robinson was :-
a) Aware of his or her role
b) Nor does it appear others were clear as to the role of the Sergeant or the resource controller.
c) It is not clear that either of these individuals had a clearly defined role prior to this night in the managing, monitoring or controlling of this incident.
Whatever the roles of these individuals was - whether they were joint or mutually exclusive, that role - their roles - was an essential to the discharge of this grade 1 incident safely and effectively.
As far as Sergeant Robinson was concerned, I am of a view that he was not the manager of this matter. He was not in a position to control or effectively monitor events.
14. That failure to clearly define an identifiable role and consequential confusion over roles , add to a lack of clarity and lead to a lack of effective co-ordination of the essential tasks set within this matter.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Failure to review incident grading and allocate resources using essential information
Wider context from the report “It is of primary importance to keep the grading of the incident under review and that with the benefit of essential and relevant information. Similarly the allocation of resource and the tasking of that resource again demands relevant and essential information sufficient to ensure the effective and safe discharge of and completion of, the task in hand.
11. The two crews were ignorant of both source and content of such essential and relevant information and were being asked to risk assess a task in the absence of such essential relevant and critical information . With that critical information available to them they would be in a better position to determine more safely the speed of approach to the task - which they essentially perceived was to visit a house where the caller was believed to be but was not.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Lack of co-ordinated management, monitoring and control of serious incidents
Wider context from the report “The matters of concern identified by this history centre on an all too apparent lack of co-ordination of the essential elements of management, monitoring and control needed to effectively respond as one would reasonably expect to a properly identified and graded serious incident.
” 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 Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clear training and understanding of graded-incident response times
Wider context from the report “Such an apparent conflict of understanding of what that time response meant or means when attached to a grade 1 incident or indeed a grade 2, or any of the other five graded responses underlines an essential need for this process to be taken into some effective control and to be the subject of particular training and clear understanding on the part of both management and staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumbria Police; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on presumed training and experience instead of individual incident control
Wider context from the report “What is not good practice and gives rise to concern is the apparent over-reliance on presumed skill sets from periods of training and years of experience and dare one say, a successful completion of a number of incidents without any apparent failing. Each incident merits appropriate levels of individual management, monitoring and control .
” 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