Police and Crime Commissioner for West Midlands

Policing · Police and crime commissioner

Pin Request correction

First report 9 Nov 2016•Latest report 3 Nov 2022

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
3

Naming this recipient

Published responses
33%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
1

Described in responses

Concerns and recipient responses

Statements from Police and Crime Commissioner for West Midlands linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Raneem Oudeh and Khaola Saleem · 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

    Raneem Oudeh and her mother, Khaola Saleem, were murdered outside Khaola’s home address just after midnight following an incident at a Birmingham shisha lounge. Both women died from multiple stab wounds. The report raises a concern that serious staff shortages in the domestic abuse team led to cases not being effectively investigated, placing repeat victims of domestic abuse and coercive control at serious risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Police and Crime Commissioner for West Midlands; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing and resources for domestic abuse investigations

    Wider context from the report

    “1. The inquest heard evidence that the domestic abuse team within the Public Protection Unit were seriously short staffed. The inquest was told that in Raneem's case the officer reviewing her case on 28/04/18 understood that more needed to be done however he filed the report due to having no staff to investigate the case. The officer stated that this problem continues. The inquest was told that cases are not being investigated due to lack of resources in the department. This leaves a very real and immediate concern that women like Raneem, who was a repeat victim of domestic violence and controlling and coercive control from a man who had made threats to kill her, are at serious risk due to a lack of effective investigation by the department responsible for investigating domestic abuse. ”
    Open source report

  2. Birmingham and Solihull

    AI-generated summary

    Karen Jane Burns · 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

    Karen Jane Burns was found hanging from a basketball net at a park in Birmingham at 06.15 on 23 March 2019, after her ex-partner had reported that she had threatened to kill herself. The inquest concluded that her death was suicide. A serious concern was raised about West Midlands Police resources, particularly at night, and the incorrect grading and non-response of the call reporting the threat.

    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 Police and Crime Commissioner for West Midlands; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient resources to deal with the volume of calls, particularly at night

    Wider context from the report

    “1. I heard evidence at the inquest that this call was graded incorrectly. It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response). The evidence confirmed that nearly all the P2 and P3 calls went unanswered that night. This raises a serious concern about the amount of resources available to West Midlands Police. Urgent attention is needed to address the resources available, particularly at night, as current resources are unable to deal with the large volume of cases the Force is expected to deal with. ”
    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 Police and Crime Commissioner for West Midlands; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to grade calls correctly

    Wider context from the report

    “1. I heard evidence at the inquest that this call was graded incorrectly. It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response). The evidence confirmed that nearly all the P2 and P3 calls went unanswered that night. This raises a serious concern about the amount of resources available to West Midlands Police. Urgent attention is needed to address the resources available, particularly at night, as current resources are unable to deal with the large volume of cases the Force is expected to deal with. ”
    Open source report

    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

    Limited resources prevented West Midlands Police from reaching most P2 and some P1 calls during periods of exceptionally high demand.

    Verbatim wording from the response

    “2. The risk created by the lack of resources available to West Midlands Police:”

    Source location

    2019-0273-Response-by-West-MIdlands-Police-and-Crime-Commissioner
    Page 1 · response
    Published 18 October 2019

    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 incorrect call grading made no difference because limited resources meant a correctly graded P2 call would also not have received a response.

    Verbatim wording from the response

    “West Midlands Police has accepted that the call was incorrectly graded, which was recognised as human error. It has been discussed with the member of staff in question by management.”

    Source location

    2019-0273-Response-by-West-MIdlands-Police-and-Crime-Commissioner
    Page 1 · response
    Published 18 October 2019

    Open published response

  3. Coventry

    AI-generated summary

    Mark Adam Yafai · 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

    Mark Adam Yafai was arrested in the early hours of 1 July 2015 after disclosing recent cocaine use, and was found convulsing and frothing at the mouth in his cell. He suffered cardiac arrest and died at hospital; the stated cause of death was acute cocaine toxicity. The report raised concerns that custody policies used unclear terminology and gave too much discretion over healthcare assessment, risk assessment and observation for detainees who had disclosed drug use.

    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 Police and Crime Commissioner for West Midlands; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to require Health Care Professional assessment after disclosed recent drug consumption

    Wider context from the report

    “i. The Safer Detention Policy and Handling of Person in Custody Composite Policy as updated August 2014 was replaced by the WMP Detention and Custody Policy Inc. Standard Operating Procedure with effect from the 22nd December 2015. The earlier policy was in operation at the time Mark Yafai died. The earlier policy lacked clarity or guidance in how the phrase “under the influence” must be interpreted. The phrase is unsuitable since it confers a very broad discretion upon a custody officer to not have the detainee examined by a Health Care Professional, despite a detainee has disclosed recently consuming drugs. The impact upon risk assessment and levels of observation is clear and significant. A broad discretion of an officer when determining risk concerning medical matters including drug use is inadequate. The jury made a determination in similar terms. ii. The evidence was the policy is accessible. Accordingly, it is paramount that the policy must provide clear unambiguous guidance/ direction to custody officers particularly in relation to drugs which can have serious consequences for an individual who has consumed. The circumstances of this inquest touching upon the death of Mark Yafai accentuated this point. The evidence was that cocaine can have toxic effects even from small quantities (as little as 0.03g). Consumption can be via a number of means and the effects delayed depending upon the method of ingestion. There is no antidote to cocaine toxicity. The evidence was custody officers range of knowledge about drugs and the effects can and do differ and this can have a bearing upon risk assessment given the terminology in the policy and broad discretion officers have. iii. The 2015 policy retains that same unclear terminology i.e. “believed to be under the influence of drugs or withdrawing from drugs” and “will be seen by a Health Care Professional (HCP) as a matter of course”. iv. It does not deal with the instances in which a detainee irrespective of presentation (which is not itself any easy assessment when a detainee is being observed by an officer most likely for the first time with no information against which a comparison may be made as whether their current presentation is indeed “normal”) has disclosed the recent consumption of drugs. What is “a line” or any quantitative opinion on drugs consumed is a very subjective assessment by the detainee and/ or the custody officer. v. An assessment as to the effect of any drugs is best assessed a by a Heath Care Professional. That was the evidence and information that emerged in the inquest. Standard medical observations can be undertaken ranging from a check as body temperature to elevated heart rate or blood pressure which may be indicators that drugs are having an adverse effect upon the body. vi. Earlier identification of these matters may prevent death particularly since treatment for many drugs, particularly cocaine, is symptomatic. Close observation of a detainee is clearly significant since early treatment of symptoms can have an impact upon an individual’s survivability. vii. The policy in other respects does use directional/ non discretion type terminology in some respects when dealing with drug issues. It is thus currently inconsistent in this respect on this topic and in interrelation with Risk assessment and appropriate observation levels which are a focus of custody personnel. ”
    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 Police and Crime Commissioner for West Midlands; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear and consistent drug-related risk assessment and observation guidance

    Wider context from the report

    “i. The Safer Detention Policy and Handling of Person in Custody Composite Policy as updated August 2014 was replaced by the WMP Detention and Custody Policy Inc. Standard Operating Procedure with effect from the 22nd December 2015. The earlier policy was in operation at the time Mark Yafai died. The earlier policy lacked clarity or guidance in how the phrase “under the influence” must be interpreted. The phrase is unsuitable since it confers a very broad discretion upon a custody officer to not have the detainee examined by a Health Care Professional, despite a detainee has disclosed recently consuming drugs. The impact upon risk assessment and levels of observation is clear and significant. A broad discretion of an officer when determining risk concerning medical matters including drug use is inadequate. The jury made a determination in similar terms. ii. The evidence was the policy is accessible. Accordingly, it is paramount that the policy must provide clear unambiguous guidance/ direction to custody officers particularly in relation to drugs which can have serious consequences for an individual who has consumed. The circumstances of this inquest touching upon the death of Mark Yafai accentuated this point. The evidence was that cocaine can have toxic effects even from small quantities (as little as 0.03g). Consumption can be via a number of means and the effects delayed depending upon the method of ingestion. There is no antidote to cocaine toxicity. The evidence was custody officers range of knowledge about drugs and the effects can and do differ and this can have a bearing upon risk assessment given the terminology in the policy and broad discretion officers have. iii. The 2015 policy retains that same unclear terminology i.e. “believed to be under the influence of drugs or withdrawing from drugs” and “will be seen by a Health Care Professional (HCP) as a matter of course”. iv. It does not deal with the instances in which a detainee irrespective of presentation (which is not itself any easy assessment when a detainee is being observed by an officer most likely for the first time with no information against which a comparison may be made as whether their current presentation is indeed “normal”) has disclosed the recent consumption of drugs. What is “a line” or any quantitative opinion on drugs consumed is a very subjective assessment by the detainee and/ or the custody officer. v. An assessment as to the effect of any drugs is best assessed a by a Heath Care Professional. That was the evidence and information that emerged in the inquest. Standard medical observations can be undertaken ranging from a check as body temperature to elevated heart rate or blood pressure which may be indicators that drugs are having an adverse effect upon the body. vi. Earlier identification of these matters may prevent death particularly since treatment for many drugs, particularly cocaine, is symptomatic. Close observation of a detainee is clearly significant since early treatment of symptoms can have an impact upon an individual’s survivability. vii. The policy in other respects does use directional/ non discretion type terminology in some respects when dealing with drug issues. It is thus currently inconsistent in this respect on this topic and in interrelation with Risk assessment and appropriate observation levels which are a focus of custody personnel. ”
    Open source report
Back to top

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

Data last updated 7 September 2026