Recipient

Recipient name withheld

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First report 25 May 2021•Latest report 25 May 2021

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. North West Kent

    AI-generated summary

    Matthew MACKELL · 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

    Matthew MACKELL was found dead on 7 May 2020 in Dunorlan Park after suspending himself from a tree using a bedsheet as a ligature. The previous evening, he had telephoned Kent Police stating that he intended to kill himself, but the call was not accurately located or treated as a suicide call. The concerns included inadequate training and procedures for using the enhanced mobile-phone location system, grading suicide calls, and recording and monitoring staff training.

    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to cascade operational information

    Wider context from the report

    “(1) In December 2019 a software update had been installed to a system in the Kent Force Control room which, if used, produced a much greater accuracy in detecting the location of mobile phone calls. There had been inadequate or no training on the use of the update which resulted in the system not being deployed to locate the deceased. The call from the deceased at 22.18 was therefore incorrectly downgraded as the area to search was regarded as too wide to be effective. The downgrade was incorrect because (a) the use of the software would have provided an accurate location and (b) the call should have been treated as a suicide call and not an abandoned 999 call. It is accepted that as a direct result of this incident the software system is now the default setting to detect locations. However, the evidence of those witnesses who were required to use the system raised a more general enquiry which identified gaps in or absence of effective training and the cascading of information. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify, schedule, monitor and record individual training and updating

    Wider context from the report

    “(2) The totality of the evidence from several experienced operatives in the Force Control Room revealed gaps in their knowledge as to operating procedure in respect of the suicide policy, appropriate downgrading of calls, checking available patrols. Whilst it is accepted that following an IOPC report steps have been taken to review and improve procedures, it was apparent that there was an absence of an effective system to identify those that required training/updating and the keeping a record of specific training/updating received by individual operatives and the date it was undertaken. There did not appear to be a structured system in place to produce a regular training rotation which monitored and recorded individual satisfactory progress. Such a system would clearly identify what training/updating had been received thus identifying those who might otherwise be missed and when training/updating was scheduled to take place. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate training on the use of location-detection software

    Wider context from the report

    “(1) In December 2019 a software update had been installed to a system in the Kent Force Control room which, if used, produced a much greater accuracy in detecting the location of mobile phone calls. There had been inadequate or no training on the use of the update which resulted in the system not being deployed to locate the deceased. The call from the deceased at 22.18 was therefore incorrectly downgraded as the area to search was regarded as too wide to be effective. The downgrade was incorrect because (a) the use of the software would have provided an accurate location and (b) the call should have been treated as a suicide call and not an abandoned 999 call. It is accepted that as a direct result of this incident the software system is now the default setting to detect locations. However, the evidence of those witnesses who were required to use the system raised a more general enquiry which identified gaps in or absence of effective training and the cascading of information. ”
    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Gaps in knowledge of suicide policy, call downgrading and patrol-checking procedures

    Wider context from the report

    “(2) The totality of the evidence from several experienced operatives in the Force Control Room revealed gaps in their knowledge as to operating procedure in respect of the suicide policy, appropriate downgrading of calls, checking available patrols. Whilst it is accepted that following an IOPC report steps have been taken to review and improve procedures, it was apparent that there was an absence of an effective system to identify those that required training/updating and the keeping a record of specific training/updating received by individual operatives and the date it was undertaken. There did not appear to be a structured system in place to produce a regular training rotation which monitored and recorded individual satisfactory progress. Such a system would clearly identify what training/updating had been received thus identifying those who might otherwise be missed and when training/updating was scheduled to take place. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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