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.
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. 6
Action
Deliver the expanded firearms licensing training package covering triage, safety, decision-making, safeguarding, domestic abuse, neurodiversity, range assessment, social media and administration.
Stated in progressThe respondent said that this action was in progress when they made their response on 10 March 2023. View source
Action
Provide Police National Decision Model training to all decision makers with delegated authority.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2023. View source
Action
Train and mentor the Deputy Manager holding delegated firearms licensing responsibilities.
Stated in progressThe respondent said that this action was in progress when they made their response on 10 March 2023. View source
Action
Complete the Mowbray Associates firearms licensing decision-making course for delegated decision makers.
Stated in progressThe respondent said that this action was in progress when they made their response on 10 March 2023. View source
Action
Introduce a Deputy Manager with delegated firearms licensing responsibilities and provide training and mentoring.
Stated in progressThe respondent said that this action was in progress when they made their response on 10 March 2023. View source
Action
Deliver the extensive firearms licensing training package, including decision-making, safety, safeguarding, domestic abuse, neuro-diversity, range assessment and social-media training.
Stated in progressThe respondent said that this action was in progress when they made their response on 10 March 2023. View source See 3 more actions
×
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 Staffordshire 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 Staffordshire 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 Staffordshire 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
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the expanded firearms licensing training package covering triage, safety, decision-making, safeguarding, domestic abuse, neurodiversity, range assessment, social media and administration.
Verbatim wording from the response “5. Historically firearms licensing training has largely been based on local delivery and mentoring. Following the tragic shooting in Keyham significant changes have been made to deliver an extensive training package, which includes:” Source location Response from Staffordshire 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 Police National Decision Model training to all decision makers with delegated authority.
Verbatim wording from the response “c. Police National Decision Model training – CoP accredited trainers delivered (all staff)” Source location Response from Staffordshire 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 and mentor the Deputy Manager holding delegated firearms licensing responsibilities.
Verbatim wording from the response “2. Decision Making, the introduction of a new Deputy Manager to hold delegated responsibilities (under section 55(2) of the Firearms Act 1968). The post holder is currently undertaking training and is being mentored.” Source location Response from Staffordshire 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 Complete the Mowbray Associates firearms licensing decision-making course for delegated decision makers.
Verbatim wording from the response “h. FEO, Decision Making and Administration Courses – Durham Police/Mowbray Associates (all staff)” Source location Response from Staffordshire 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 Deputy Manager with delegated firearms licensing responsibilities and provide training and mentoring.
Verbatim wording from the response “2. Decision Making, the introduction of a new Deputy Manager to hold delegated responsibilities (under section 55(2) of the Firearms Act 1968). The post holder is currently undertaking training and is being mentored.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the extensive firearms licensing training package, including decision-making, safety, safeguarding, domestic abuse, neuro-diversity, range assessment and social-media training.
Verbatim wording from the response “5. Historically firearms licensing training has largely been based on local delivery and mentoring. Following the tragic shooting in Keyham significant changes have been made to deliver an extensive training package, which includes:” Source location Response from West Midlands Police
Open published response
3 Nov 2021 Saskia Jones and 2 others · Prevention of Future Deaths report London City
View report summary
Concerns raised 24 Failure to inform MAPPA panels about regularity and form of overt offender-management contact View source Insufficient consideration of extremist offenders’ dishonest self-presentation View source Failure to share and consider counter-terrorism police intelligence in MAPPA management View source Failure to properly reason and record offender-manager licence-condition approvals View source Failure to provide MAPPA panels important prison-history information View source Failure to provide MAPPA panels direct input from the preparing forensic psychologist View source Failure to communicate between offender managers and event organisers before extremist offenders attend events View source Insufficient risk assessment and management for prison higher education programmes involving post-release offender contact View source Sudden disruption of DDP mentoring arrangements View source Sudden loss of supervised internet access for employment searches View source Failure to complete the full structured assessment before changing an OASys risk rating View source Failure to properly consider security-sensitive information in MAPPA decisions View source Lack of precautionary search capability for terrorist offenders on licence View source Failure to detect Class A drug use by terrorist offenders on licence View source Unavailability of offender risk-profile information to prison-based higher education providers View source Failure to ensure all MAPPA meeting attendees receive meeting minutes View source Failure to ensure direct forensic psychologist involvement in ERG 22+ assessment reports View source Failure to assess risks of continuing close contact between serious offenders and young students View source Excessive reliance on compliance in management of extremist offenders View source Failure to communicate high-risk event attendance to host venues View source Failure to directly address risks when approving licence-condition changes View source Lack of formal risk assessment for higher education events held outside university premises View source Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes View source Failure to record proper rationale for changes to OASys risk ratings View source See 21 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
Saskia Jones and 2 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 29 November 2019, Usman Khan carried out a terrorist attack at Fishmongers’ Hall, fatally stabbing Saskia Jones and Jack Merritt before being fatally shot by firearms officers on London Bridge. The report raised concerns about risk assessment and communication for events involving high-risk offenders, and about the assessment, information-sharing, supervision and management of terrorist offenders released into the community.
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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform MAPPA panels about regularity and form of overt offender-management contact
Wider context from the report “The facts of this case give cause for concern that MAPPA panels responsible for managing terrorist offenders may be unaware of the regularity and form of contact with police officers responsible for overt offender management .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of extremist offenders’ dishonest self-presentation
Wider context from the report “The facts of this case give rise to concern that probation officers may give insufficient regard to instances of dishonesty in self-presentation by extremist offenders .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to share and consider counter-terrorism police intelligence in MAPPA management
Wider context from the report “This case gives cause for concern that counter-terrorism police may be in possession of intelligence or information which may be useful to the management of an offender by the MAPPA panel, but that such intelligence or information may not be brought to the knowledge of or taken into account by MAPPA 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to properly reason and record offender-manager licence-condition approvals
Wider context from the report “This case gives rise to concern that offender managers may take significant decisions to give approvals under licence conditions without those decisions being properly reasoned and recorded .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MAPPA panels important prison-history information
Wider context from the report “The facts of this case give cause for concern that some members of MAPPA panels responsible for managing extremist offenders may not be aware of important information from the offender’s time in prison .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MAPPA panels direct input from the preparing forensic psychologist
Wider context from the report “It is a matter for concern that MAPPA panels managing even the most serious offenders may not have the benefit of hearing directly from a forensic psychologist who has prepared an ERG report shortly prior to the offender’s release .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate between offender managers and event organisers before extremist offenders attend events
Wider context from the report “This case gives rise to concern that an extremist offender may be permitted to attend an event or venue without there having been proper communication between the probation and police officers responsible for managing the offender and the event organisers and/or venue hosts .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient risk assessment and management for prison higher education programmes involving post-release offender contact
Wider context from the report “Consideration should be given to whether further measures of risk assessment and management can be introduced for any higher education programmes running in prisons which involve continued contact with offenders after their release into the community .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Sudden disruption of DDP mentoring arrangements
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work.
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Sudden loss of supervised internet access for employment searches
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the full structured assessment before changing an OASys risk rating
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale.
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to properly consider security-sensitive information in MAPPA decisions
Wider context from the report “The facts of this case give cause for concern that security sensitive information may not be properly taken into account in decision-making by MAPPA panels concerning the management of terrorist offenders.
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of precautionary search capability for terrorist offenders on licence
Wider context from the report “The facts of this case gave cause for concern that those involved in managing terrorist offenders on licence may lack a valuable means of addressing risks they pose, namely an ability to carry out a search on a precautionary basis .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to detect Class A drug use by terrorist offenders on licence
Wider context from the report “The facts of this case give cause for concern that a terrorist offender on licence, who was subject both to strict licence conditions and to a priority investigation, could obtain and use Class A drugs without that being detected .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of offender risk-profile information to prison-based higher education providers
Wider context from the report “It is a matter of concern that Learning Together could operate courses in prisons in the way it did without being given information about the risk profiles of offenders joining courses .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure all MAPPA meeting attendees receive meeting minutes
Wider context from the report “Based on the evidence in this case, there is cause for concern that effective procedures are not in place to ensure that all MAPPA meeting attendees receive meeting minutes .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure direct forensic psychologist involvement in ERG 22+ assessment reports
Wider context from the report “Notwithstanding the measures which the NPS has put in place since the attack, there remains cause for concern that ERG 22+ assessment reports may be prepared by a CTPO without the direct involvement of a forensic psychologist .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to assess risks of continuing close contact between serious offenders and young students
Wider context from the report “It is a matter of concern that focussed consideration was not given to the risks of serious offenders being placed in close and continuing contact with young students .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Excessive reliance on compliance in management of extremist offenders
Wider context from the report “Based on the facts of this case, there is cause for concern that probation officers may attach excessive weight in their management of extremist offenders to “compliance” (i.e. absence of evidence of breach of licence conditions and police behaviour).
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate high-risk event attendance to host venues
Wider context from the report “It is a matter of concern that a major event could be held by a University at a livery company hall in London without clear communication of the fact that it would be attended by serving and recently released serious offenders .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to directly address risks when approving licence-condition changes
Wider context from the report “This case gives cause for concern that an offender manager and/or MAPPA panel participants could approve a permission, variation or relaxation in relation to a licence condition without directly addressing the potential risks involved .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal risk assessment for higher education events held outside university premises
Wider context from the report “It is a matter of concern that there was no such risk assessment for Learning Together events as set out above.
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes
Wider context from the report “The facts of this case give rise to concern that important decisions on approvals, variations and relaxations in relation to licence conditions may be taken without clearly reasoned discussion and decision-making in MAPPA panels .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record proper rationale for changes to OASys risk ratings
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale .
” Open source report
30 Jul 2021 Amanda DUNN · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Failure to take reported harassment incidents sufficiently seriously View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amanda DUNN · 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
Amanda Dunn died at home on 21 March 2021 from a self-administered overdose of prescribed medication, with the inquest conclusion recording suicide while suffering anxiety and depression. The substantive concern was that alleged harassment by neighbours had been reported to police several times but may not have been taken sufficiently seriously or investigated, although the report notes that only one side of the story was heard.
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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to take reported harassment incidents sufficiently seriously
Wider context from the report “Family members told me that for a period of about two years prior to her death Amanda had received a lot of aggravation from a set of neighbours. Police were contacted several times but took no action. The evidence I heard clearly seemed to amount to harassment. Prior to the inquest I was not aware of the full extent of the concerns and had not requested evidence from the police on this (PC ████████ gave evidence about the circumstances of the death itself). I realise therefore that I have only heard one side of the story but there is a real concern that police are seeking to brush such incidents under the carpet and not taking them sufficiently seriously. Clearly, I do not want another death reported to me of a similar nature.
” 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 Review repeat anti-social behaviour cases involving vulnerable people to identify cases requiring additional work.
Verbatim wording from the response “More broadly, the Force is reviewing whether there are any similar repeat cases of anti-social behaviour which have been reported to Staffordshire Police that involve vulnerable people. The aim of this work is to identify any cases that have been reported to Staffordshire Police which need additional work, in response to these findings. The second aim is to examine our systems and processes to ensure we provide a consistently good level of service to those people who report matters of anti-social behaviour.” Source location 2021-0261-Response-from-Staffordshire-Police_Published
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 Share learning about failures to investigate and record allegations with neighbourhood policing, anti-social behaviour leads and relevant local officers.
Verbatim wording from the response “In addition, the police did not respond effectively to the allegation of a criminal offence (the pushing incident). We have found no material where the police have confirmed, recorded or explored this allegation. This learning has been promptly shared with colleagues who are responsible for neighbourhood policing, the thematic business lead for anti-social behaviour as well as the specific officers responsible for the area in which Mrs. Dunn lived.” Source location 2021-0261-Response-from-Staffordshire-Police_Published
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 Disseminate learning from the case to help prevent recurrence.
Verbatim wording from the response “I want to reassure you that we take this matter very seriously and are committed to ensuring that the learning from this case is captured, understood and disseminated in a way that prevents future re-occurrences.” Source location 2021-0261-Response-from-Staffordshire-Police_Published
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 Examine systems and processes to improve consistency of service for people reporting anti-social behaviour.
Verbatim wording from the response “More broadly, the Force is reviewing whether there are any similar repeat cases of anti-social behaviour which have been reported to Staffordshire Police that involve vulnerable people. The aim of this work is to identify any cases that have been reported to Staffordshire Police which need additional work, in response to these findings. The second aim is to examine our systems and processes to ensure we provide a consistently good level of service to those people who report matters of anti-social behaviour.” Source location 2021-0261-Response-from-Staffordshire-Police_Published
Open published response
Concerns raised 2 Failure to provide out-of-hours access to urgent Integrated Offender Manager communications View source Lack of post-release accommodation assistance 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
Thomas Philip Lear · 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
Thomas Philip Lear died by suicide on 6 January 2018 after he was found hanging from a fence post at his ex-partner’s property. The report raised concerns that no help with accommodation appeared to have been offered after his release from prison, and that urgent text messages reporting threats to hang himself were sent to an Integrated Offender Manager phone that was unavailable outside Monday to Friday without an apparent divert.
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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide out-of-hours access to urgent Integrated Offender Manager communications
Wider context from the report “(2) On Saturday 6th January 2018 he threatened to hang himself. At 3.37pm and at 5.03pm that day the mother of the deceased sent two text messages to the mobile phone of ████████is allocated Integrated Offender Manager (IOM) indicating that he had threatened to hang himself. The IOM phone number is only available Monday-Friday and there was no apparent divert to any other number which might have picked up the urgent nature of the text messages .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of post-release accommodation assistance
Wider context from the report “(1) The deceased had been released from prison on the 29th December 2018. He was homeless and lapsed quickly back into drug taking. An ex-partner offered him some temporary accommodation. On the 6th January she refused him admission to her house because he was clearly under the influence of drugs. Shortly after he hung himself in the rear garden at her address. It was not apparent at the inquest that any help had been offered to the deceased with regards to accommodation following his release from prison.
” Open source report
Concerns raised 6 Failure to make detailed notes in detainees’ custody medical records View source Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels View source Insufficient targeted training on drug and alcohol-related risks in custody View source Insufficient training emphasis on correct observation levels View source Lack of joint training exercises for medical practitioners, custody sergeants, custody detention officers and assistants View source Failure to specify detainee observation levels precisely View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Name not published · 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
The deceased was arrested on 2 October 2011 and held in custody, where he received prescribed methadone and medication for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on 3 October 2011; the recorded medical cause of death was methadone intoxication, with alcohol withdrawal in a chronic alcoholic also identified. Concerns included communication between medical practitioners and custody staff, inconsistent observation levels, joint training, and training on drug and alcohol-related risks.
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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to make detailed notes in detainees’ custody medical records
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical record .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels
Wider context from the report “1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical record.
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient targeted training on drug and alcohol-related risks in custody
Wider context from the report “5. That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal , particularly if the detainee is likely to be in custody for upwards of 24 hours.
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient training emphasis on correct observation levels
Wider context from the report “3. That training should provide targeted emphasis on the correct levels of observation .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of joint training exercises for medical practitioners, custody sergeants, custody detention officers and assistants
Wider context from the report “2. That consideration be given to the provision of joint training exercises for medical practitioners, custody sergeants and custody detention officers and assistants .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to specify detainee observation levels precisely
Wider context from the report “4. That consideration should be given to eliminating the phrase ‘continue observations at the current level’ and require that doctors and custody sergeants specify the level of observation precisely .
” 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 Review Force Policy to incorporate the verbal medical consultation update requirement.
Verbatim wording from the response “1. Guidance has been issued to all custody trained staff and our medical services provider, Nestor Primcare, to ensure that a verbal update is given by the medical practitioner to the appropriate Custody Sergeant following any consultation of a detained person by such a medical practitioner within the custody environment. This will be captured within Force Policy which is being reviewed currently, and tested through the monthly QA process already in place.” Source location 2015-0138-Response-by-Staffordshire-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 Plan and oversee the Staffordshire custody personnel training programme through the Custody Training sub-group.
Verbatim wording from the response “2. A Custody Training sub-group has been created to oversee the training of all custody personnel. This sub-group will report directly to the Force Custody, Mental Health and Vulnerability Steering Group, which I currently chair. The first meeting of this sub-group will take place on Monday 8th June 2015, and will include the following personnel:” Source location 2015-0138-Response-by-Staffordshire-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 Issue guidance requiring medical practitioners to provide custody sergeants with verbal consultation updates.
Verbatim wording from the response “1. Guidance has been issued to all custody trained staff and our medical services provider, Nestor Primcare, to ensure that a verbal update is given by the medical practitioner to the appropriate Custody Sergeant following any consultation of a detained person by such a medical practitioner within the custody environment. This will be captured within Force Policy which is being reviewed currently, and tested through the monthly QA process already in place.” Source location 2015-0138-Response-by-Staffordshire-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 Instruct custody officers and medical practitioners to record agreed observation levels and avoid non-specific continuation phrases.
Verbatim wording from the response “4. Custody Officers and medical practitioners have been instructed to specify the agreed level of observation within the custody record and to avoid the use of such phrases as ‘I agree with the current observation level’ or ‘Continue observations at the current level’. This will be monitored within the monthly monitoring process and feedback provided where necessary.” Source location 2015-0138-Response-by-Staffordshire-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 Consider further training to supplement and enhance observation-level guidance.
Verbatim wording from the response “3. Further guidance has recently been issued with regard to the correct levels of observation, although we will consider further training to supplement and enhance this guidance.” Source location 2015-0138-Response-by-Staffordshire-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 Secure force training on drug and alcohol risks, including methadone intoxication and alcohol withdrawal.
Verbatim wording from the response “5. Training will be secured by the Force regarding the risks and dangers of drug and alcohol abuse, including Methadone intoxication and alcohol withdrawal. This will be built into the aforementioned training programme.” Source location 2015-0138-Response-by-Staffordshire-Police
Open published response
14 Aug 2014 Oлеgs Sulaimovs · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 6 Lack of encouragement to wear reflective clothing View source Lack of information about the nature of the road for the migrant population View source Lack of speed restrictions in a highly populated area View source Absence of a footpath View source Absence of suitable lighting View source Lack of supply of reflective clothing 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
Oлеgs Sulaimovs · 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
Oлеgs Sulaimovs, a Latvian national and migrant worker, was struck by a vehicle while walking along an unlit, single-carriageway road towards Stafford in the early hours of 9 March 2014. The reported concerns included limited information for migrant workers about the road’s dangers, insufficient encouragement to wear reflective clothing, the absence of a footpath and suitable lighting, and a lack of speed restrictions in a populated area.
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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of encouragement to wear reflective clothing
Wider context from the report “2. The lack of supply/encouragement to wear reflective clothing .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of information about the nature of the road for the migrant population
Wider context from the report “1. The lack of information given to the migrant population temporally resident in the area with regard to the nature of the road .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of speed restrictions in a highly populated area
Wider context from the report “4. The lack of speed restrictions in an apparently highly populated area .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Absence of a footpath
Wider context from the report “3. The absence of a footpath and suitable lighting.
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Absence of suitable lighting
Wider context from the report “3. The absence of a footpath and suitable lighting .
” 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 Staffordshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of supply of reflective clothing
Wider context from the report “2. The lack of supply /encouragement to wear reflective clothing.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations