7 Nov 2025 Anthony Robert CARD · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Lack of a mechanism for police to communicate consented mental-health risk information to medical or mental health care providers 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
Anthony Robert CARD · 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
Anthony Robert CARD, known as Tony, died by suicide by suspension by ligature at 15 Duke Street, Ipswich, between about noon on 21 and 22 November 2023. The report identifies a concern that, outside Care Act safeguarding criteria, there was no mechanism for police to communicate medium-risk mental-health information to relevant medical or mental-health providers, potentially resulting in missed support or affecting later decision-making.
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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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for police to communicate consented mental-health risk information to medical or mental health care providers
Wider context from the report “Outside of situations where section 42 of the Care Act 2014 applies, there appears to be no mechanism available to enable front-line police officers who wish, of their own volition and with the subject's consent, to communicate risk information, arising out of an interaction with an adult at Medium risk to self from mental ill-health, to medical or mental health care providers , whom may be the right person or agencies to provide support in the medium term.
The information that an individual has, for example, been reported as presenting in such a way that police have had to consider detaining them under section 136 of the Mental Health Act 1983 could be important risk information that would assist medical or mental health care providers.
Not having this risk information available in future assessments may adversely affect decision-making - e.g. not having this information available could contribute to a decision not to admit compulsorily the patient for mental health care if they were to present again in, say, one week from the police interaction.
If such risk information is not received by treating medical or mental health care providers, there may be omission to offer vital further mental health support.
” 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 Continue consulting partner agencies to evaluate NHS 111 Option 2’s operability, reliability, staff knowledge, and training needs.
Verbatim wording from the response “Suffolk Constabulary is committed to continuing to consult with partner agencies to encourage a multi-agency approach to evaluating the operability and reliability of NHS 111 Option 2 and whether improvements can be made to strengthen staff knowledge and training. It is respectfully submitted that the existing clinical pathways provide an adequate mechanism for raising mental health concerns in circumstances where statutory thresholds are not met. It is important to consider alongside this the limitations of police powers, the role of Adult Social Care and the statutory role of NSFT in dealing with adult mental health concerns across Suffolk as addressed above.” Source location Response from Suffolk Constabulary
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 Require the Contact and Control Room to confirm NHS 111 Option 2 was signposted or contacted before closing a CAD incident.
Verbatim wording from the response “Suffolk Constabulary commit to:” Source location Response from Suffolk Constabulary
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A new MASH pathway is not viable because projected referrals would impose substantial operational impact and require structural redesign.
Verbatim wording from the response “A new MASH referral pathway for adult mental health concerns is not, in our respectful submission, viable. Creating a pathway for Medium-risk adult mental health referrals falling short of section 42 of the Mental Health Act would generate an estimated 500 additional referrals per month, creating substantial operational impact across the police and Adult Social Care. This would require a structural redesign of MASH which, in our view, would not lead to improved outcomes due to adult mental health sitting wholly within the remit of NSFT as opposed to within MASH. As addressed below, NHS 111 Option 2 already exists as the appropriate clinical route for sharing concerns falling outside of the statutory framework.” Source location Response from Suffolk Constabulary
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 NSFT holds statutory and operational responsibility for adult mental health care across Suffolk, rather than MASH or the police.
Verbatim wording from the response “Your Regulation 28 Report is addressed to both Suffolk Constabulary and Suffolk County Council (Adult Social Care), however is not addressed to Norfolk and Suffolk NHS Foundation Trust (“NSFT”). It is important to note that NSFT hold both the statutory and operational responsibility for adult mental health care across Suffolk.” Source location Response from Suffolk Constabulary
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NHS 111 Option 2 clinical pathways provide an adequate mechanism for raising adult mental health concerns below statutory thresholds.
Verbatim wording from the response “Suffolk Constabulary is committed to continuing to consult with partner agencies to encourage a multi-agency approach to evaluating the operability and reliability of NHS 111 Option 2 and whether improvements can be made to strengthen staff knowledge and training. It is respectfully submitted that the existing clinical pathways provide an adequate mechanism for raising mental health concerns in circumstances where statutory thresholds are not met. It is important to consider alongside this the limitations of police powers, the role of Adult Social Care and the statutory role of NSFT in dealing with adult mental health concerns across Suffolk as addressed above.” Source location Response from Suffolk Constabulary
Open published response
30 May 2024 Katie MADDEN · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 7 Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children View source Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations View source Failure of the funding pathway to provide access to specialist psychological treatment View source Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS View source Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification View source Lack of independent Social Services support for vulnerable parents View source Lack of independent professional holistic case review for vulnerable parents View source See 4 more concerns
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
Katie MADDEN · 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
Katie Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.
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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to assess additional risks to vulnerable parents in safeguarding referrals concerning their children
Wider context from the report “4. Safeguarding referrals made the Multi-Agency Safeguarding Hub in respect of Kate’s children were viewed in isolation , with no system in place to assess any additional risks posed to Kate herself . There were no additional steps, or risk assessments undertaken in relation to Kate , even though she was a recipient of a ‘Claires Law’ Domestic Violence Disclosure and therefore known to be more vulnerable.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to provide additional support for vulnerable recipients of a ‘Claires Law’ Domestic Violence Disclosure during child-care investigations
Wider context from the report “1. No evidence was seen that recipients of a ‘Claires Law’ Domestic Violence Disclosure are treated as being of greater vulnerability, or at a higher risk, when Child Services are undertaking investigations regarding the provision of children’s care, and removal of the children from a parent is being considered . It was heard in evidence that the Social Worker appointed to this case, quite properly focused on what was in the best interest of Kate’s children. There was however no formal system in place to provide additional support for Kate herself, even though she was known to be vulnerable.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure of the funding pathway to provide access to specialist psychological treatment
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS.
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved .
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding ’. In addition, funding was very rarely made available , and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Schema-based Cognitive Behavioural Therapy on the NHS
Wider context from the report “5. In 2022 it was recognised by a Clinical Psychologist that Kate could benefit from Schema-based Cognitive Behavioural Therapy, which is not routinely available on the NHS .
The psychological review had been ordered by the Family Court, and funding for this course needed to be applied for.
Applying for funding involved requests to the Legal Aid Board, Integrated Care Board (Individual Funding Request), Wellbeing Service and Social Services, none of whom provided the funding, with each suggesting contacting one of the other agencies involved.
An experienced mental health clinician with many years’ experience described the ‘whole route as very complicated’ and ‘it was difficult to find a solution for funding’. In addition, funding was very rarely made available, and as a service they were usually unable to meet patient expectations (who believe a treatment might be made available), where in reality it almost certainly would not be available.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification
Wider context from the report “2. It was identified that when Kate was informed there may be an application to the Family Court to place her children into care (using the Public Law Outline process), the impact of such a decision on her mental health, or physical wellbeing was not taken into consideration . As a recipient of a ‘Claires Law’ Domestic Violence Disclosure, it was acknowledged that she was of greater vulnerability, but no system is currently in place which allows a risk assessment to be undertaken at the time the Public Law Outline notification is given to a parent . The day after Kate was told of the Public Law Outline notification, she had intentionally crashed her car in an unsuccessful attempt to end her life, requiring 4 weeks in an Intensive Treatment Unit to recover from the serious injuries she received.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of independent Social Services support for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services , and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities. It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of independent professional holistic case review for vulnerable parents
Wider context from the report “3. Once the Public Law Outline process was initiated, independent legal advice was provided, and a voluntary sector advocate supported Kate through the legal process. However, Katie received no independent support from Social Services, and had no independent professional to undertake a holistic review of her case, in light of her known circumstances and vulnerabilities . It was heard that mental health professionals had assumed that she had a Social Worker of her own, and expressed surprise when finding out that she did not.
” 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 Social services support and therapy-access processes are outside the Constabulary’s direct control or involvement, limiting action in response.
Verbatim wording from the response “Further, we note your concerns regarding the limited support that the deceased received from social services during this process and the difficulties in accessing recommended therapy. These are processes that the Constabulary do not have any direct control or involvement in and therefore the Constabulary is very limited in what action it can take in response to those concerns.” Source location Response from Suffolk Constabulary
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.
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AI-generated summary
Maxine Betty Davison and 4 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Suffolk Constabulary; 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 Suffolk Constabulary; 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 Suffolk Constabulary; 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
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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 Deliver externally commissioned firearms licensing training to enquiry and licensing officers over the next 12 months.
Verbatim wording from the response “The two forces recognise the need to ensure that those with delegated responsibility from the Chief Constables should be appropriately trained in the application of the Home Office Guidance on Firearms Licensing Law (Nov 22) and the Revised Statutory Guidance for Chief officers of Police (Feb 23).” Source location Response from Suffolk Constabulary
Open published response
11 May 2021 Paul Steven Reynolds · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 13 Failure to place a person subjected to prone restraint in the recovery position View source Lack of accurate and clear guidance on information to share with police View source Failure to provide or arrange additional training for security staff View source Failure to control the scene to facilitate assessment of a person’s condition View source Lack of clarity about incident command and staff responsibilities View source Failure to closely and effectively monitor breathing during prone restraint View source Failure to restrict restraint participation to appropriately badged staff View source Physical intervention policy permitting ground restraint methods not taught in accredited courses View source Reduction in time allowed for officer training View source Officers’ misunderstanding of the circumstances in which pain or pressure testing is justifiable View source Insufficient officer skills in non-physical aspects of conflict management View source Lack of consistency in the training curriculum View source Failure to document staff induction and training View source See 10 more concerns
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
Paul Steven Reynolds · 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
Paul Steven Reynolds died on 16 February 2017 after being restrained by the neck and placed in a prone position at Pontins Pakefield in Lowestoft. The principal concerns included inadequate monitoring of his breathing, failure to place him in the recovery position, insufficient staff training, unclear responsibilities, and poor sharing of information with police.
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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to place a person subjected to prone restraint in the recovery position
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of accurate and clear guidance on information to share with police
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or arrange additional training for security staff
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to control the scene to facilitate assessment of a person’s condition
Wider context from the report “(4) Officers did not control the scene by clearing the ballroom and switching off the music which would have improved their ability to assess Mr Reynolds’ condition .
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about incident command and staff responsibilities
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to closely and effectively monitor breathing during prone restraint
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict restraint participation to appropriately badged staff
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Physical intervention policy permitting ground restraint methods not taught in accredited courses
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses .
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Reduction in time allowed for officer training
Wider context from the report “(2) The time allowed for training had been reduced from 12 to 4.25 hours. Positional asphyxia training had been reinforced, but there were questions about the impact of the reduction upon officers.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Officers’ misunderstanding of the circumstances in which pain or pressure testing is justifiable
Wider context from the report “(1) Officers appeared to be under the impression that pain/pressure testing to determine whether a person was unconscious or simply asleep was an assault rather than being justifiable in certain circumstances.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Insufficient officer skills in non-physical aspects of conflict management
Wider context from the report “(3) The College of Policing and NPCC Officer and Staff safety Review made two recommendations to include revising the curriculum to ensure greater consistency, and to implement guidelines to ensure officers are sufficiently skilled in non-physical aspects of conflict management . The time scales for implementation were not stated.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of consistency in the training curriculum
Wider context from the report “(3) The College of Policing and NPCC Officer and Staff safety Review made two recommendations to include revising the curriculum to ensure greater consistency , and to implement guidelines to ensure officers are sufficiently skilled in non-physical aspects of conflict management. The time scales for implementation were not stated.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to document staff induction and training
Wider context from the report “(1) The Physical Intervention Policy August 2016 places the onus on staff to seek additional training.
(2) Pontins do not undertake any internal training or employ external trainers for security staff.
(3) Unbadged staff are allowed to participate in restraint
(4) Ground restraint remains in the PI policy as an appropriate method to contain an incident even though this is not taught in SIA accredited courses.
(5) At no point during the prone restraint was Mr Reynolds placed in the recovery position. Neither did any member of staff appear to seriously consider the potential for positional asphyxia by closely or effectively monitoring Mr Reynolds breathing.
(6) There appeared to be no clarity in the Policy about who should take charge of an incident or what the responsibilities are for security staff and Managers.
(7) There appeared to be a lack accurate information and clarity around what information should be shared with the police about the incident.
(8) There was no documented evidence of the induction or any other training for staff.
” 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 Adopt assessed, scenario-based training replicating the incident to test medical responsibilities, use of force, and scene management.
Verbatim wording from the response “It will reinforce this learning through practical based assessed scenarios, as part of the nationally revised curriculum design (see paragraph 3), that will specifically test officer’s ability to assess a person being detained and determine whether the circumstances warrant a medical intervention or the reinforcement of restraint.” Source location 2021-0151-Response-from-Suffolk-Constabulary-Redacted
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 redesigned personal safety training programme when adopted.
Verbatim wording from the response “The College of Policing is leading the redesign of the personal safety training programme and we will support the College through this period and implement the new programme upon its adoption. We understand that this new programme will come into fruition during 2022 and will be more scenario orientated. From our understanding of the programme design there will be opportunity for us to re-enact scenarios of concern and, as identified in paragraph 1, we will adopt scenario-based assessments that recreates the events of this incident. This will allow Trainers to assess officer understanding of their medical responsibilities and use of force powers.” Source location 2021-0151-Response-from-Suffolk-Constabulary-Redacted
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 acute behaviour disorder and positional asphyxia learning in Personal Safety Training through supplementary videos and Learning Management System guidance.
Verbatim wording from the response “However, we recognise that nationally there have been changes to the programme that may have created a perception of a reduction in the time assigned to positional asphyxia. The time allocated to individual areas of the curriculum are subject to change and nationally the focus of positional asphyxia has shifted towards the signals and signs of acute behaviour disorder. This is a precursor behaviour but is part of the same continuum. Material surrounding both acute behaviour disorder and positional asphyxia is delivered in accordance with national guidance and time allocations, but the Constabulary will do more to embed this learning within the wider aspects of its Personal Safety Training through supplementary videos and guidance on its Learning Management System.” Source location 2021-0151-Response-from-Suffolk-Constabulary-Redacted
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 Invest in a skills management system linking officers’ training records to the training received.
Verbatim wording from the response “In response to this learning, we have invested in a new skills management system that will make it easier for our learning and development department to track and identify officer training records as well as link these records to the training the officer received.” Source location 2021-0151-Response-from-Suffolk-Constabulary-Redacted
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 Review learning and development practices and procedures to identify records-management weaknesses and refresher-training lapses.
Verbatim wording from the response “As reflected within our evidence, the Learning and Development department did undertake a comprehensive review of its practices and procedures following this incident. We acknowledge our responsibilities as a professional organisation to learn lessons and our review identified weaknesses within our records management. This resulted in the lapses surrounding the frequency of refresher training for some of the officers involved, as shared during the inquest.” Source location 2021-0151-Response-from-Suffolk-Constabulary-Redacted
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 Enhance training and guidance on initial assessment, proportionate health checks, and use of force.
Verbatim wording from the response “The Constabulary’s involvement with Mr Reynolds stemmed from a reported incident of assault by Pontins Security Officers. Upon finding Mr Reynolds being restrained, the Constabulary training would have directed officers to assess the person being detained and review the evidence being presented. It was clear from the Inquest that the officers involved did not fulfil this assessment robustly and we acknowledge that their evidence identified confusion surrounding their police powers. The Constabulary has enhanced its training delivery and supporting guidance to clarify the importance of the initial assessment and the differences between proportionate and necessary checks of health and the application of force.” Source location 2021-0151-Response-from-Suffolk-Constabulary-Redacted
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 College of Policing leads redesign of the personal safety training programme; the Constabulary will support it and implement the adopted programme.
Verbatim wording from the response “The College of Policing is leading the redesign of the personal safety training programme and we will support the College through this period and implement the new programme upon its adoption. We understand that this new programme will come into fruition during 2022 and will be more scenario orientated. From our understanding of the programme design there will be opportunity for us to re-enact scenarios of concern and, as identified in paragraph 1, we will adopt scenario-based assessments that recreates the events of this incident. This will allow Trainers to assess officer understanding of their medical responsibilities and use of force powers.” Source location 2021-0151-Response-from-Suffolk-Constabulary-Redacted
Open published response
9 Jun 2014 Thomas Allen · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Police/local authority protocol not in force in Suffolk View source Lack of criminalisation of fly grazing in England 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 Allen · 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 Allen died from injuries sustained when five untethered horses entered the unlit A14 on Christmas Eve 2012, causing a series of collisions; he died the following day. The principal concerns were that fly grazing was a national problem, was not a criminal offence in England, and that a police/local authority protocol was not yet in force in Suffolk.
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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Police/local authority protocol not in force in Suffolk
Wider context from the report “Fly grazing is a national problem which is currently more difficult to curtail because
(1) It is not currently a criminal offence in England (although I understand that steps are being taken to remedy this in Wales)
(2) A police/local authority protocol is being worked on but not currently in force in Suffolk .
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of criminalisation of fly grazing in England
Wider context from the report “Fly grazing is a national problem which is currently more difficult to curtail because
(1) It is not currently a criminal offence in England (although I understand that steps are being taken to remedy this in Wales)
(2) A police/local authority protocol is being worked on but not currently in force in Suffolk.
” Open source report
7 Apr 2014 Jamie Raymond Barlow · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 4 Lack of clarity about the tasks requested from police assistance View source Failure to review the operating processes View source Failure to maintain effective inter-agency working View source Lack of an inter-agency protocol for jointly managing mental health assessments where risk is perceived View source See 1 more concern
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
Jamie Raymond Barlow · 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
Jamie Raymond Barlow had been receiving mental health support after concerns were raised about his wellbeing, but communication and coordination between services affected plans for a further assessment. He subsequently failed to attend a GP appointment and was found hanging near his home; concerns included better inter-agency working, clarity about police assistance, and processes for jointly managing mental health assessments where risks were perceived.
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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the tasks requested from police assistance
Wider context from the report “The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working, clarity when police assistance was sought in respect of exactly what they were being asked to do , a need to look at the processes operating here, and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to review the operating processes
Wider context from the report “The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working, clarity when police assistance was sought in respect of exactly what they were being asked to do, a need to look at the processes operating here , and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective inter-agency working
Wider context from the report “The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working , clarity when police assistance was sought in respect of exactly what they were being asked to do, a need to look at the processes operating here, and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public.
” 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 Suffolk Constabulary; that does not assign responsibility.
PFD Monitor interpretation Lack of an inter-agency protocol for jointly managing mental health assessments where risk is perceived
Wider context from the report “The significant extent of the post mortem changes to the body were such that it could not be established that a visit at the time requested would have avoided the tragic outcome in this particular instance but, although the inquest heard of some changes that had been made since the death, it was clear that there needed to be better inter-agency working, clarity when police assistance was sought in respect of exactly what they were being asked to do, a need to look at the processes operating here, and consideration of an inter-agency protocol for jointly managing the mental health assessment of patients who require such assessments but where there is a perception of risk to mental health professionals or members of the public .
” 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