10 Jun 2025 Amy Anne Levy · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of general guidance on when to leave voicemail messages in non-domestic-abuse cases View source Unclear applicability of voicemail guidance to police officers and control-room staff View source
Responses linked to these concerns
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AI-generated summary
Amy Anne Levy · 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
Amy Anne Levy, a 22-year-old student, took an overdose of prescription drugs on 18 June 2023 and later died in hospital on 22 June 2023. Police and ambulance services did not know her address for over two hours despite knowing that her condition was deteriorating and that the case required an immediate response. The principal concern was that police officers and call handlers did not leave voicemail messages when attempting to contact her parents, potentially delaying the discovery of her location; the inquest jury identified a catalogue of missed opportunities to obtain her correct address.
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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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of general guidance on when to leave voicemail messages in non-domestic-abuse cases
Wider context from the report “As I have outlined above, this was an ‘immediate’ priority search to obtain the address of a young woman who whose life was believed to be at risk.
It is hard to understand the decision (made by more than one police caller) not to leave any voicemail/message.
We heard evidence from two police Inspectors (one from Avon and Somerset Constabulary and one from Surrey Police) that although there is guidance in Avon not to leave voicemails when the incident in question concerns domestic abuse, there is no general guidance about when to leave a voicemail message in other cases (ie, it is neither encouraged not discouraged by any policy or standard operating procedure) .
I was subsequently provided with an updated ‘Deployment of Resources Procedure’ from Surrey Police, which indicates that ‘call takers and dispatchers must consider whether it is appropriate to leave a voicemail, unless there is a compelling operational reason not to do so’. It is not clear from the title of the document or the wording of the guidance whether this is intended to affect police officers, or only the actions of those in Surrey’s contact centre and force control room.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Unclear applicability of voicemail guidance to police officers and control-room staff
Wider context from the report “As I have outlined above, this was an ‘immediate’ priority search to obtain the address of a young woman who whose life was believed to be at risk.
It is hard to understand the decision (made by more than one police caller) not to leave any voicemail/message.
We heard evidence from two police Inspectors (one from Avon and Somerset Constabulary and one from Surrey Police) that although there is guidance in Avon not to leave voicemails when the incident in question concerns domestic abuse, there is no general guidance about when to leave a voicemail message in other cases (ie, it is neither encouraged not discouraged by any policy or standard operating procedure).
I was subsequently provided with an updated ‘Deployment of Resources Procedure’ from Surrey Police, which indicates that ‘call takers and dispatchers must consider whether it is appropriate to leave a voicemail, unless there is a compelling operational reason not to do so’. It is not clear from the title of the document or the wording of the guidance whether this is intended to affect police officers, or only the actions of those in Surrey’s contact centre and force control room .
” 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 Update the Deployment of Resources Procedure with force-wide voicemail guidance, safeguards, rationale recording, and contact-attempt requirements.
Verbatim wording from the response “5. Action Taken by Surrey Police: Policy Update” Source location Response from Surrey Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed voicemail guidance in the Initial Development Programme for Force Command Centre contact and dispatch staff.
Verbatim wording from the response “5.6 Learning and Professional Development is now incorporating this updated guidance into multiple training pathways. Specifically:” Source location Response from Surrey Police
Open published response
18 Sep 2024 Helen Jane Kerr · Prevention of Future Deaths report Surrey
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Concerns raised 6 Failure to access relevant police records during assessment View source Failure to inform refuge workers of a relevant police presentation View source Lack of evidenced efficacy of implemented changes View source Failure to appropriately assess declining mental health information and provide timely mental health referrals View source Lack of timely out-of-hours information sharing between police, mental health agencies and adult safeguarding View source Failure to assess and act on risk to the public View source See 3 more concerns
Responses linked to these concerns
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AI-generated summary
Helen Jane Kerr · 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
Helen Jane Kerr had a history of drug and alcohol abuse, developed psychosis, and died by hanging after being found dead at a refuge on 3 April 2023. The report identified concerns about failures to respond appropriately and promptly to information about her deteriorating mental health, inadequate assessment and treatment, limited out-of-hours information sharing, and failure to inform the refuge about risks associated with her presentation.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to access relevant police records during assessment
Wider context from the report “(2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform refuge workers of a relevant police presentation
Wider context from the report “(4) The refuge was not made aware of Ms Kerr’s presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of evidenced efficacy of implemented changes
Wider context from the report “(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment.
Despite the evident significant changes are being put in place the efficacy of these changes has not yet been evidenced .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately assess declining mental health information and provide timely mental health referrals
Wider context from the report “(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment.
Despite the evident significant changes are being put in place the efficacy of these changes has not yet been evidenced.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of timely out-of-hours information sharing between police, mental health agencies and adult safeguarding
Wider context from the report “(3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and act on risk to the public
Wider context from the report “(2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk.
” 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 Remind response officers to undertake timely research, using the Force Control Room when necessary, through force emails and daily briefings.
Verbatim wording from the response “As a point of learning, all officers are being reminded to ensure that research is undertaken as soon as practicable when dealing with members of the public, including asking the Force Control Room to do so on their behalf when it is impracticable to do so themselves. In this instance, by asking the Force Control Room, this would have enabled an alternative Surrey Police employee to assess previous information held on Surrey Police systems whilst they were engaging with Ms Kerr. This message will be conveyed by force emails and a reminder on the daily briefing to response officers. We fully accept that this research should have been conducted in order to inform the officer’s decision making.” Source location Response from Surrey Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adult Social Care is responsible for facilitating any appropriate onward information sharing with the refuge after multi-agency assessment.
Verbatim wording from the response “Information sharing protocols are in place with statutory partners. The refuge is not a statutory partner, so with regard to the sharing of SCARF, there would be no existing process that would include them in Surrey Police’s safeguarding information sharing protocols. Adult Social Care would be responsible and facilitate any onward information sharing if appropriate, based on a multi-agency assessment.” Source location Response from Surrey Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There was no information at the time indicating that Ms Kerr posed a risk to herself or the public.
Verbatim wording from the response “Although Ms Kerr did previously carry a nail file for her own protection, the officer would have required grounds to search Ms Kerr. Although some forces are operating a pilot allowing them to search a person with a previous conviction of a weapons offence, who has a court order made against them upon conviction, Surrey is not a pilot force, and Ms Kerr was in any case highly unlikely to have met the required threshold for such an order. Therefore, an officer would rely on the powers conveyed in Section 1 of the Police and Criminal Evidence Act to conduct a search in order to do so, they would need to have reasonable grounds to suspect that they will find something prohibited (i.e. a weapon). At the relevant time, the officer did not have this suspicion. There was no information at the time to suggest Ms Kerr was a risk to either herself or the public at large.” Source location Response from Surrey Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing emergency communication routes provide sufficient means to share information and formulate safety plans for imminent out-of-hours risks.
Verbatim wording from the response “There are numerous things that officers can do in terms of informing our partners about more imminent risk. The primary one is the Emergency Duty Team (EDT) – this process is long established for response officers. This is person-to-person communication between agencies, where agreements can be made and issues escalated. Likewise, there are other methods, such as the professionals / crisis line / Accident and Emergency departments etc. All of these are 24/7 where ‘real time’ concerns can be discussed and safety plans formulated.” Source location Response from Surrey Police
Open published response
8 Aug 2024 Emma Pattison and 2 others · Prevention of Future Deaths report Surrey
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Concerns raised 2 Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour View source Failure to ensure full disclosure of shotgun certificate applicants’ medical history 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
Emma Pattison 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
Between 22:49 on 4 February 2023 and 00:40 on 5 February 2023, George Pattison shot and killed his wife, Emma Pattison, and daughter, Ellette Pattison, before shooting himself. The report raises concerns about online medical consultations potentially bypassing disclosure safeguards for shotgun licensing and about obtaining full information concerning coercive controlling behaviour.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure full and accurate disclosure of shotgun certificate applicants’ history of coercive controlling behaviour
Wider context from the report “3. Consideration should be given as to how a licensing authority can obtain full and accurate disclosure of an applicant’s history of coercive controlling behaviour towards another / others .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure full disclosure of shotgun certificate applicants’ medical history
Wider context from the report “1. An applicant for a shotgun certificate is able to obtain medication from an on-line doctor without the knowledge of their GP , giving rise to a risk that a licensing authority might grant a shotgun certificate to an applicant who has a relevant previous medical history about which the authority is not aware .
2. In consulting an on-line doctor, it is possible for an applicant for a shotgun certificate to avoid the current safeguards relating to full disclosure of their previous and current medical history .
” 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 Consult the College of Policing and NPCC lead about adding certificate conditions reminding holders to report changes in domestic and health circumstances.
Verbatim wording from the response “Surrey Police licensing officers take a negative view of applicants who fail to disclose relevant information. However, there seems to be little within legislation to require a holder to disclose a change in personal circumstances during each 5-year period. Therefore, I am consulting with the College of Policing and the NPCC lead on the potential to add a condition to holder certificates, reminding them of their obligations to inform the police of any changes in domestic and health situation. I believe this would allow more robust oversight between renewals.” Source location Response from Surrey Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require Firearms Enquiry Officers to ask applicants about medical treatment obtained outside their GP practice.
Verbatim wording from the response “I share your concern that any certificate holder or applicant can, it would appear, hide certain medical treatment by using an online facility. The national application form asks, “Are there any periods in the past 10 years when you have not been registered with a UK GP or have consulted medical practitioners other than at your GP practice?” In this case, Mr Pattison answered “no” in both his 2016 and 2022 renewals. Surrey Police acknowledge that, although the force re-asks all other questions on the medical form during the Firearms Enquiry Officer (FEO) visit, Surrey Police did not ask about the use of other medical services in this visit. Surrey Police has, because of this case, revised our practice, and FEOs now do cover this in their visits to try and elicit the information from an applicant.” Source location Response from Surrey Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police currently have no method to detect whether firearms applicants withhold information about medical treatment.
Verbatim wording from the response “Surrey Police acknowledges that an applicant could still withhold this information, and there is currently no method for the police to find out if it is being so withheld.” Source location Response from Surrey Police
Open published response
23 Jul 2024 Neil Woodley · Prevention of Future Deaths report South London
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Concerns raised 1 Failures in communication during welfare-check responses 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
Neil Woodley · 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
Neil Woodley was found ████████ at 7.25 am on 4 January 2024, and evidence from suicide notes suggested that he had killed himself overnight. A colleague called the police because he had not arrived at work, but an ambulance attended the following day after an alleged communication failure between Surrey Police and the Metropolitan Police. The concern was that failures in communication could result in avoidable fatalities in future cases, although the report states that earlier attendance would not have affected this outcome.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failures in communication during welfare-check responses
Wider context from the report “Mr Woodley’s brother and sister-in-law gave evidence at the hearing that a colleague of Mr Woodley called the police on the morning of 4 January concerned that he had not arrived at work. Their evidence was that an ambulance arrived to carry out a welfare check the following day (5 January) at around 1pm. They were told that the reason for the delay was confusion between Surrey Police and the Metropolitan Police .
On the evidence before me, including that of Mr Woodley and his wife, I am satisfied that an earlier attendance would not have affected the outcome. However, I am concerned that failures in communication could result in avoidable fatalities in future cases .
” 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 Existing procedures for transferring calls to other police forces were followed appropriately and ensured timely information transfer.
Verbatim wording from the response “Having carefully considered the records relating to both calls, it is evident that they were handled correctly and were promptly passed to the MPS to manage. The policies and procedures that Surrey Police have in place to ensure the smooth transfer of calls to other police forces were followed appropriately. All relevant information was passed to the MPS in a timely manner and the informants were made aware of the transfer to the MPS to allow them to take appropriate action.” Source location Response from Surrey Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The records do not show a communication failure between Surrey Police and the Metropolitan Police Service; both calls were handled correctly.
Verbatim wording from the response “Having carefully considered the records relating to both calls, it is evident that they were handled correctly and were promptly passed to the MPS to manage. The policies and procedures that Surrey Police have in place to ensure the smooth transfer of calls to other police forces were followed appropriately. All relevant information was passed to the MPS in a timely manner and the informants were made aware of the transfer to the MPS to allow them to take appropriate action.” Source location Response from Surrey Police
Open published response
22 Dec 2023 Barbara Ann WOODMAN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 8 Inaccessibility of primary care records to secondary mental health services View source Delays in considering SCARF information View source Failure to communicate relevant SCARF information to family View source Failure of the out-of-hours SCARF process to provide timely effective information transfer View source Failure to produce a clear holistic care and crisis contingency plan View source Lack of a unified record-keeping system for sharing patient information View source Breakdowns in communication between inpatient staff and the CMHT View source Failure to gather relevant collateral history while respecting patient confidentiality View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Barbara Ann WOODMAN · 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
Barbara Ann WOODMAN was found deceased at her residence on 31 March 2021 after police attended following concerns for her welfare. The post-mortem determined that she died from Paracetamol, Codeine and Amlodipine toxicity, having also consumed alcohol. Concerns included missed opportunities to obtain collateral information, the handling of a risk form, care planning and record-keeping, communication between inpatient and community teams, and information-sharing systems.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Inaccessibility of primary care records to secondary mental health services
Wider context from the report “ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission.
It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████.
The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services . This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Delays in considering SCARF information
Wider context from the report “b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant SCARF information to family
Wider context from the report “b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur . The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the out-of-hours SCARF process to provide timely effective information transfer
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians.
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to produce a clear holistic care and crisis contingency plan
Wider context from the report “c. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community . Although not causative of the death and I noted ████████’s very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a unified record-keeping system for sharing patient information
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS , including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians .
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Breakdowns in communication between inpatient staff and the CMHT
Wider context from the report “d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP .
There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians.
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to gather relevant collateral history while respecting patient confidentiality
Wider context from the report “ a. ████████ evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions ████████ spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact ████████ concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ████████; Ms. Woodman’s partner and who knew her well in the lead up to her admission.
It would seem that staff speaking with ████████ on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with ████████ .
The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself.
” Open source report
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 Surrey 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 Surrey 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 Surrey 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 Support development of the national Firearms Enquiry Officer curriculum and learning outcomes with the NPCC lead and College of Policing.
Verbatim wording from the response “Surrey Police have been supporting the national NPCC lead and the College of Policing over the past 12 months in developing a national curriculum and learning outcomes for Firearms Enquiry Officers. The intention is that the training will be delivered this year, which will be aligned with quality assurance and mandatory professional development. Surrey Police FELU will be active participants at the two day CPD event hosted by the College of Policing in May 2023. This will enable critical learning from the detailed de-brief of the lessons from the Keyham Shootings Inquests and the new Home Office Statutory Guidance.” Source location Response from Surrey 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 Maintain trained delegated-authority reviewers across senior ranks and provide additional senior oversight capacity for returning certificates and weapons after revocation decisions.
Verbatim wording from the response “There are seven staff trained across different senior ranks and roles who are authorised to carry out delegated authorities - the review function within the FELU. All have received training and have relevant experience to perform this role within the department. All have delegated authority for the force and complete regular professional development. The” Source location Response from Surrey Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing training arrangements are considered appropriate and proportionate to staff roles.
Verbatim wording from the response “I am satisfied that based on the information available to me, that all staff have received and will be continuing to receive appropriate training, proportionate to their respective roles within the Surrey Police FELU.” Source location Response from Surrey Police
Open published response
14 Mar 2022 Aliny Godinho · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Lack of accessible cultural risk information for domestic abuse risk assessment View source Lack of systematic monitoring and auditing of domestic abuse investigations View source Lack of call-handler training on managing reports relating to ongoing domestic abuse investigations View source Failure of the Officer in the Case to complete required DASH risk assessment and DA Matters training View source Lack of effective training on the Domestic Abuse Policy and Procedure View source Lack of timely effective supervision of domestic abuse investigations 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
Aliny Godinho · 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 8 February 2019, Aliny Godinho was attacked and repeatedly stabbed in Ewell, Surrey, and died at the scene despite emergency medical attention. The report states that Surrey Police’s handling of earlier and same-day domestic abuse reports included failures in risk assessment, safeguarding, investigation, supervision, monitoring, call-centre handling and consideration of cultural risk; the inquest found that her death was probably more than minimally contributed to by Surrey 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible cultural risk information for domestic abuse risk assessment
Wider context from the report “CONCERN 6
Cultural Risk: I found that there was a failure to take account of the risk arising from the fact that the perpetrator was from Brazil , where there is a considerably higher incidence of domestic homicide than in the United Kingdom. I was told that no national source of information concerning such cultural risks exists for the benefit of officers investigating domestic abuse who are required to assess and manage the risks arising. Although steps are being taken in Surrey to build knowledge of relevant cultural norms for local communities, I was told that a national data base of relevant and evidenced cultural information, whether based on statistical incidence of domestic violence or homicide, or otherwise, would assist in ensuring cultural risk is not overlooked .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of systematic monitoring and auditing of domestic abuse investigations
Wider context from the report “CONCERN 4
Monitoring and Auditing: I was told that there is no system in place to monitor and audit the performance and effectiveness of the Domestic Abuse Team . Data from the “PowerBI” system is used to monitor matters such as case load, but there is no systematic monitoring or auditing (whether by use of Key Performance Indicators or otherwise) of the conduct of the investigations , including (for example) whether and when safeguarding and investigation plans have been made and implemented.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of call-handler training on managing reports relating to ongoing domestic abuse investigations
Wider context from the report “CONCERN 5
Call Centre Training: The evidence at the inquest revealed that, on three occasions, reports made to Surrey Police concerning the perpetrator’s conduct were incorrectly passed to the Metropolitan Police, and without sufficient information first being adduced and risk assessed. I found that, on the third occasion in particular, the error contributed to Aliny Godinho’s death. I was told by the Contact Centre Performance Manager for Surrey Police that these errors had not been appreciated until the inquest hearing and that there were important lessons to be learned concerning the proper management by the Call Centre of reports relating to an ongoing Surrey domestic abuse investigation, when the victim is currently living outside Surrey. It was acknowledged that training for call handlers in respect of this learning is required but has not yet been provided .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the Officer in the Case to complete required DASH risk assessment and DA Matters training
Wider context from the report “CONCERN 2
Training of DC ████████: I found that failures by the Officer in the Case, to implement the Domestic Abuse Policy and Procedure in relation to the investigation of Aliny Godinho’s complaint, contributed to the death. The outcome of the officer’s misconduct meeting was a requirement for her to undertake DASH risk assessment and “DA Matters” training by March 2021. The officer is currently working in Surrey Police’s Domestic Abuse Team but has not yet undertaken the required training and I consider this presents an ongoing risk .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of effective training on the Domestic Abuse Policy and Procedure
Wider context from the report “CONCERN 1
Training of the Domestic Abuse Team: At the inquest I heard that, at the time of the death, not all members of the Surrey Police SIU were familiar with and were implementing the contents of its Domestic Abuse Policy and Procedure ; this led directly to a number of the failings which, I found, contributed to Aliny Godinho’s death.
I have been told that all members of its new Domestic Abuse Team have been required to read its amended Domestic Abuse Policy and Procedure, but that training on the same, which is still being written, has not yet been delivered . I am concerned that unless and until effective training is delivered, a risk will continue .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of timely effective supervision of domestic abuse investigations
Wider context from the report “CONCERN 3
Supervision of the Domestic Abuse Team: I found that Aliny Godinho’s death was contributed to not only by the failures of the Officer in the Case, but also by those of her supervising sergeant. At that time, there was an expectation that the sergeant would ensure that safeguarding and investigation plans were in place and were implemented, but there was no system in place to ensure that happened and, in relation to the investigation of Aliny Godinho’s complaint, it did not happen.
There continues to be no system in place to ensure, through supervision, that the steps which the Officer in the Case must take from the start of the investigation, including in relation to the initial risk assessment and the setting of safeguarding and investigation plans, have been taken in a timely manner . I was told that a supervisory review every 28 days is now included on “niche” as a task for the sergeant but, in my view, this will not ensure that there is effective supervision at any earlier stage of the investigation .
” Open source report
9 Nov 2020 Name not published · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to inform the general practitioner of children’s removal and care proceedings View source Failure to involve general practitioners in MARAC meetings View source Failure to inform the treating general practitioner of domestic abuse and coercion allegations View source Failure to communicate MARAC-identified risks and planned safeguarding measures to general practitioners 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
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 died at home on 29 November 2017 after consuming considerable amounts of alcohol and cocaine and hanging herself with a ligature. Concerns included limited communication between the MARAC process and her general practitioner about domestic abuse risks and safeguarding measures, and the GP not being informed about her children being removed from her care and subsequent care proceedings, or the associated mental health stressors.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the general practitioner of children’s removal and care proceedings
Wider context from the report “6. ████████ children were removed from her care in ████████ and she was then involved in care proceedings. Her general practitioner was not made aware of this although it would have been a further significant stressor so far as her mental health was concerned .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to involve general practitioners in MARAC meetings
Wider context from the report “3. ████████ general practitioner was not invited to contribute to the MARAC meetings held in July and August 2017 . General Practitioners are not routinely invited to MARAC meetings .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the treating general practitioner of domestic abuse and coercion allegations
Wider context from the report “5. The general practitioner responsible for treating ████████ mental health was not made aware of the allegations of domestic abuse and coercion that ████████ had made.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate MARAC-identified risks and planned safeguarding measures to general practitioners
Wider context from the report “4. The risks and the planned safeguarding measures identified by the MARAC were not communicated to the general practitioner .
” Open source report
30 Mar 2020 KAREN JANE BINGHAM · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Insufficient understanding between police and ambulance dispatch functions of each other’s triaging, dispatching processes and response times View source Failure of police mental health training to provide information about behaviours associated with common mental health conditions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
KAREN JANE BINGHAM · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Karen died by hanging at her home on 18 November 2017 after contacting police and ambulance services. The jury identified concerns about the safeguarding plan used when she was informed that her perjury allegation was being filed, including insufficient information gathering, failure to involve mental health services, and inadequate multi-agency planning. The report also identified concerns about police mental health training and the understanding between police and ambulance services of each other’s triage and dispatch processes.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding between police and ambulance dispatch functions of each other’s triaging, dispatching processes and response times
Wider context from the report “2. Those responsible for the dispatch of emergency services in the police and ambulance services do not have a sufficient understanding of the triaging and dispatching processes used by each other’s service nor their response times .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure of police mental health training to provide information about behaviours associated with common mental health conditions
Wider context from the report “1. Police training in respect of mental health does not provide information as to the type of behaviours associated with common mental health conditions.
” 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 Mandate the revised online Mental Health training package for all officers and staff, including recognition of common behaviours.
Verbatim wording from the response “There is a revised online Mental Health training package which is to be mandated for all officers and staff to refresh their knowledge and skills in this area, including recognising common behaviours in those with mental health conditions. This will feature an input from SECambs Clinical Operations Manager on NHS Pathways and response times. This will also be supplemented by training input at officers’ annual officer safety refresher training during the autumn.” Source location 2020-0081-Response-from-Chief-Constable-of-Surrey-Police_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 Deliver a one-day common-mental-health-conditions training session to all Contact Centre staff.
Verbatim wording from the response “The Contact Centre (where all 101 and 99 calls into Force are received) are including a one day training session for all of their staff on common mental health conditions later in 2020 to help those dealing with the public over the telephone recognise signs and symptoms.” Source location 2020-0081-Response-from-Chief-Constable-of-Surrey-Police_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 Add NHS Pathways and response-time input from SECambs Clinical Operations to the online Mental Health training package.
Verbatim wording from the response “There is a revised online Mental Health training package which is to be mandated for all officers and staff to refresh their knowledge and skills in this area, including recognising common behaviours in those with mental health conditions. This will feature an input from SECambs Clinical Operations Manager on NHS Pathways and response times. This will also be supplemented by training input at officers’ annual officer safety refresher training during the autumn.” Source location 2020-0081-Response-from-Chief-Constable-of-Surrey-Police_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 Train Contact Centre and Force Control Room staff on NHS Pathways, ambulance response categories, response times and surge arrangements.
Verbatim wording from the response “2. In the summer and autumn of 2018 (since Karen’s death) all staff from the Contact Centre and Force Control Room (resource dispatch) received training from South East Coast Ambulance (SECambs). This included input on NHS Pathways (as described during the inquest), Ambulance Response Programme (categories of response and associated time frames) and their Operational Business Plan Surge (which protects calls with the highest clinical need where there is excess demand).” Source location 2020-0081-Response-from-Chief-Constable-of-Surrey-Police_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 Conduct staff exchanges between Surrey Police and SECambs contact and dispatch functions.
Verbatim wording from the response “To supplement the training a number of staff “exchanges” between Surrey Police and SECambs to gain a better understanding of the roles of their respective contact and dispatch functions.” Source location 2020-0081-Response-from-Chief-Constable-of-Surrey-Police_Redacted
Open published response
15 Jul 2019 Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Absence of a system providing firearms licensing departments with current medical fitness information View source Lack of skills and training for Firearms Enquiry Officers assessing applicants’ medical fitness View source Lack of mandatory comprehensive training for new Firearms Enquiry Officers View source Insufficient gathering of applicants’ relevant medical information before firearms certification decisions 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
Christine Ann Lee and Lucy Daisy Lee · 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
Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The jury found that failures in Surrey Police’s firearms licensing decisions contributed more than minimally to the deaths. The report also raised concerns about insufficient mandatory training for firearms licensing officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Absence of a system providing firearms licensing departments with current medical fitness information
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application .
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm . These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of skills and training for Firearms Enquiry Officers assessing applicants’ medical fitness
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably . I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation .
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory comprehensive training for new Firearms Enquiry Officers
Wider context from the report “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”) . I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete.
Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so.
I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role, in the form of the South Yorkshire Training Course or equivalent , will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient gathering of applicants’ relevant medical information before firearms certification decisions
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant , and the lack of clarity as to what medical conditions may be relevant and must be disclosed , together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness .
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system: 1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report
15 Jul 2019 Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Absence of mandatory comprehensive training for Firearms Enquiry Officers View source Lack of relevant training and competence among Firearms Enquiry Officers assessing medical fitness View source Absence of ongoing notification of relevant medical changes during firearms certificate validity View source Insufficient medical-condition disclosure and evidence gathering before firearms licensing decisions View source Absence of a required current GP medical report before firearms certificate applications View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Christine Ann Lee and Lucy Daisy Lee · 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
Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The report identified failures by Surrey Police firearms licensing staff to sufficiently investigate and consider relevant information, apply the correct standard of proof, and ensure appropriate senior oversight before returning the perpetrator’s shotgun certificate and shotguns. It also raised concerns about insufficient mandatory training for firearms enquiry officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Absence of mandatory comprehensive training for Firearms Enquiry Officers
Wider context from the report “It was apparent from the evidence that, at the time of the deaths, there was no national training course for staff working in police firearms licensing departments as Firearms Enquiry Officers (“FEOs”) . I was told that work is now being undertaken by the College of Policing to produce an accreditation process for FEOs, but that this work is not yet complete.
Currently, what is known as “the South Yorkshire Training Course” is available. This is a five day, residential course which appears to be comprehensive. I was told that all Surrey Police’s current FEOs have completed the South Yorkshire Training Course, but that it is not mandatory for them to do so .
I am concerned that, pending the introduction of a full accreditation scheme, the absence of a mandatory requirement for all new FEOs (whether in Surrey or elsewhere) to undertake comprehensive training for the role , in the form of the South Yorkshire Training Course or equivalent, will result in the risk of insufficient training, incorrect decision making concerning certification and, consequently, 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of relevant training and competence among Firearms Enquiry Officers assessing medical fitness
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably . I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation .
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Absence of ongoing notification of relevant medical changes during firearms certificate validity
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes .”
I understand that this recommendation has not been implemented . This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient medical-condition disclosure and evidence gathering before firearms licensing decisions
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant , and the lack of clarity as to what medical conditions may be relevant and must be disclosed , together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness .
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP, obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate, and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented. This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Absence of a required current GP medical report before firearms certificate applications
Wider context from the report “It was apparent from the evidence that, prior to the deaths of Christine and Lucy Lee, (i) the perpetrator had failed to declare medical conditions from which he was suffering on his most recent application to renew his shotgun certificate and (ii) following a concern being raised that he may be suffering from Alzheimer’s Disease, Surrey FEOs had been required to visit the perpetrator in order to assess whether he was suffering from that condition, but that they had not had the skills or training to enable them to do so reliably.
I also heard further evidence concerning the system currently in place for assessing the medical fitness of an applicant to hold a shotgun certificate. It was clear that there are two areas of concern arising in relation to the current system.
First, whereas an applicant for a shotgun certificate was previously required to declare any medical condition, the most recent Home Office Guide on Firearms Licensing Law, being that of 2016, suggests that an applicant should be asked to declare only certain identified conditions, as well as “any other relevant condition”. No guidance is given to applicants as to what medical conditions may or may not be relevant to the safe holding of a certificate. Currently, Surrey Police (and, no doubt, other Forces) use an application form which reflects this guidance. In my view, the fact that the responsibility for disclosure is placed entirely on the applicant, and the lack of clarity as to what medical conditions may be relevant and must be disclosed, together raise a very real risk of insufficient evidence gathering prior to a decision being made as to the applicant’s fitness.
Secondly, I was shown a document containing a list of medical conditions which, I was told, is currently provided to Surrey FEOs as they may be expected to assess whether an applicant is suffering from a condition on the list and, if so, its severity. I was told that the FEOs may then be expected to judge whether a certificate may be granted without more, or whether a referral to a General Practitioner (or other clinician) should be made for further assessment. The list of medical conditions is substantial and wide-ranging, and included not only physical conditions but also mental health and other complex matters such as (to give two examples only) autism and post-natal depression. It seems that this approach is actively encouraged by the 2016 Home Office Guide (at paragraph 10.25) which indicates that FEOs may make judgements on medical matters “based on their own knowledge and experience”. However, Surrey FEOs are provided with no relevant training and, in my view, are almost certainly without the necessary skills, knowledge or experience to perform such assessments safely, effectively and reliably. I was told that the document containing the list of medical conditions, and the system for assessing applicants, is in use in other police forces also. In the circumstances, I am concerned that in Surrey, and elsewhere, a fundamentally unreliable system for assessing medical fitness to hold a shotgun certificate is in operation.
Taking these two concerns together, in my view there is currently a risk of future deaths in Surrey and elsewhere resulting from the absence of a system to ensure that, before a decision is made on the application, the FLD is fully aware of (i) all medical conditions from which an applicant is suffering and (ii) the relevance of each medical condition to the application.
In this regard, my attention was drawn to the fact that in September 2015 Her Majesty’s Inspectorate of Constabulary published a report entitled “Targeting the risk : An inspection of the efficiency and effectiveness of firearms licensing in police forces in England and Wales”. In that report HMIC highlighted the same concern, namely that “police forces are expected to make licensing decisions without confirmation that the applicant is medically fit to possess a firearm. These unsatisfactory arrangements leave fundamental gaps in the establishment of a safe and effective firearms licensing system in England and Wales.”
In its report HMIC recommended (at recommendation 11) that, “Immediately, and with a view to implementation within 18 months, the Home Office should ensure that the current proposals for the sharing of medical information between medical professionals and the police for the purpose of firearms licensing, allow the police effectively to discharge their duty to assess the medical suitability of an applicant for a section 1 firearms or shotgun certificate. This should have due regard to ensuring the system:
1. Does not allow licensing to take place without a current medical report from the applicant’s GP , obtained and paid for by the applicant in advance of an application for the granting or renewal of a certificate , and which meets requirements prescribed by law; and 2. Is supported by a process whereby GPs are required, during the currency of a certificate, to notify the police of any changes to the medical circumstances (including mental health) of the certificate holder which are relevant to the police assessment of suitability for such a certificate, and within which the certificate holder is statutorily required to notify the police of any such changes.”
I understand that this recommendation has not been implemented . This is of concern because, in my view, the ongoing absence of a system such as that recommended by HMIC does create a risk of future deaths for the reasons given above.
” Open source report
31 May 2019 Joshua Oliver Maxwell Blackham · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 6 Use of Welfare Officers with line-management responsibilities instead of a specialised Welfare Officer cadre View source Insufficient training for Welfare Officers and their supervisors View source Lack of written policies defining the Welfare Officer role View source Ineffective communication of concerns between PSD and the Welfare Officer View source Lack of a written policy governing the location of arrest of a serving officer View source Unavailability of Welfare Officer contact when the primary Welfare Officer is off duty 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
Joshua Oliver Maxwell Blackham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joshua Blackham, a 30-year-old police officer, was found hanged on 29 November 2016 after his suspension from duty and amid increasing personal pressures, including relationship breakdown, financial concerns and concerns about contact with his daughter. The report raised concerns about inadequate welfare-officer training, insufficient information sharing, lack of arrangements for welfare contact when the officer was unavailable, and shortcomings in the NHS mental-health support for which Joshua had been referred.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Use of Welfare Officers with line-management responsibilities instead of a specialised Welfare Officer cadre
Wider context from the report “2. It was suggested in evidence that a cadre of specialised Welfare Officers would be more effective than appointing individual officers with line management responsibilities . The advantages of this arrangement will be that the specialised skills would be held within that cadre , and that an individual officer who has been suspended from duty may feel reluctant to discuss personal matters with a senior officer in his/her own management line . I consider this suggestion should be considered by Surrey Police.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient training for Welfare Officers and their supervisors
Wider context from the report “1. Training – for Welfare Officers and those who supervise them .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of written policies defining the Welfare Officer role
Wider context from the report “There remain, however, a number of areas where there are no written policies in place in relation to the role of a Welfare Officer . I remain concerned that, given that Joshua died in 2016 and these policies are not yet in place, the impetus could be lost after the inquest.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication of concerns between PSD and the Welfare Officer
Wider context from the report “3. Consideration should be given as to how communication of concerns between PSD and the Welfare Officer can take place more effectively .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a written policy governing the location of arrest of a serving officer
Wider context from the report “6. There should be a written policy as to the location of the arrest of a serving officer , so as to reduce the impact of this on his/her welfare.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Welfare Officer contact when the primary Welfare Officer is off duty
Wider context from the report “5. Any new arrangement should make allowances for contact with a Welfare Officer where the primary Welfare Officer is off duty .
” 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 Include welfare considerations concerning the arrest location of serving officers in the relevant Professional Standards Department guidance policy.
Verbatim wording from the response “6. Consideration about the location of the arrest of a serving officer so as to reduce the impact on his/her welfare has been included within the relevant PSD guidance policy.” Source location 2019-0182-Response-by-Surrey-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 Develop and implement a Welfare Officer training and revised guidance package, including an explanatory video and risk-assessment oversight guidance.
Verbatim wording from the response “1. The Force has agreed to provide training and refreshed guidance for any officer/staff member who is assigned as Welfare Officer (previously referred to as Wellbeing and Support Officers). Surrey Police’s Learning and Development Department are in the process of creating a short video which will fully explain the Welfare Officer (WO) role which all WOs, on being assigned the role, will watch as part of a full guidance package. This package will include revised Welfare Officer Guidance documentation. This is anticipated to be finalised by the end of August 2019 with all Senior Management Teams across the Force being briefed from September 2019.” Source location 2019-0182-Response-by-Surrey-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 secondary Welfare Officer cover for absences and list relevant support contacts at the front of each Duty of Care Risk Assessment.
Verbatim wording from the response “5. Having a secondary (back up) WO who has been included in the revised process to ensure that there is suitable cover for annual leave or other absence. Contact details of all relevant persons supporting the particular officer/staff member will be listed at the front of the DOCRA.” Source location 2019-0182-Response-by-Surrey-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 Ensure Welfare Officers directly contact relevant parties and share available concerns in risk assessments, documenting justified exceptions and providing a reference flowchart.
Verbatim wording from the response “3. As to ensuring that all concerns about a person held by PSD, Federation, Unison or otherwise are available to the WO in completing their risk assessment, the new process will ensure that the DOCRA is completed having directly contacted all relevant parties. The default position will be that all information will be shared unless there is a specific reason not to do so which should be recorded with suitable justification. This way no relevant information is invisible to the WO. The new guidance is also accompanied by a simple visual flowchart for WOs as a reference document.” Source location 2019-0182-Response-by-Surrey-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A specialised Welfare Officer cadre will not be pursued because training, revised guidance and managerial oversight are considered sufficient and more practical.
Verbatim wording from the response “2. A cadre of specialised WOs has been considered in more detail by the Force since the inquest but the Force has made the decision not to pursue this on the grounds that it is not practical and may not be in the person’s best interest. Having a cadre limits the number of people undertaking the role and it is also important that the person involved has a say in who their WO is, which may not include anyone within a cadre. The Force felt that the selection of a WO should be considered by the relevant SMT for the area/department where the person works and that with the introduction of training, revised guidance and managerial oversight a cadre of specialists was not necessary.” Source location 2019-0182-Response-by-Surrey-Police
Open published response
23 May 2019 Sasha Sabrina FORSTER · Prevention of Future Deaths report Central Hampshire
View report summary
Concerns raised 6 Risk of using prescribed Propranolol for overdose View source Failure to agree and update a common action plan for revoked s.17 leave View source Failure to collect and return patients to the ward when s.17 leave is revoked View source Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol View source Failure to finalise the formal revocation of s.17 leave View source Lack of shared awareness of powers and responsibilities when s.17 leave is revoked 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
Sasha Sabrina FORSTER · 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
Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Risk of using prescribed Propranolol for overdose
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to agree and update a common action plan for revoked s.17 leave
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked, or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances .
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to collect and return patients to the ward when s.17 leave is revoked
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked , was that they did not have the resources to allow them to do this , despite it being their legal responsibility so to do .
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked , placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised, Sasha’s mother was given to believe that it would be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
Wider context from the report “Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither of which was given ), neither GP had the means of discovering her worrying psychiatric background. Had they had those means, it is likely that neither GP would have given her a 28 day supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she would so use it.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to finalise the formal revocation of s.17 leave
Wider context from the report “(1) Evidence was given during the inquest by SBP staff on the ward concerned, that the reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17 leave had been revoked, was that they did not have the resources to allow them to do this, despite it being their legal responsibility so to do.
(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in circumstances when she and the rest of the family were struggling to keep Sasha safe. Knowing that SBP would not send someone out to collect Sasha made her feel that she had no choice but to agree to their request.
(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave was never finalised , Sasha’s mother was given to believe that it would be , and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to run off and take the substantial Propranolol overdose which proved to be fatal.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of shared awareness of powers and responsibilities when s.17 leave is revoked
Wider context from the report “Evidence received at the inquest suggested that the various hospitals and police forces which had regular dealings with Sasha were not always aware of their powers and responsibilities towards her in circumstances when her s.17 leave was being revoked , or else had not agreed and, where required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked, which led to an increased risk that Sasha might act in such a way which would result in her death, whether intentionally or not.
” Open source report
21 Feb 2019 Terrence Arthur Albert Smith · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 17 Lack of call-handling provision for identifying unrecognised ED/ABD presentations View source Inconsistency between police conveyance policy and officer training View source Conveyance policy restricting timely transport of medical emergencies View source Unavailability of national guidance for out-of-hospital rapid tranquilisation View source Lack of timely escalation of serious ED/ABD safety matters to senior management View source Insufficient coverage of ED/ABD training for front-line response staff View source Contradictory ambulance call-handling instructions View source Training that conflates ED/ABD death risk with positional asphyxia View source Conveyance policy restricting timely transport of medical emergencies View source Failure of the police Mental Health Guide to separately address ED/ABD View source Police training that mischaracterises ED/ABD as controversial View source Omission of patient containment guidance from ED/ABD training View source Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD View source Inaccurate monitoring and capture of ED/ABD incidents View source Confusing clinical-staff ED/ABD training content View source Police training that conflates ED/ABD with positional asphyxia View source Failure of call-handling guidance to capture patient restraint status View source See 14 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
Terrence Arthur Albert Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Terrence Smith died in hospital on 13 November 2013 after developing amphetamine-induced Excited Delirium/Acute Behavioural Disturbance, being subjected to prolonged restraint, and stopping breathing while being transported to hospital. The principal concerns included failures to recognise the condition as a medical emergency, inadequate assessment and training, excessive restraint, delayed conveyance to hospital, and deficiencies in relevant emergency response, clinical, police and custody policies and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of call-handling provision for identifying unrecognised ED/ABD presentations
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Inconsistency between police conveyance policy and officer training
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I have two concerns :
(a) I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary, and could result in a fatal delay in the provision of life-saving treatment.
(b) I am concerned that the content of this policy is inconsistent with the training I was told is given to police officers , namely that they may convey a patient to hospital by police vehicle if the use of an ambulance is not an available or practical option , and as long as the conveyance is approved by a senior officer.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Conveyance policy restricting timely transport of medical emergencies
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary , and could result in a fatal delay in the provision of life-saving treatment .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of national guidance for out-of-hospital rapid tranquilisation
Wider context from the report “I was told that although the London Ambulance Service has provided out of hospital rapid tranquilisation of patients (such as may well be needed by a patient suffering ED/ABD) for some years, SECAMB will not do so until a national protocol or guidance has been issued by JRCALC . In those circumstances, whilst I understand that work on the production of such guidance is being undertaken, I am nevertheless concerned that none is yet in place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of timely escalation of serious ED/ABD safety matters to senior management
Wider context from the report “I was told by the Chief Executive Officer of SECAMB that he was not aware of Terry’s death and SECAMB’s involvement in it, nor of the issues arising at the Inquest, until very shortly before being required to give oral evidence at the Regulation 28 hearing. Given the length of the Inquest and the seriousness of the issues arising in relation to SECAMB (including their failure to recognise that Terry was suffering ED/ABD and to ensure he was treated as a medical emergency and taken to an Accident and Emergency Department), I am concerned that there is no system in place to ensure that such matters are drawn to the attention of the most senior management in a timely manner so as to ensure there is strategic planning for the prevention of other 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient coverage of ED/ABD training for front-line response staff
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be). Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Contradictory ambulance call-handling instructions
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint. If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Training that conflates ED/ABD death risk with positional asphyxia
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all .
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of the patient.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Conveyance policy restricting timely transport of medical emergencies
Wider context from the report “The Joint Surrey Police, Sussex Police, Kent Police and South East Coast Ambulance Service NHS Foundation Trust Conveyance Policy is currently being re-drafted but I have concerns about the current and draft proposed versions I was shown. Both versions indicate that a patient suffering ED/ABD (or other life threatening conditions) should not be conveyed to hospital by police vehicle under any circumstances or unless a series of 11 conditions are satisfied. Some of the 11 conditions could take some time to satisfy and some are dependent on the presence of SECAMB at the scene (which could be subject to delay). I have two concerns :
(a) I am concerned that the policy could prevent a patient who is suffering a medical emergency being conveyed to hospital as soon as possible, and by police vehicle if necessary , and could result in a fatal delay in the provision of life-saving treatment .
(b) I am concerned that the content of this policy is inconsistent with the training I was told is given to police officers, namely that they may convey a patient to hospital by police vehicle if the use of an ambulance is not an available or practical option, and as long as the conveyance is approved by a senior officer.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the police Mental Health Guide to separately address ED/ABD
Wider context from the report “Surrey Police’s Mental Health Guide addresses ED/ABD only in bullet point form alongside reference to Positional Asphyxia . The conditions are separate and different and the absence of a separate sheet addressing ED/ABD alone could mislead those reading the Guide in to thinking that the conditions are necessarily connected .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Police training that mischaracterises ED/ABD as controversial
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD .
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia. The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Omission of patient containment guidance from ED/ABD training
Wider context from the report “I am concerned about the following within the training materials :
(a) Under the heading “What causes Death in Excited Delirium ?” there follows a series of six slides dealing with positional asphyxia when a patient has been “hogtied”. A later slide, headed “Hypoxia The last nail in the coffin?”, suggests that hypoxia is an element in what causes death from ED/ABD. In fact, the evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxiation or hypoxia. Whilst many patients suffering ED/ABD in a custodial setting may well be under restraint (although they will not necessarily be), it is of real importance that FMEs (and all involved) understand that there is a risk of sudden death from ED/ABD whatever the patient’s position, whether or not there is restraint, and whether or not there is hypoxia. The evidence I heard showed that it is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint, no matter what the sufferer’s position. On the basis of the current training material, students may be misled in to thinking that a patient is not at risk of death as long as the position in which he is being restrained is not causing him asphyxiation (which was the thinking of the officers restraining Terry), and that they will fail to understand that there is a risk of death from ED/ABD whatever the sufferer’s position under restraint and even if he is not being restrained at all.
(b) The material suggests that FMEs should encourage the use of minimal force and minimal restraint and the use of de-escalation techniques, but it makes no reference to encouraging the containment rather than restraint of the patient .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure of ambulance call-triage tools to support recognition and appropriate response to ED/ABD
Wider context from the report “The version of NHS Pathways currently in use is version 16 which does not enable operators to recognise potential ED / ABD and respond accordingly . I was told that it is intended that version 17 will do so but this is not yet in use. My concern is that, unless and until it is in use, there will continue to be a failure by call handlers to recognise ED/ABD and respond appropriately .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Inaccurate monitoring and capture of ED/ABD incidents
Wider context from the report “I am concerned that SECAMB is not currently monitoring accurately the incidence of cases of ED/ABD in the regions it covers. A witness told me that she believed there were very few incidents (under ten a year) and that they were all apparent from the data gathered. On the basis of the evidence heard at the Inquest it seems unlikely that there are very few incidents given that SECAMB cover three large counties with a total population of over 4 million people and given the much higher incidence in other areas. Further, there were at least two incidents of ED/ABD (from 2018 and 2019) referred to in evidence which had not been captured at all by SECAMB’s data gathering.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Confusing clinical-staff ED/ABD training content
Wider context from the report “I was told that in 2016/17 SECAMB sought to address the absence of training of its clinical staff by providing some “key skills” training in relation to the condition of ED/ABD and its management, but that it was only in 2018 that it introduced a specific training package on the condition. I have two concerns about this training package. First, its content is potentially confusing in that (a) it refers to the condition of ED/ABD as “controversial” (when it is not) and (b) it links ED/ABD to patients detained under section 136 of the Mental Health Act (which a patient suffering ED/ABD will not necessarily be) . Secondly, to date the training has been given to only about 150 out of about 650 front-line response staff (and out of a much higher number of all employees who should be trained). I was told that there are plans to create an e-learning package to aid faster delivery, but this has not yet been created.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Police training that conflates ED/ABD with positional asphyxia
Wider context from the report “It is clear that Surrey Police now ensure that all officers and staff receive training in relation to ED/ABD and its management, including the fact that it is a medical emergency. I was provided with a copy of the current training material and told that it was, to a very large extent, reflective the material provided by The College of Policing’s National Curriculum, Module 5. I have two concerns :
(a) I am concerned that the material includes reference to ED/ABD being “controversial” when this is not the case. A number of the officers who restrained Terry stated in evidence that they believed the condition was “controversial”. The inclusion of this reference continues the risk that trainees are misled into doubting the existence of ED/ABD and this may result in their failing to recognise or accept a presentation of ED/ABD.
(b) I am concerned that, within the training material, the guidance in relation to ED/ABD is closely linked to the guidance in relation to positional asphyxia . The evidence provided to me at the Inquest established that ED/ABD and positional asphyxia are two entirely separate and quite different conditions. Death from ED/ABD can result even though there is no asphyxia. Whilst many of those suffering ED/ABD may be under restraint (although they will not necessarily be) it is of real importance that police officers and staff understand that there is a risk of sudden death from ED/ABD whatever the sufferer’s position and whether or not he is under restraint. It is vital that it is understood that the risk of death from ED/ABD comes from the condition itself, which can be exacerbated by restraint and resistance against the restraint. On the basis of the current training material, there is a risk that students may be misled in to thinking that there is no risk of death as long as there is no positional asphyxiation (which was the thinking of the officers restraining Terry).
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure of call-handling guidance to capture patient restraint status
Wider context from the report “I was told that, whilst waiting for version 17 of NHS Pathways, SECAMB has provided its call handlers with guidance (by way of a “Hot Topic”) that a call from the Police or a Health Care Professional stating that a patient is suffering ED/ABD should be given a category 2 response. I was also told, however, that SECAMB’s call handlers have no discretion when using NHS Pathways which must be followed precisely. I have three concerns about the current situation. First, there appears to be a contradiction between the call handlers being told they have no discretion when using NHS Pathways and their being given additional guidance for certain calls. This contradiction could cause confusion. Secondly, the guidance given in the “Hot Topic” is concerned only with calls from the Police or an HCP in which ED/ABD is identified. Currently, therefore, there is no provision for identifying the condition in calls from the Police or an HCP which do not expressly mention ED/ABD or in calls from the public (meaning the call from Terry’s family would still not be recognised as a call relating to ED/ABD, even today). Thirdly, the “Hot Topic” does not guide the call handlers to ask whether the patient is under restraint . If a patient suffering ED/ABD is under restraint this could add to his risk of sudden death and this information could affect the proper categorisation of the response to the call .
” Open source report
8 May 2018 Stephen Ian William Tidey · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Failure to record the basis for reduced risk-of-self-harm assessments View source Lack of safeguards to ensure MASH referrals are followed up by the appropriate Community Mental Health Team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Ian William Tidey · 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
Stephen Ian William Tidey was found deceased on 22 December 2016, having been found hanging from a tree outside the cabin where he was residing, with self-inflicted wounds to both wrists. The report raised concerns that a high-risk MASH referral, made after he lost his job, was not followed up and that there were no safeguards to ensure referrals were acted upon, including outside normal office hours.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record the basis for reduced risk-of-self-harm assessments
Wider context from the report “He was assessed by a member of the Criminal Liaison and Diversion Service (CLDS) on the same day and was initially assessed by them as being at risk of self-harm. The member of the CLDS subsequently telephoned the Home Treatment Team to discuss referring him to the service. Mr Tidey was then re-assessed by the same member of the CLDS who stated he appeared calmer and was no immediate risk to himself. No notes were recorded on the Police or Mental Health Service computer system to record how this assessment of reduced risk of self-harm had been reached.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguards to ensure MASH referrals are followed up by the appropriate Community Mental Health Team
Wider context from the report “On Friday 16th December 2016, Police were made aware that Mr Tidey had lost his job as a consequence of being charged with the offences and therefore that one of the contingent events highlighted in the MASH referral of 3.2.2016 as placing Mr Tidey at higher risk of self-harm had materialised. They therefore completed a further MASH referral form and this was emailed to the MASH hub at 15.40 and forwarded on to Waverley CMHRS at 16.41.
On Monday 19th December 2016 at 11.30am, Waverley CMHRS forwarded the MASH report to Guildford CMHRS, but then emailed again at 11.36am to state they noted Waverley CMHRS should actually follow up Mr Tidey. However, for reasons, which cannot be ascertained, no further action was taken. It is not possible to ascertain who the duty worker was who received the referral by email.
████████, Community Services Manager for South West Community Mental Health Recovery Service, stated in evidence that had he received Mr Tidey’s MASH referral on 16th December 2016, he would have taken action the same day, initially via a telephone triage assessment and then via the options available of HTT referral; EDT Mental Health Act Assessment, crisis planning with safe havens or CMHRS non-crisis support, as appropriate.
Evidence was given that there were no safeguards in place to check referrals were being acted upon, and that this remains the case.
” 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 Triage SCARF referrals by checking factual content, risks, vulnerabilities, warnings, previous referrals and escalation needs, with risk ratings adjusted and justified where necessary.
Verbatim wording from the response “Police Officers submit a risk assessment form called a Single Combined Assessment of Risk Form (SCARF) to the Police MASH where it is triaged.” Source location 2018-0140-Response-by-Surrey-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SABP and Adult Social Care are responsible for responding on whether Community Mental Health Teams follow up MASH referrals.
Verbatim wording from the response “Once a referral is made from Surrey Police to a partner agency via the MASH there is no current means for Surrey Police to ensure it is being acted upon and this would be outside of the existing agreement between Surrey Police and Surrey County Council. A partners response to a referral is not monitored by Surrey Police and unfortunately we are unable to respond in detail to this question. Surrey Police therefore respectfully request that this question is passed onto the SABP and Adult Social Care for their response.” Source location 2018-0140-Response-by-Surrey-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensuring partner agencies act on MASH referrals falls outside the existing Surrey Police and Surrey County Council agreement.
Verbatim wording from the response “Once a referral is made from Surrey Police to a partner agency via the MASH there is no current means for Surrey Police to ensure it is being acted upon and this would be outside of the existing agreement between Surrey Police and Surrey County Council. A partners response to a referral is not monitored by Surrey Police and unfortunately we are unable to respond in detail to this question. Surrey Police therefore respectfully request that this question is passed onto the SABP and Adult Social Care for their response.” Source location 2018-0140-Response-by-Surrey-Police
Open published response
22 Jun 2015 Jan McLEAN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Lack of full and adequate police officer training on interrogating all PNC warning-marker details 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
Jan McLEAN · 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
Jan McLean was arrested at a flat in Guildford where drugs were being used, became unwell in a police van, and died in hospital on 14 August 2013. The inquest found drug-related death from cocaine, amphetamine and butylone toxicity, after he swallowed an unknown quantity of unknown drugs while in police custody. The principal concern was that police officers may not have received adequate training to fully interrogate warning markers on the Police National Computer.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of full and adequate police officer training on interrogating all PNC warning-marker details
Wider context from the report “Training
Consideration should be given to providing full and adequate training to all police officers on the need to interrogate fully all details relating to warning markers held on the PNC , whether by means of an MDT or by enquiry through the FCR.
” Open source report
24 Nov 2014 William Philip Hafele · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Failure of communication between police and hospital staff about missing-person status View source Failure to make enquiries or investigations to ascertain a missing person’s whereabouts View source Failure of briefing training to accurately reflect the definition of absent View source Lack of adequate training for police and hospital staff on missing-person procedures, responsibilities and risk assessment View source Omission of critical information required for missing-or-absent risk assessment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Philip Hafele · 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
William Philip Hafele, who had a history of mental ill health and alcohol dependence, was admitted to hospital after being found intoxicated and wanting to take his own life. After leaving the ward and being redesignated by police from missing to absent, no immediate enquiries were made; he was later found dead in a hotel room after suffocating using helium gas. The principal concerns related to inadequate training, risk assessment, communication, and understanding of responsibilities between the police and hospital staff.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between police and hospital staff about missing-person status
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to make enquiries or investigations to ascertain a missing person’s whereabouts
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure of briefing training to accurately reflect the definition of absent
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate training for police and hospital staff on missing-person procedures, responsibilities and risk assessment
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions .
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Omission of critical information required for missing-or-absent risk assessment
Wider context from the report “• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions.
• Critical information required to make an informed risk assessment as to whether was missing or absent was omitted.
• The decision to re classify from missing to absent was not communicated to the hospital
• As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts
• Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place
• In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking
• Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person
• Ineffective communications between Police and Elgar Ward
” 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 Continue working with NHS and medical partners to establish effective communication channels and consistent responses to mental-health issues.
Verbatim wording from the response “The Force is committed to working with NHS and other medical partners to ensure effective channels of communication and consistent response and handling of mental ill health issues.” Source location 2014-0511-Response-by-Surrey-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 Modify TPT briefing training to align with the Surrey Police Missing Person Procedure’s definition of absent.
Verbatim wording from the response “This was noted by the Force and the TPT briefing training will be modified to take account of this and ensure consistency in the future.” Source location 2014-0511-Response-by-Surrey-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement training and a familiarisation programme for police and mental-health or medical staff after completing the policy review.
Verbatim wording from the response “Once the review of the MPP is complete, training and a familiarisation programme will be implemented for officers and mental health/medical staff (which may even include consideration for joint enterprise) to ensure that all staff understand and implement the policy and work effectively together to deliver successful outcomes for missing individuals.” Source location 2014-0511-Response-by-Surrey-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 Circulate guidance to personnel emphasising provision of all necessary information for accurate missing-person risk assessments.
Verbatim wording from the response “Guidance has since been circulated to all appropriate personnel to emphasise and ensure, so far as is possible, that all necessary details are provided in order for an accurate risk assessment to be made.” Source location 2014-0511-Response-by-Surrey-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 Develop and enhance the Force training programme addressing missing-person procedures and mental-health risk assessment.
Verbatim wording from the response “• The Force has in place a comprehensive program of training and is developing and enhancing this as an on-going matter.” Source location 2014-0511-Response-by-Surrey-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 Review the Force Missing Person Policy with NHS partners to address missing-person responsibilities and communication issues.
Verbatim wording from the response “The Force’s Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility:” Source location 2014-0511-Response-by-Surrey-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 Mobile Data Terminals across the Force to provide officers with documented information directly during missing-person responses.
Verbatim wording from the response “The risk of this happening again will also be significantly mitigated by the full introduction of Mobile Data Terminals (M.D.T’s). This will ensure that officers receive the necessary documented information first hand and do not have to rely on information being verbally relayed to them.” Source location 2014-0511-Response-by-Surrey-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing Missing Person Policy comprehensively provides risk assessment criteria and clearly allocates responsibility for enquiries.
Verbatim wording from the response “The Force’s Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility:” Source location 2014-0511-Response-by-Surrey-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The communication failure concerned notification of an absent classification, not mental health issues in the wider context.
Verbatim wording from the response “8. “Ineffective communications between police and Elgar Ward”” Source location 2014-0511-Response-by-Surrey-Police
Open published response
6 Aug 2014 Lee Michael FRIEND · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Lack of operative guidance or training on placing traffic lights near blind bends View source Lack of a clear route for locating the person responsible for placing road works View source Failure to pass public calls about serious road-network safety issues directly to those responsible for action View source Failure to carry out effective risk assessments for road works View source Insufficient visibility distance between approaching drivers and temporary traffic light heads View source Inadequate staff training in the safe setting up of road works View source Lack of a clear police policy or protocol for responding to public risks created by road works View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lee Michael FRIEND · 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
Lee Michael Friend died on 21 February 2013 after his motorcycle collided with stationary traffic near temporary road works on a blind bend. The report raised concerns about the positioning and visibility of temporary traffic lights, the adequacy of risk assessments and training for road works, the response to public safety concerns, and Surrey Police’s procedures for identifying and reporting risks created by road works.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of operative guidance or training on placing traffic lights near blind bends
Wider context from the report “1. Action is required to ensure that when temporary traffic lights are placed there is a minimum distance of visibility (line of sight) between approaching drivers and the temporary traffic light heads. Further, guidance or training should be provided to operatives as to placing traffic lights near to blind bends or where waiting traffic will encroach upon blind bends .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear route for locating the person responsible for placing road works
Wider context from the report “2. Action is required by Surrey Police to formulate a clear policy/protocol for all Officers to follow when they identify a risk created to the public by road works which should include a clear route allow them to locate who is responsible for the placing of the road works if not apologies board is seen/present .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to pass public calls about serious road-network safety issues directly to those responsible for action
Wider context from the report “3. Action is required by Reigate and Banstead Council to ensure that any calls from members of the public to the Council about serious safety issues relating to the road network are passed directly to those with responsibility to take action .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out effective risk assessments for road works
Wider context from the report “4. Action is required by Sutton and East Surrey Water to take steps to ensure all members of staff are fully and properly trained in the safe setting up of road works and the carrying out of effective risk assessments .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient visibility distance between approaching drivers and temporary traffic light heads
Wider context from the report “1. Action is required to ensure that when temporary traffic lights are placed there is a minimum distance of visibility (line of sight) between approaching drivers and the temporary traffic light heads . Further, guidance or training should be provided to operatives as to placing traffic lights near to blind bends or where waiting traffic will encroach upon blind bends.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training in the safe setting up of road works
Wider context from the report “4. Action is required by Sutton and East Surrey Water to take steps to ensure all members of staff are fully and properly trained in the safe setting up of road works and the carrying out of effective risk assessments.
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear police policy or protocol for responding to public risks created by road works
Wider context from the report “2. Action is required by Surrey Police to formulate a clear policy/protocol for all Officers to follow when they identify a risk created to the public by road works which should include a clear route allow them to locate who is responsible for the placing of the road works if not apologies board is seen/present.
” Open source report
9 Jun 2014 Ryan Patrick BOYLE · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Lack of an efficient and effective pursuit notification system for Force Control Room staff View source Insufficient training and retraining of force control operators and personnel likely to deal with police pursuits View source Insufficient continuous staffing of the Force desk for dealing with police pursuits View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ryan Patrick BOYLE · 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 21 February 2013, 19-year-old Ryan Patrick Boyle died following a road traffic collision while driving during a police pursuit. The jury found that dynamic risk assessments by the Force Control Room were insufficient. The report raised concerns about staff training, notification of pursuits, and ensuring that at least two people monitor the Force desk at all times.
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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Lack of an efficient and effective pursuit notification system for Force Control Room staff
Wider context from the report “2. Action is required to ensure that there is an efficient and effective notification system (beyond the current practice of shouting) for controllers to notify supervisors and/or other members of Force Control Room staff that a pursuit has commenced .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and retraining of force control operators and personnel likely to deal with police pursuits
Wider context from the report “1. Action is required to ensure that ALL force control operators and those likely to deal with a police pursuit are sufficiently trained and/or re-trained so that they understand their responsibilities, powers and obligations under force policy when dealing with a pursuit .
” 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 Surrey Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient continuous staffing of the Force desk for dealing with police pursuits
Wider context from the report “3. Action is required to ensure that a minimum of two persons are monitoring the ‘Force desk’ at all times so as to allow effective dealing with any pursuits that might arise .
” 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 Install a Call Supervisor alert button on FCR operator terminals to notify Ops 1 and Ops 2 of incidents requiring attention.
Verbatim wording from the response “A “Call Supervisor” button has been installed at the top of radio channel management screen on all FCR operator terminals. If the operator presses this button then a corresponding alert button flashes up on the Ops 1 and Ops 2 terminals. This alerts Ops 1 and Ops 2 that there is an incident occurring within the FCR (such as pursuits/firearms) that requires their immediate attention and intervention.” Source location 2014-0263-Response-by-Surrey-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide FCR staffing-pool officers with current training materials and require receipt and understanding confirmation.
Verbatim wording from the response “In the meantime all members of the pool:” Source location 2014-0263-Response-by-Surrey-Police
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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 FCR staffing-pool constables to complete FCR training days alongside permanent FCR staff.
Verbatim wording from the response “When addressing staffing shortfalls in the FCR, the Force uses police constables who have previous FCR experience. All constables who are in the pool of officers which can be drawn upon as an FCR staffing resource will be required to complete the FCR training days along with full-time members of FCR staff. Action has been taken to schedule training for these individuals in the next training cycle in September/October 2014 and thereafter on an annual basis.” Source location 2014-0263-Response-by-Surrey-Police
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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 Revise and update FCR pursuit and TPAC refresher training materials covering staff responsibilities, powers and obligations.
Verbatim wording from the response “The FCR Pursuit and TPAC Refresher 2014 have been fully revised and updated (June 2014) to ensure that the Force’s training materials are up-to-date and clear on” Source location 2014-0263-Response-by-Surrey-Police
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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 Brief staff that two people must continuously monitor the Force Channel and require Ops 2 to provide cover when necessary.
Verbatim wording from the response “All FCR staff and supervisors have been briefed that two people must physically monitor the Force Channel at all times. The practical arrangements for putting this into effect have been notified to all staff, including that if necessary Ops 2 must step in to monitor the Force Channel.” Source location 2014-0263-Response-by-Surrey-Police
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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 Instruct FCR staff to use the alert button and verbal notification together, and obtain supervisor acknowledgement.
Verbatim wording from the response “The Force has consulted with the FCR Inspectors/Chief Inspectors in Hampshire, Cambridgeshire, Dorset, Thames Valley, Sussex and Kent Constabularies, as well as the Metropolitan Police to investigate best practice in the FCRs of other forces. After detailed consideration Surrey Police remains of the view that the single most effective means of alerting Ops 1 and Ops 2 to an incident requiring their attention (e.g. firearms/pursuits) is by shouting to them. Clearly, this method is effective even when the Ops 1 is not in physical sight of their terminal and acts as an additional safeguard over and above the alert button that has now been installed. Therefore all FCR staff have been instructed that if/when they need to alert Ops 1 or 2 to an incident they should always shout to them, but that they should also press the “Call Supervisor” button as well as a means of attracting attention.” Source location 2014-0263-Response-by-Surrey-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Give each FCR staffing-pool officer an Ops 2 one-to-one training session and record completion.
Verbatim wording from the response “• will, on their next shift in the FCR, be given a one-to-one session by the Ops 2 on duty who will take them through the training materials and check their understanding of the contents of the training materials. Records will be kept to note that this has been completed.” Source location 2014-0263-Response-by-Surrey-Police
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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 Draft a standing operating procedure defining Ops 2 responsibility for Force Channel cover when an operator leaves the desk temporarily.
Verbatim wording from the response “A standing operating procedure has been drafted setting out the responsibilities of Ops 2 for providing cover for the Force Channel where one of the operators has temporarily left the Force Desk.” Source location 2014-0263-Response-by-Surrey-Police
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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 Shouting remains the most effective incident alert, with the button as an additional safeguard.
Verbatim wording from the response “The Force has consulted with the FCR Inspectors/Chief Inspectors in Hampshire, Cambridgeshire, Dorset, Thames Valley, Sussex and Kent Constabularies, as well as the Metropolitan Police to investigate best practice in the FCRs of other forces. After detailed consideration Surrey Police remains of the view that the single most effective means of alerting Ops 1 and Ops 2 to an incident requiring their attention (e.g. firearms/pursuits) is by shouting to them. Clearly, this method is effective even when the Ops 1 is not in physical sight of their terminal and acts as an additional safeguard over and above the alert button that has now been installed. Therefore all FCR staff have been instructed that if/when they need to alert Ops 1 or 2 to an incident they should always shout to them, but that they should also press the “Call Supervisor” button as well as a means of attracting attention.” Source location 2014-0263-Response-by-Surrey-Police
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations