Concerns raised 1 Failure to remove an observed item from the home in response to continued suicidal ideation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Narjit Gill · 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
Narjit Gill died by hanging on 5 May 2023 after recently receiving mental health support and continuing to express suicidal thoughts. The principal concern was the failure to remove an unspecified item seen during a home visit on 3 May 2023, in light of his continued suicidal ideation.
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 Warwickshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to remove an observed item from the home in response to continued suicidal ideation
Wider context from the report “(1) Failure to remove ████████ when it was seen on 3 May 2023 by mental health practitioners who visited Mr Gill at his home, in light of his continued expression of suicidal ideation .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mental health services were the appropriate authority responsible for supporting Mr Gill after police involvement ended.
Verbatim wording from the response “As a result of the further attendance of police officers, the Access Hub were contacted again but refused to attend and further refused to make contact again with Mr Gill by telephone. They were advised that officers had correctly identified that they had no powers to act under section 136 of the Mental Health Act as Mr Gill was in his own home, and therefore a Mental Health Act assessment was requested, and the Access Hub agreed to attempt to contact the on-call AMHP. When police advised, they would need to leave Mr Gill’s property as they had no powers and could not do no more, the Access Hub agreed that a manager would review the case and take ownership.” Source location Response from Warwickshire Police
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 Warwickshire 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 Warwickshire 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 Warwickshire 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 Develop national accredited firearms licensing training modules for Firearms Enquiry Officers, caseworkers and decision makers, including risk assessment and the National Decision Model.
Verbatim wording from the response “We have already scoped out the roles where accredited training should be a requirement (all Firearms Enquiry Officers (FEOs) and all caseworkers and decision makers) and work is now well developed in putting together the modules that will be required for staff to be deemed Competent including by way of example: National Decision Model (NDM), identification of risk and risk assessment.” Source location Response from Warwickshire 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 Work with the College of Policing to determine delivery arrangements for national firearms licensing training and align them with quality assurance and continuing professional development.
Verbatim wording from the response “We are currently working with the College to identify the best delivery option and how this will be aligned with quality assurance and mandatory continuing professional development aspect of the training. This will include the validation of licensing departments for reassurance and pending future HMIC inspection.” Source location Response from Warwickshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Secure funding to support implementation of national accredited firearms licensing training.
Verbatim wording from the response “The College is committed to implementing this training during the 2023/24 business year, and through recent negotiations, as NPCC lead, I was able to secure £500,000 from the Policing Minister to support with the assisted implementation of National Firearms Licensing Training.” Source location Response from Warwickshire 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 a quality assurance framework to assess competency, validate licensing departments and support consistent delivery of national firearms licensing training.
Verbatim wording from the response “With agreed College of Policing Learning Outcomes now in place for the training, we are also developing an accompanying Quality Assurance framework to assess and ensure operational competency is demonstrated at the conclusion of the training package.” Source location Response from Warwickshire 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 Work with the Home Office to progress the firearms licensing fees review and develop sustainable funding for training, quality assurance and national coordination.
Verbatim wording from the response “Fees Review
The review of Firearms licence application fees, mentioned above, is also being worked through nationally to develop a funding stream, in part, to fund the training product development and sustainable Quality Assurance, along with a national coordination facility. Whilst the funding review is led by the Home Office, the NPCC has provided data from 31 forces to inform the review and will continue to work closely with the Home Office to bring the fees review to fruition, as this will support ongoing work with the College to maintain up to date training materials and oversight.” Source location Response from Warwickshire 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 local training and supervision are considered adequate for licensing staff and delegated decision-makers to meet legislative and guidance requirements.
Verbatim wording from the response “WARWICKSHIRE POLICE
I have carefully considered the recommendations you have made that Chief Constables should satisfy themselves that within their own forces there is adequate local training for Firearms Licensing Unit (FLU) staff and supervisors, and that we have only delegated our decision-making duties to those who we believe are appropriately trained.” Source location Response from Warwickshire Police
Open published response
20 Jan 2022 Neil Kenneth PARKES · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 2 Failure to identify unconscious patients View source Failure of police to act on requests for assistance identifying hospital patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Issue organisation-wide learning requiring hospital enquiries to identify unknown patients, linked incidents to be researched, and fingerprints to be considered where medically relevant.
Stated completedThe respondent said that this action was complete when they made their response on 25 January 2022. View source
Action
Circulate control-room learning on SNT referrals, intelligence checks, supervisory review, incident closure, and reopening logs when further action is required.
Stated completedThe respondent said that this action was complete when they made their response on 25 January 2022. View source
Action
Advise control-room staff to complete full THRIVE assessments, record enquiry rationales and actions, obtain supervisory review, and fully update logs before closure.
Stated completedThe respondent said that this action was complete when they made their response on 25 January 2022. View source
×
AI-generated summary
Neil Kenneth PARKES · 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 Kenneth Parkes was found unconscious after an apparent unwitnessed fall in a stairwell on 29 April 2020 and later died in hospital on 14 May 2020. His identity remained unknown throughout his hospital admission despite reports from hospital staff and his parents, and the failure to identify him meant the hospital could not access his previous medical history, which may have assisted his treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Warwickshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to identify unconscious patients
Wider context from the report “Throughout the time that Mr Parkes lay unconscious in UHCW his identity was unknown . He had been reported as a missing person by his parents to another police force during the time he was in hospital. Additionally, on 2 separate occasions, UHCW staff directly contacted Warwickshire police to seek assistance to identify him. No clear explanation has been provided to explain why Warwickshire failed to act on those requests. The effects of the failure to identify Mr Parkes meant the hospital had no access to his previous medical history which my have been of assistance in his 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 Warwickshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of police to act on requests for assistance identifying hospital patients
Wider context from the report “Throughout the time that Mr Parkes lay unconscious in UHCW his identity was unknown. He had been reported as a missing person by his parents to another police force during the time he was in hospital. Additionally, on 2 separate occasions, UHCW staff directly contacted Warwickshire police to seek assistance to identify him . No clear explanation has been provided to explain why Warwickshire failed to act on those requests . The effects of the failure to identify Mr Parkes meant the hospital had no access to his previous medical history which my have been of assistance in his treatment.
” 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 Issue organisation-wide learning requiring hospital enquiries to identify unknown patients, linked incidents to be researched, and fingerprints to be considered where medically relevant.
Verbatim wording from the response “• An entry made available to all officers and staff through the Vulnerability and Safeguarding Newsletter on 1st December 2021 setting out lessons learnt from this Inquest. They were as follows:
◦ The necessity for officers conducting hospital enquiries to ask specifically for details of any “unknown” or “unidentified” patients within their care.
◦ The necessity to consider researching other local incidents which may be linked to missing person enquiries.
◦ The necessity to take fingerprints (using the Mental Capacity Act 2005 provisions) where establishing identity may assist with treatment of a medical need.” Source location 2022-0019-Response-from-Warwickshire-Police_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate control-room learning on SNT referrals, intelligence checks, supervisory review, incident closure, and reopening logs when further action is required.
Verbatim wording from the response “• Control Room staff have received words of advice and organisational learning has been circulated on the following issues:
◦ When using the “SNT” tag, ensure there is a full explanation of what is needed from the Safer Neighbourhood Team and who the SNT are to make contact with,
◦ Call handlers are to check whether SNT are actually on duty at the time of the call and consider liaising directly
◦ Any incident of note is to be brought to the attention of the OCC supervision for full review before closing
◦ Consideration to be given and documented on the incident for the 24 hour Intelligence Team to complete additional checks.
◦ Incidents should be resulted with actions taken and rational for closing and just not just marked as “closed pending further calls”
◦ SNT to request logs to be re-opened if further actions need to be taken following their involvement.” Source location 2022-0019-Response-from-Warwickshire-Police_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advise control-room staff to complete full THRIVE assessments, record enquiry rationales and actions, obtain supervisory review, and fully update logs before closure.
Verbatim wording from the response “All staff involved with this incident have been spoken to by the Control Room Manager about undertaking a full THRIVE (threat and risk) assessment and detailed rationale for inclusion on the incident log to show all enquiries made and actions completed.” Source location 2022-0019-Response-from-Warwickshire-Police_Published
Open published response
13 Jun 2018 Keiron Christopher Bould · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to verbally confirm transfers of cases between police forces View source Failure to verbally confirm which force has primacy for an incident View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Keiron Christopher Bould · 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
Keiron Christopher Bould left home on 17 September 2017 after taking his girlfriend’s morphine tablets and was later found in his parked vehicle. He was taken to hospital and pronounced deceased on 18 September 2017; the medical cause of death was recorded as a morphine overdose and the inquest concluded suicide. Concerns were raised about the lack of clear communication over which police force had primacy for the missing-person inquiry and about a four-hour delay in actioning the transfer email.
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 Warwickshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to verbally confirm transfers of cases between police forces
Wider context from the report “2. When Warwickshire police decided to transfer the case to West Midlands police an email was sent at 01.53 to a generic email address . There was a 4 hour delay in this email being picked up and actioned . There should be a system in place to ensure verbal confirmation about a transfer so the receiving force is aware of the referral .
” 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 Warwickshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to verbally confirm which force has primacy for an incident
Wider context from the report “1. When each force received a missing person report soon after 12 midnight on 18/09/17, there was no communication about who would take primacy of the inquiry . There should be a system in place to ensure verbal communication confirms who is dealing with any incident .
” 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 Re-circulate College of Policing guidance on missing-person ownership to control-room managers, supervisors and staff.
Verbatim wording from the response “In addition, we are aware of the response you have received from Chief Constable Thornton on behalf of the NPCC and would clarify that the College of Policing Approved Professional Practice (APP) direction around ownership of missing people has been re-circulated to our Control Room Management, supervisors and staff to remind them of what should be done to provide clarity on ownership of missing persons enquiries, and the importance of that ownership.” Source location 2018-0178-Response-by-Warwickshire-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 a mandatory follow-up telephone call to confirm receipt when transferring missing-person reports to another force before closing the log.
Verbatim wording from the response “Having learnt that West Midlands system is different to the Warwickshire system (where call handlers have a separate screen to monitor emails as well as a system showing the calls and incidents logs) changes were made to our policies and procedures as detailed in the witness statement of Chief Inspector Kent from Warwickshire Police and West Mercia Police, including the need for telephone contact with the other force in respect of transfer of primacy. These changes were implemented in February 2018.” Source location 2018-0178-Response-by-Warwickshire-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 Telephone contact did occur to confirm which police force should deal with the case, despite the concern seeking verbal confirmation.
Verbatim wording from the response “It can be seen therefore, that at 00:59 Warwickshire Police did make telephone contact with West Midlands in respect of confirming who should best deal with this case. There was confusion as to which Police area Mr Bould lived within, and therefore Warwickshire confirmed that we would make further enquiries, including travelling to the West Midlands police area to do so.” Source location 2018-0178-Response-by-Warwickshire-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 issues did not appear to affect the outcome because the overdose likely occurred before Mr Bould was reported missing.
Verbatim wording from the response “I note the matters you raise as concerns, and would say at the outset that we acknowledge that there were issues with the communication between Warwickshire Police and West Midlands Police at the initial stages of the police involvement in this tragic case. However we also note that, based on your findings that the evidence indicates it is likely that Mr Bould took the morphine overdose at around midnight – shortly before the time he was reported missing to both forces – the matters giving rise to concern in this case would not appear to have affected the outcome in relation to Mr Bould.” Source location 2018-0178-Response-by-Warwickshire-Police
Open published response
30 Jun 2016 Luisa Mendes · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 4 Lack of specific training in handovers between controllers coming on and off shift View source Failure to categorise incidents involving allegations of violence as violent View source Lack of formalised handover procedures between controllers coming on and off shift View source Absence of a STORM computer system feature alerting management to unauthorised deferrals View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luisa Mendes · 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
Luisa Mendes was pronounced deceased on 25 October 2012 after a catastrophic abdominal bleed caused by rupture of the spleen, following the deliberate application of force by a third party. The report raised concerns about incident categorisation, handover procedures between control-room staff, and the STORM computer system's handling of unauthorised deferrals. The inquest also identified errors or omissions involving the police response, handover process, deferral of the response, computer-screen configuration, and supervision of the control room.
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 Warwickshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of specific training in handovers between controllers coming on and off shift
Wider context from the report “(2) The handover procedures between controllers coming on and off shift in the Operations and Communications Centre. The basis for the concern is that there are no formalised procedures and no specific training in relation to handovers between controllers coming on and off shift .
” 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 Warwickshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to categorise incidents involving allegations of violence as violent
Wider context from the report “(1) The approach of controllers and call handlers to the categorisation of incidents which include allegations of violence . The basis for the concern is that the incident should have been categorised as “violent” but it was 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 Warwickshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formalised handover procedures between controllers coming on and off shift
Wider context from the report “(2) The handover procedures between controllers coming on and off shift in the Operations and Communications Centre. The basis for the concern is that there are no formalised procedures and no specific training in relation to handovers between controllers coming on and off shift.
” 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 Warwickshire Police; that does not assign responsibility.
PFD Monitor interpretation Absence of a STORM computer system feature alerting management to unauthorised deferrals
Wider context from the report “(3) The set up of the STORM computer system as it relates to deferrals. The basis for the concern is the absence of any feature on the STORM computer system which will alert management to the effect that an unauthorised deferral has been effected by a controller .
” 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 Develop a STORM alert that automatically reactivates out-of-time priority incidents and notifies relevant staff to mitigate unauthorised deferrals.
Verbatim wording from the response “There remains a difficulty with substantive technical adaptations to the STORM system as it is used by a large number of police forces and other emergency service providers. After discussions with the company who own the system, Sopra-Steria, we have identified a change to the system that we are seeking to introduce in the next few weeks that will provide some mitigation to the issue of unauthorised deferrals. This change is still under development and it is intended that it will provide an alert on all priority incidents out of time. It is recognised that this does not prevent irregular deferrals being made, however within the current restraints of the system, is considered the best change we can deliver.” Source location 2016-0243-Response-by-Warwickshire-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 Strengthen controller handover training and incorporate handover requirements into the controller task book.
Verbatim wording from the response “Compelling evidence was identified during the preparation and ultimate delivery of the evidence to the inquest that showed the handover procedure between controllers in the OCC required improvement. However, the complex and varied nature of the calls received within the OCC means that the handover process must be dynamic and cannot be subject of an over-prescriptive process. It has been recognised that there was a need to reinforce the critical importance of passing vital information between controllers. In order to achieve this, changes have been made to the initial training programme for controllers and additional requirements incorporated into the controller ‘task book’, which is a list of skills that controllers need to demonstrate before progression in their role.” Source location 2016-0243-Response-by-Warwickshire-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 Build a new command-and-control platform incorporating inquest-related changes, including correct authority levels for deferring incidents.
Verbatim wording from the response “Finally, Warwickshire Police and West Mercia Police are in the advanced stages of the procurement of a new Command and Control system. We are building the new platform with the suppliers, to our specifications, which will include the changes required as a result of the learning through the inquest. This will include the correct authority level around deferring incidents.” Source location 2016-0243-Response-by-Warwickshire-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 Check deferred priority incidents for supervisor consent for a defined period and reinforce the prohibition on unauthorised deferrals.
Verbatim wording from the response “The change will be in addition to the reinforcement of the policy in relation to deferrals and the commitment that for a given period, all deferred priority incidents should be subject to checks to ensure that they were deferred with the consent of a supervisor. This will also serve to reinforce the training that no priority incident should be deferred without the consent of a supervisor. It addresses the deferral issue because, if the incident in question has been deferred, either rightly or wrongly, the system will automatically re-activate it and then send the relevant alerts.” Source location 2016-0243-Response-by-Warwickshire-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 varied nature of OCC calls prevents handover procedures from being made over-prescriptive.
Verbatim wording from the response “2. The handover procedures between controllers coming on and off shift in the Operations and Communications Centre (OCC). The basis of the concern is that there are no formalised procedures and no specific training in relation to handovers between controllers coming on and off shift.” Source location 2016-0243-Response-by-Warwickshire-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 Substantive STORM adaptations are constrained by the shared system, so only the best feasible mitigation can be delivered.
Verbatim wording from the response “3. The set up of the STORM computer system as it relates to deferrals. The basis for the concern is the absence of any feature on the STORM computer system which will alert management to the effect that an unauthorised deferral has been effected by a controller.” Source location 2016-0243-Response-by-Warwickshire-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 Incident categorisation need not determine response; controllers should focus instead on threat, harm, risk and vulnerability.
Verbatim wording from the response “1. The approach of controllers and call handlers to the categorisation of incidents which include allegations of violence. The basis for the concern is that the incident should have been categorised as ‘violent’ but it was not.” Source location 2016-0243-Response-by-Warwickshire-Police
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations