8 May 2024 Donna Smith · Prevention of Future Deaths report Worcestershire
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Concerns raised 2 Failure to provide formal written guidance allocating responsibilities for urgent ambulance calls View source Lack of formalised written governance of the relationship between CCTV operators and police View source
Responses linked to these concerns
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AI-generated summary
Donna 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
Donna Smith was found unresponsive in Worcester city centre on 4 March 2023 and later died in hospital from acute alcohol intoxication. The report raises concerns about the lack of formal written guidance governing communication and responsibilities between the CCTV operator and West Mercia Police, which led to neither making an immediate ambulance call. It also notes that a related Memorandum of Understanding had not been formalised, creating a risk to others.
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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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formal written guidance allocating responsibilities for urgent ambulance calls
Wider context from the report “(1) I heard evidence at the inquest that there was at the time of these events, and there remains now, a complete lack of formalised written policies, procedures or guidance governing the relationship between those operating CCTV cameras in Worcestershire ( as Wychavon District Council do in respect of Worcester city centre CCTV cameras ) and West Mercia Police;
(2) At the inquest I found as a matter of fact that the failure by either the CCTV operator or the police communications officer to call the ambulance service immediately after their call over Airwaves , and their lack of understanding over whose responsibility it was to make such a call , arose substantially because of this lack of formal written guidance ;
(3) Furthermore, I heard evidence that despite Ms. Smith’s death having occurred over 12 months ago, a draft Memorandum of Understanding between West Mercia Police and those operating CCTV cameras in Worcestershire had not yet been completed or formalised, but rather was still “being drawn up”.
For all of the above reasons, I am concerned that unless action is taken to formalise the relationship between those operating CCTV cameras in Worcestershire and West Mercia Police, and to provide proper guidance setting out their respective responsibilities in situations such as this , there is a risk that other deaths may occur in the future.
” 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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formalised written governance of the relationship between CCTV operators and police
Wider context from the report “(1) I heard evidence at the inquest that there was at the time of these events, and there remains now, a complete lack of formalised written policies, procedures or guidance governing the relationship between those operating CCTV cameras in Worcestershire ( as Wychavon District Council do in respect of Worcester city centre CCTV cameras ) and West Mercia Police ;
(2) At the inquest I found as a matter of fact that the failure by either the CCTV operator or the police communications officer to call the ambulance service immediately after their call over Airwaves, and their lack of understanding over whose responsibility it was to make such a call, arose substantially because of this lack of formal written guidance;
(3) Furthermore, I heard evidence that despite Ms. Smith’s death having occurred over 12 months ago, a draft Memorandum of Understanding between West Mercia Police and those operating CCTV cameras in Worcestershire had not yet been completed or formalised, but rather was still “being drawn up” .
For all of the above reasons, I am concerned that unless action is taken to formalise the relationship between those operating CCTV cameras in Worcestershire and West Mercia Police , and to provide proper guidance setting out their respective responsibilities in situations such as this, there is a risk that other deaths may occur in the future.
” 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 Implement the revised CCTV-to-police communication procedure, replacing Airwave contact with telephony and recording calls, triage decisions, attendance decisions and agency responsibility.
Verbatim wording from the response “The incident was investigated separately by the IOPC, having been referred by West Mercia Police, resulting in a recommendation that a Memorandum of Understanding (MOU) should be agreed between the Local Policing Area and Local Authority CCTV Centres. Part of the development of that MOU includes the withdrawal of Airwave Radio from CCTV rooms in recognition that this may not be the most appropriate way for them to communicate with West Mercia's Public Contact Centre. As a result of the removal of the ability for CCTV to contact the police via Airwaves, we now receive all contact from them via telephony. This allows for the automatic creation of a Contact Record on receipt of their call whereupon any decision around police attendance and the Most Appropriate Agency (MAA) Policy will follow the TRIAGE process.” Source location Response from West Mercia 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 The outlined procedure is considered robust enough to prevent similar incidents and is fully embedded within the Public Contact Centre.
Verbatim wording from the response “I am keen to ensure that all necessary action is taken to prevent other families from experiencing such tragic loss in similar circumstances and am assured that the procedure outlined above is robust enough to meet that aim and fully embedded within the Public Contact Centre. I do recognise that there may be a disadvantage with CCTV operators not having access to Airwave and I will keep the policy under review.” Source location Response from West Mercia 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.
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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 West Mercia 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 West Mercia 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 West Mercia 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
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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 Present the locally developed training material to the College of Policing and NPCC licensing lead for consideration as a national programme.
Verbatim wording from the response “In absence of a national or College of Policing accredited training package, West Mercia Police are currently working with the Firearms and Explosives Licensing Working Group (FELWG) to present the locally developed material to College of Policing and to the NPCC Lead for Firearms and Explosive Licensing with a view that it is considered for adoption (or further developed by COP) as the national Firearms and Explosive training programme.” Source location Response from West Mercia 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 Deliver the locally developed firearms licensing training package to all Firearms Licensing Unit staff through induction and continuing professional development.
Verbatim wording from the response “West Mercia Police have a robust scrutiny and assessment process and have taken the initiative to develop a training package for the receipt by all staff as part of initial induction and Continuous Professional Development (CPD). This training package has been subject of a local Learning Needs Assessment (LNA) with colleagues in Learning and Development, set against the Statutory Guidance that existed at that time.” Source location Response from West Mercia Police
Open published response
Concerns raised 4 Failure to classify people presenting indicators of vulnerability as vulnerable persons rather than absconding suspects View source Inconsistent understanding of risk of harm among police duty sergeants View source Failure to make a further NPAS helicopter request when a person who has absconded may be at risk of harm View source Lack of shared understanding between police forces and NPAS about what each may expect of the other View source See 1 more concern
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
Tyrone Lock · 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
Tyrone Lock left a hotel wearing only boxer shorts and socks on a cold, windy night and was found deceased two days later in a pond. The jury concluded that he should have been classified as a vulnerable person rather than an absconder, and that a second helicopter request should have been made; it identified police failings contributing to his death.
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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Failure to classify people presenting indicators of vulnerability as vulnerable persons rather than absconding suspects
Wider context from the report “(1) The jury concluded that Tyrone should have been assessed differently from the first male and should have been classified as a vulnerable person and not as a suspect that was absconding .
(2) The jury believed that a second request for a helicopter should have been issued and that it would have been deployed and that in this case there would have been a chance to find Tyrone in a survivable state.
(3) Collectively there was information available to the police from the OIS logs, what was said to them by the night manager and from their own observations that Tyrone’s departure could be described as “hallucinating, foaming/frothing at the mouth, spaced out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks only. It was very cold, 4 degrees, it was windy and he ran out into open ground with water courses with somebody out to get him and on the police log according to the night manager an ambulance probably would be a good idea.” It was on this evidence that the jury concluded that Tyrone should have been classified as a vulnerable person .
(4) On that information witnesses from the National Police Air Service (NPAS) confirmed that they would have classified Tyrone as a vulnerable person and would have made every effort to deploy a helicopter to the scene. NPAS further indicated that because one request in the same incident had met with a refusal that did not mean a second request would also be refused. Each request would be dealt with on its own merits. Here a second call would have been treated as a top priority job. NPAS would not be concerned with why someone was running away from the police, their concern would be, having run away, that was he at risk of harm.
(5) Contrary to the NPAS evidence the police officers concerned believed that, regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request. Further two duty sergeants involved on the Saturday and Monday mornings had different views as to what risk of harm meant. One thought it meant risk of suicide only, the other that it would extend to non-fatal or accidental harm.
(6) As NPAS serves all police forces in England and Wales they are included in this report so that:
a. They may liaise with West Mercia Police as to any lack of understanding as to what one may expect of the other.
b. To review whether any other police force may also have a similar lack of understanding.
” 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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding of risk of harm among police duty sergeants
Wider context from the report “(1) The jury concluded that Tyrone should have been assessed differently from the first male and should have been classified as a vulnerable person and not as a suspect that was absconding.
(2) The jury believed that a second request for a helicopter should have been issued and that it would have been deployed and that in this case there would have been a chance to find Tyrone in a survivable state.
(3) Collectively there was information available to the police from the OIS logs, what was said to them by the night manager and from their own observations that Tyrone’s departure could be described as “hallucinating, foaming/frothing at the mouth, spaced out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks only. It was very cold, 4 degrees, it was windy and he ran out into open ground with water courses with somebody out to get him and on the police log according to the night manager an ambulance probably would be a good idea.” It was on this evidence that the jury concluded that Tyrone should have been classified as a vulnerable person.
(4) On that information witnesses from the National Police Air Service (NPAS) confirmed that they would have classified Tyrone as a vulnerable person and would have made every effort to deploy a helicopter to the scene. NPAS further indicated that because one request in the same incident had met with a refusal that did not mean a second request would also be refused. Each request would be dealt with on its own merits. Here a second call would have been treated as a top priority job. NPAS would not be concerned with why someone was running away from the police, their concern would be, having run away, that was he at risk of harm.
(5) Contrary to the NPAS evidence the police officers concerned believed that, regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request. Further two duty sergeants involved on the Saturday and Monday mornings had different views as to what risk of harm meant . One thought it meant risk of suicide only, the other that it would extend to non-fatal or accidental harm .
(6) As NPAS serves all police forces in England and Wales they are included in this report so that:
a. They may liaise with West Mercia Police as to any lack of understanding as to what one may expect of the other.
b. To review whether any other police force may also have a similar lack of understanding.
” 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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Failure to make a further NPAS helicopter request when a person who has absconded may be at risk of harm
Wider context from the report “(1) The jury concluded that Tyrone should have been assessed differently from the first male and should have been classified as a vulnerable person and not as a suspect that was absconding.
(2) The jury believed that a second request for a helicopter should have been issued and that it would have been deployed and that in this case there would have been a chance to find Tyrone in a survivable state.
(3) Collectively there was information available to the police from the OIS logs, what was said to them by the night manager and from their own observations that Tyrone’s departure could be described as “hallucinating, foaming/frothing at the mouth, spaced out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks only. It was very cold, 4 degrees, it was windy and he ran out into open ground with water courses with somebody out to get him and on the police log according to the night manager an ambulance probably would be a good idea.” It was on this evidence that the jury concluded that Tyrone should have been classified as a vulnerable person.
(4) On that information witnesses from the National Police Air Service (NPAS) confirmed that they would have classified Tyrone as a vulnerable person and would have made every effort to deploy a helicopter to the scene . NPAS further indicated that because one request in the same incident had met with a refusal that did not mean a second request would also be refused. Each request would be dealt with on its own merits. Here a second call would have been treated as a top priority job . NPAS would not be concerned with why someone was running away from the police, their concern would be, having run away, that was he at risk of harm.
(5) Contrary to the NPAS evidence the police officers concerned believed that, regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request . Further two duty sergeants involved on the Saturday and Monday mornings had different views as to what risk of harm meant. One thought it meant risk of suicide only, the other that it would extend to non-fatal or accidental harm.
(6) As NPAS serves all police forces in England and Wales they are included in this report so that:
a. They may liaise with West Mercia Police as to any lack of understanding as to what one may expect of the other.
b. To review whether any other police force may also have a similar lack of understanding.
” 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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between police forces and NPAS about what each may expect of the other
Wider context from the report “(1) The jury concluded that Tyrone should have been assessed differently from the first male and should have been classified as a vulnerable person and not as a suspect that was absconding.
(2) The jury believed that a second request for a helicopter should have been issued and that it would have been deployed and that in this case there would have been a chance to find Tyrone in a survivable state.
(3) Collectively there was information available to the police from the OIS logs, what was said to them by the night manager and from their own observations that Tyrone’s departure could be described as “hallucinating, foaming/frothing at the mouth, spaced out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks only. It was very cold, 4 degrees, it was windy and he ran out into open ground with water courses with somebody out to get him and on the police log according to the night manager an ambulance probably would be a good idea.” It was on this evidence that the jury concluded that Tyrone should have been classified as a vulnerable person.
(4) On that information witnesses from the National Police Air Service (NPAS) confirmed that they would have classified Tyrone as a vulnerable person and would have made every effort to deploy a helicopter to the scene. NPAS further indicated that because one request in the same incident had met with a refusal that did not mean a second request would also be refused. Each request would be dealt with on its own merits. Here a second call would have been treated as a top priority job. NPAS would not be concerned with why someone was running away from the police, their concern would be, having run away, that was he at risk of harm.
(5) Contrary to the NPAS evidence the police officers concerned believed that, regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request. Further two duty sergeants involved on the Saturday and Monday mornings had different views as to what risk of harm meant. One thought it meant risk of suicide only, the other that it would extend to non-fatal or accidental harm.
(6) As NPAS serves all police forces in England and Wales they are included in this report so that:
a. They may liaise with West Mercia Police as to any lack of understanding as to what one may expect of the other .
b. To review whether any other police force may also have a similar lack of understanding.
” 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 Maintain an organisation-wide programme developing officers and staff to identify and manage vulnerability and protect people from harm.
Verbatim wording from the response “I can confirm that in terms of supporting officers and staff West Mercia Police has already embarked on an extensive programme of work to raise awareness and understanding of vulnerability. We are keen that our people are professionally curious and recognise where those who cannot help themselves may require our help, support and intervention.” Source location 2016-0355-Response-by-West-Mercia-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 Finalize a vulnerability strategy incorporating nationally recognized effective practice.
Verbatim wording from the response “I can confirm that in terms of supporting officers and staff West Mercia Police has already embarked on an extensive programme of work to raise awareness and understanding of vulnerability. We are keen that our people are professionally curious and recognise where those who cannot help themselves may require our help, support and intervention.” Source location 2016-0355-Response-by-West-Mercia-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 vulnerability-related training, online learning and knowledge checks across public-protection disciplines.
Verbatim wording from the response “To increase our professionalism further, officers and staff have been provided with an ongoing programme of development built around protecting people from harm. Officers and staff with specialist knowledge have provided training across the 13 strands of public protection, including high harm areas such as mental health and missing persons. These sessions are also supported by an extensive programme of on-line learning and knowledge checks provided by the College of Policing.” Source location 2016-0355-Response-by-West-Mercia-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 Introduce the THRIVE model across the force to support information gathering, risk assessment and public protection decisions.
Verbatim wording from the response “We have complemented the NDM by introducing the THRIVE model, (Threat, Harm, Risk, Investigation, Vulnerability, Engagement) across the Force. NDM and THRIVE both provide a framework for officers and staff to seek out as much information that they can and make sound rational decisions to protect the public.” Source location 2016-0355-Response-by-West-Mercia-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 fuller explanations when NPAS attendance is declined so officers can reassess whether a further request is necessary.
Verbatim wording from the response “Further, in consultation with NPAS, we have ensured that where attendance is declined, a fuller explanation setting out the reasons for non-attendance is provided. This additional information will assist officers on the ground to review the information they have, to re-assess whether another request may be necessary. This was an important aspect of this particular case and I am satisfied that this change in procedure will help to ensure that further secondary requests for air support are always considered in the future.” Source location 2016-0355-Response-by-West-Mercia-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 the National Decision Model across West Mercia for structured assessment and decision-making.
Verbatim wording from the response “The use of the National Decision Making Model (NDM) is embedded across West Mercia. The NDM has six key elements. Each provides frontline officers and staff with an area for focus and consideration and can be applied to a range of circumstances.” Source location 2016-0355-Response-by-West-Mercia-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 Roll out the piloted “see beyond the obvious” vulnerability programme across West Mercia in 2017.
Verbatim wording from the response “We have piloted a programme within the Telford area which encourages officers and staff to see beyond the obvious and think wider. This will be rolled out across West Mercia in 2017.” Source location 2016-0355-Response-by-West-Mercia-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 Consult with NPAS and disseminate clear guidance on aircraft call-out procedures, capability and the possibility of making a second request.
Verbatim wording from the response “Throughout the investigation into Tyrone’s death, there has been extensive consultation with colleagues in NPAS in order that we better understand the NPAS call out procedure and ensure that this is clearly articulated to operational officers and staff.” Source location 2016-0355-Response-by-West-Mercia-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 vulnerability training and improvements with NPAS are considered sufficient; the force has done all it can to prevent recurrence.
Verbatim wording from the response “I am satisfied that with the extensive programme of vulnerability training already underway, coupled with the ongoing improvements already put in place with NPAS colleagues, the force has done all it can to prevent such a circumstance arising again.” Source location 2016-0355-Response-by-West-Mercia-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 NPAS is separately responsible for reviewing whether other police forces had a similar lack of understanding.
Verbatim wording from the response “b) I understand that NPAS are actioning this point separately and have responded to you directly.” Source location 2016-0355-Response-by-West-Mercia-Police
Open published response
3 Mar 2016 STEWART AKINS · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure to communicate custody-recorded suicide and self-harm risks for full MG7 preparation View source Failure to raise suicide and self-harm risks with the prosecutor before bail decisions 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
STEWART AKINS · 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 25 May 2015, Stewart Akins took his own life by placing himself in the path of a train after being released on conditional bail following his arrest. The report raised concerns that his repeated statements indicating a high risk of suicide or self-harm were not communicated to the prosecution or Magistrates’ Court, resulting in the risk being significantly downplayed and no objection to bail being made.
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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate custody-recorded suicide and self-harm risks for full MG7 preparation
Wider context from the report “(1) Throughout Mr. Akins' time in custody, entries were made on the custody record which recorded his repeatedly stated intention to end his own life. Statements to that effect were recorded as having been made, inter alia, to the Custody Sergeant, ████████ to a nurse, to a Forensic Medical Examiner ████████ and to the officer in charge of the investigation ████████ at the end of his police interview. The view was taken that he presented a high risk of suicide/self-harm.
(2) The officer in charge of the investigation into the offences with which Mr. Akins was eventually charged, ████████ submitted an MG7 remand application form for consideration by the Crown Prosecution Service, and with a view to bail being opposed in the Magistrates' Court. In that form, she set out of objections on a number of grounds including a remand for Mr. Akins' own protection. However, in giving details substantiating that particular ground for opposing bail she stated:
"AKINS has a problem with alcohol and mental health, clearly a combination that does not mix well. AKINS spoke of his suffering with post traumatic stress disorder (PTSD) and there is a real concern that, being charged with offences and now being NFA, he may pose a significant risk to not only those he encounters, but also to himself. It is therefore requested that a remand in custody be sought for AKINS own protection."
(3) ████████ evidence at the inquest was that those details substantiating that ground for opposing bail ( for Mr. Akins' own protection ) were based solely on her own dealings with Mr. Akins, and not on what was recorded in the Custody Record. In fact, she was not aware of any of the entries recorded on the Custody Record and was therefore not aware of the level of risk of suicide/self-harm which those in charge of his detention felt that Mr. Akins presented. She had not sought to check the Custody Record for any such entries, nor to speak to the Custody Sergeant, nor had the Custody Sergeant sought to make her aware of such entries.
(4) Because ████████ was unaware of the contents of these entries in the Custody Record, the description in the MG7 of the risk of suicide/self-harm which Mr. Akins presented was significantly downplayed.
(5) In addition to that under-reporting of risk, prior to the hearing in the Magistrates' Court ████████ was informed by the Senior Crown Prosecutor that she was considering agreeing to bail with certain conditions. Those conditions did not address the issue of risk of suicide/self-harm, but ████████ accepted that she had not sought to raise this with the prosecutor.
(6) A direct result of that under-reporting of risk of suicide/self-harm, and of ████████ failure to raise it with the prosecutor, was that the prosecutor was minded to agree to conditional bail as proposed. No objections to bail were raised with the Magistrates, and conditional bail was duly granted.
(7) I am therefore concerned that no chain of communication appeared to be in place whereby ████████ had made aware of the risks highlighted in the Custody Record, so that an MG7 could be properly and fully prepared.
(8) The explanations for this appear to be either:
(i) that provision does not exist generally for such a chain of communication to be in place; or
(ii) that provision does exist, and that ████████ and/or the Custody Sergeant(s) failed to operate in accordance with such provision.
” 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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Failure to raise suicide and self-harm risks with the prosecutor before bail decisions
Wider context from the report “(1) Throughout Mr. Akins' time in custody, entries were made on the custody record which recorded his repeatedly stated intention to end his own life. Statements to that effect were recorded as having been made, inter alia, to the Custody Sergeant, ████████ to a nurse, to a Forensic Medical Examiner ████████ and to the officer in charge of the investigation ████████ at the end of his police interview. The view was taken that he presented a high risk of suicide/self-harm.
(2) The officer in charge of the investigation into the offences with which Mr. Akins was eventually charged, ████████ submitted an MG7 remand application form for consideration by the Crown Prosecution Service, and with a view to bail being opposed in the Magistrates' Court. In that form, she set out of objections on a number of grounds including a remand for Mr. Akins' own protection. However, in giving details substantiating that particular ground for opposing bail she stated:
"AKINS has a problem with alcohol and mental health, clearly a combination that does not mix well. AKINS spoke of his suffering with post traumatic stress disorder (PTSD) and there is a real concern that, being charged with offences and now being NFA, he may pose a significant risk to not only those he encounters, but also to himself. It is therefore requested that a remand in custody be sought for AKINS own protection."
(3) ████████ evidence at the inquest was that those details substantiating that ground for opposing bail ( for Mr. Akins' own protection ) were based solely on her own dealings with Mr. Akins, and not on what was recorded in the Custody Record. In fact, she was not aware of any of the entries recorded on the Custody Record and was therefore not aware of the level of risk of suicide/self-harm which those in charge of his detention felt that Mr. Akins presented. She had not sought to check the Custody Record for any such entries, nor to speak to the Custody Sergeant, nor had the Custody Sergeant sought to make her aware of such entries.
(4) Because ████████ was unaware of the contents of these entries in the Custody Record, the description in the MG7 of the risk of suicide/self-harm which Mr. Akins presented was significantly downplayed.
(5) In addition to that under-reporting of risk, prior to the hearing in the Magistrates' Court ████████ was informed by the Senior Crown Prosecutor that she was considering agreeing to bail with certain conditions. Those conditions did not address the issue of risk of suicide/self-harm, but ████████ accepted that she had not sought to raise this with the prosecutor.
(6) A direct result of that under-reporting of risk of suicide/self-harm, and of ████████ failure to raise it with the prosecutor, was that the prosecutor was minded to agree to conditional bail as proposed. No objections to bail were raised with the Magistrates, and conditional bail was duly granted.
(7) I am therefore concerned that no chain of communication appeared to be in place whereby ████████ had made aware of the risks highlighted in the Custody Record, so that an MG7 could be properly and fully prepared.
(8) The explanations for this appear to be either:
(i) that provision does not exist generally for such a chain of communication to be in place; or
(ii) that provision does exist, and that ████████ and/or the Custody Sergeant(s) failed to operate in accordance with such provision.
” 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 Require the responsible custody sergeant to verify and sign every Prisoner Escort Form before a detainee leaves or moves from custody, ensuring documented risks are communicated.
Verbatim wording from the response “It is clear that there were failings in suitably communicating the degree of risk that was posed by Mr Akins following his movement from custody to the Magistrates Court. As a result of this incident West Mercia Police have immediately revised its’ practice to minimise risk and prevent future deaths by ensuring that all Prisoner Escort Forms (PER), whether completed by a detention officer or sergeant, are signed as accurate by the custody sergeant responsible for the detainees welfare prior to their release / movement from custody. The custody sergeant will have overall responsibility for ensuring that the risks are correctly documented and communicated. This practice will ensure that all known and documented risks contained within the custody record will travel with the person and properly inform their decision making processes.” Source location S-Akins-Response
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 Include in mandatory custody-sergeant training the requirement to highlight known risks and concerns to the officer in charge when considering an MG7 remand application.
Verbatim wording from the response “West Mercia has also ensured that mandatory training for custody sergeants includes the awareness of highlighting known risks and concerns to the OIC upon consideration of a MG7 remand application. This will enable prosecutors and the courts to make fully informed decisions about a person’s vulnerabilities and needs.” Source location S-Akins-Response
Open published response
Concerns raised 3 Failure to ensure explicit communication of wrong-way dual-carriageway travel during police pursuits View source Failure to align local police pursuit policy and training with national guidance View source Unavailability of dash-cam recording from pursuing police vehicles 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
Stefen Neil BOSWELL · 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
Following a car-key burglary in Craven Arms on 6 June 2014, Stefen Neil Boswell was involved in a police pursuit and died after the vehicle lost control at Emstrey Island. The jury concluded that he died from multiple injuries due to a road traffic collision. Concerns included differences between local and national police-pursuit policies, communication about travelling on the wrong side of a dual carriageway, and the absence of dash-camera recording from the pursuing police vehicle.
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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure explicit communication of wrong-way dual-carriageway travel during police pursuits
Wider context from the report “7) At the time of the pursuit the pursuing police driver believed that the supervising inspector would have known that he was travelling on the wrong side of the dual carriageway. The supervising inspector, who was not based in the immediate area, did not know and when she did the pursuit was abandoned. Local knowledge cannot be guaranteed in a regional police force and systems should be in place that if such a situation were to reoccur, the police driver should expressly state, and the supervising inspector expressly request, if the police vehicle is travelling on the wrong side of a dual carriageway.
” 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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Failure to align local police pursuit policy and training with national guidance
Wider context from the report “1) The West Mercia Police policy states that ‘at no time must police patrols pursue the wrong way along dual carriageways/motorways’.
2) This policy appears at variance with national policy. A report from the Association of Chief Police Officers, Police Pursuits Review Group, dated 3rd November 2014 (the ACPO report) states, in part:
• ‘we draw reference to the views of the national ACPO portfolio on pursuits, which consider that in exceptional circumstances such decision making may be justifiable’.
• ‘entering a dual carriageway contrary to the normal directional flow is extremely high risk and potentially very dangerous for reasons which are obvious. Such decision making is one for the officer himself to justify ... It is the view of the ACPO pursuits group that such decisions should only be made in rare and exceptional circumstances’.
• ‘travelling the wrong way down a dual carriageway is not something we would endorse as suitable unless exceptional circumstances prevail and it is necessary and proportionate to attempt this tactic based upon the high degree of threat, risk and harm required to justify this decision’.
3) The evidence of the police driver training instructor, since retired, was that he had trained the police driver concerned in accordance with national guidance, in so far as the police driver, as accepted by the jury, followed the stolen car on the wrong side of the dual carriageway and justified his decision to do so.
4) Without challenging the evidence given by the driver training instructor West Mercia Police state that the training, as given, differed from and was not their policy.
5) On the face of it therefore is a difference between local and national policies, resulting in the possibility that a police officer, in one area, may pursue a vehicle on the wrong side of a dual carriageway, when another officer in the same set of circumstances, in another area, may not.
6) The ACPO report stated that the national Authorised Professional Practice (APP) document covering police pursuits should be the guide and accepted policy for pursuit management, thereby ensuring consistency and standards are applied.
” 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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of dash-cam recording from pursuing police vehicles
Wider context from the report “9) The pursing police vehicle did not have a dash cam recorded on-board. If it had considerable time would have been avoided at the inquest in seeking to establish and/or resolve the factual circumstances leading to and the course of the police pursuit. The absence of a dash cam could not be said to have caused or contributed to the accident nor arguably could it be said likely to cause or contribute to another. It is though possible that lessons could be learnt from replaying such a recording which may in turn prevent other deaths. Further it may in part discharge the State’s obligation to investigate deaths which could be said to have been caused by an act or omission of a police officer.
” 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 Align pursuit policies, driver-training materials and learning outcomes with College of Policing Authorised Professional Practice.
Verbatim wording from the response “In the intervening time since the collision, West Mercia Police and Warwickshire Police have gone through a period of harmonising policies and procedures. During this time we have taken the opportunity to align these with the Authorised Professional Practice (APP) as set out by the College of Policing. As an Alliance we follow APP and conduct pursuit training to this standard. There no longer exists an Alliance or force policy in relation to pursuits, accepting APP as best practice. All driver trainers train to APP and all lesson plans and learning outcomes refer to it. We have consulted with the National Police Chiefs’ Council lead on Pursuits, DCC Anthony Bangham, and he is also reassured that the Warwickshire and West Mercia position does not differ from the APP.” Source location Response from West Mercia 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 Complete tendering and evaluation for a dash-camera system for the pursuit and firearms fleet.
Verbatim wording from the response “In relation to dash cam footage, I can report that in December 2015 we formally put the contract out to tender which was then followed by an evaluation phase which concluded in January 2016. It is anticipated that we will award the contract at the end of March. Thereafter, it is hoped to begin procurement and configuration in April with a full roll-out across the pursuit and firearms fleet anticipated to commence from 5th July onwards.” Source location Response from West Mercia 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 Emphasise timely risk updates, train pursuit commanders to call off inadequately informed pursuits, and require OCC inspectors to prompt and challenge risk assessments.
Verbatim wording from the response “In order to provide effective command across the Alliance, we have now moved to a model of one Operational Control Centre (OCC) Inspector across the two forces. It is, therefore,” Source location Response from West Mercia 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 No separate Alliance or force pursuit policy is maintained because the forces follow College of Policing Authorised Professional Practice.
Verbatim wording from the response “Training and Policies - Police Pursuits” Source location Response from West Mercia 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 Full telematics and dash-camera implementation was delayed by procurement requirements and the need to spend wisely during technological change.
Verbatim wording from the response “All police vehicles entering service are now currently fitted with an Information Data Recorder (IDR). There are now only a few vehicles on the fleet which do not have this capability and they will soon be replaced. The Alliance has put out to tender and is now in the process of signing contracts with a supplier to bring a far more advanced telematics system to all operational police vehicles. We envisage that we will enter the trial phase of the new system in March 2016 with a view to rolling out across the wider fleet by June 2016.” Source location Response from West Mercia Police
Open published response
Concerns raised 3 Failure to share significant safeguarding information between concerned professionals View source Failure to refer and assess an adult at risk as a vulnerable adult or victim of domestic violence View source Failure to inform an adult at risk of increased domestic violence risk 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
Christine Ann WILLIAMSON · 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 Williamson, aged 62, died following a physical assault by her husband, who had advanced Alzheimer’s dementia and was unaware of his actions or their consequences. The concerns included the absence of an earlier referral and assessment of her as a vulnerable adult at risk, and inadequate information sharing that might have enabled preventative measures.
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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Failure to share significant safeguarding information between concerned professionals
Wider context from the report “(2) Had such an earlier assessment as a Vulnerable Adult been made then discussions would have taken place with all concerned with every having significant information sharing it with others . This would have increased the likelihood that preventative measures would have been put in place as the deceased being better or fully informed as to the increased risk she was putting herself in by continuing to live with her husband whose condition was deteriorating. The best illustration of this lack of shared information is that the evidence given at the Inquest when all relevant witnesses were present, should have taken place in a meeting before the situation became critical.
” 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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Failure to refer and assess an adult at risk as a vulnerable adult or victim of domestic violence
Wider context from the report “(1) A referral and assessment should have been made that the deceased was a Vulnerable Adult at risk from her husband . Such a referral and assessment could have been made before or after April 2012, but most notably on or around the 2nd - 4th April 2012 when the deceased’s GP made a direct referral to social services. This should have led to an assessment as a Vulnerable Adult but if not as the victim of domestic violence .
” 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 West Mercia Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform an adult at risk of increased domestic violence risk
Wider context from the report “(2) Had such an earlier assessment as a Vulnerable Adult been made then discussions would have taken place with all concerned with every having significant information sharing it with others. This would have increased the likelihood that preventative measures would have been put in place as the deceased being better or fully informed as to the increased risk she was putting herself in by continuing to live with her husband whose condition was deteriorating. The best illustration of this lack of shared information is that the evidence given at the Inquest when all relevant witnesses were present, should have taken place in a meeting before the situation became critical.
” 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 Provide all operational staff with a reminder to complete DASH, crime reports and vulnerable adult documentation.
Verbatim wording from the response “Response: This recommendation is not relevant to West Mercia Police as all operational staff are trained in the DASH risk assessment process. There are policies and procedures in place to guide staff and the DASH risk assessment process is regularly audited by the Business Assurance” Source location 2013-0371-Response-by-West-Mercia-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 Recognising vulnerable adults is considered sufficient to trigger referral for specialised assistance, without individualised dementia training.
Verbatim wording from the response “Recommendation 7 – Support Services
All agencies need to review their service responses to people who suffer from Alzheimer’s and other Dementia Diseases and their Carers. This should be done in partnership with groups such as the Alzheimer’s Society who have significant knowledge and understanding of the issues.” Source location 2013-0371-Response-by-West-Mercia-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 DASH training, policies, procedures and auditing are considered sufficient for domestic violence responses.
Verbatim wording from the response “Recommendation 6 – Domestic Violence
All agencies must ensure that there are improvements in service responses for all domestic violence victims (both adults and children), all relevant staff to attend multi-agency training programme based on the DASH model.” Source location 2013-0371-Response-by-West-Mercia-Police
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations