Concerns raised 3 Failure to provide specific briefing discussion or direction on when to announce “armed police” View source Insufficient training and guidance on positioning firearms officers close to property entrances View source Lack of clear and consistent guidance and training on timing and factors for announcing “armed police” during containment and call-out operations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
SEAN FITZGERALD · 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 4 January 2019 in Coventry, Sean Fitzgerald emerged from the rear door of a house during a West Midlands Police firearms operation and was shot in the chest by a police firearms officer. He died at 6.55pm despite first aid and medical treatment. The report identifies concerns about inconsistent guidance and training on when to announce “armed police” and how firearms officers should position themselves near property entrances, including the risks associated with close proximity.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide specific briefing discussion or direction on when to announce “armed police”
Wider context from the report “(1) Training and practice in relation to timing of any announcement of “armed police” in police firearms operations involving containment of properties
In the police operation in which Mr Fitzgerald was killed, the officers employed the tactic of “contain and call out with limited entry.” This involves firearms officers “containing” a property by surrounding it and providing firearms cover with their weapons; creating a breach by forcing entry; and “calling out” the subjects inside (directing them to leave through the point of breach), without the officers themselves entering. In evidence, it was explained that this is a very common tactic, which is used in a range of scenarios.
████████ a former senior firearms officer and armed policing lead within the College of Policing, gave evidence in the inquest. He explained that an integral part of the tactic is for officers to announce their presence by loud shouts of “armed police.” This warns those inside the property that it is the police forcing entry and informs them that the officers are armed. It was explained that this warning helps to avoid confusion and encourage compliance, thereby reducing the risk of harm to officers and occupants. The timing of the announcement is plainly important, and any potential for confusion or for making the announcement at the wrong time risks fatal consequences.
████████ said that the timing of any such announcement is not prescribed by national training or guidance, and that there is no “template” for when it should be done, although he understood that it would usually be made after achieving a breach (e.g. breaking down a door). The procedural and training documents (both national and from WMP) which were put in evidence in the inquest gave no detailed guidance on the subject. The Chief Firearms Instructor at WMP, ████████, gave evidence that WMP trains its officers to make the announcement after achieving a breach.
The evidence of the officers involved in the operation as to the recommended or standard practice was inconsistent. The Strategic Firearms Commander said that he expected officers to announce themselves as armed police as soon as they were in position. The Operational Firearms Commander said that the shout should first be made as soon as the chainsaw was being applied to the door and again as the breach was made. One further member of the team said that he thought best practice was to give the shout as the chainsaw was being applied, but acknowledged that he had not done so on this occasion. Several other members of the team thought that proper practice was only to make the announcement after the door had been breached.
The firearms briefing told the officers that method of entry would be conducted and “[o]nce breached, challenges will be made at the threshold and suspects will be handcuffed”. There was no further discussion or direction about when the officers should first announce their presence .
In the event, the officers at the front of the property did not shout “armed police” before breaking down the two doors at the front of the property. Before any announcement was made, Mr Fitzgerald left through the rear door of the premises and was shot by Officer K, who was providing rear containment.
In these circumstances, I am concerned that the guidance and training given to firearms officers on tactics of containing and entering properties (and specifically in relation to the containment and call out with limited entry tactic) does not ensure a clear and consistent understanding of when they should announce their presence, or what factors to consider in deciding when to make the announcement. I am also concerned that the topic was not the subject of more specific discussion or direction in the briefing .
It is important that officers conducting these kinds of highly challenging firearms operation should have proper guidance on this subject. If the approach of different officers is inconsistent, there is the clear potential for mistakes to be made and for the lives of officers and others to be put at risk. I appreciate that expert firearms training officers are best placed to produce any further guidance, and that it may not be possible to have a hard and fast rule. However, the inconsistent views of highly trained officers which were given in this inquest indicate that the subject ought to be further addressed in training and in formal guidance.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and guidance on positioning firearms officers close to property entrances
Wider context from the report “(2) Training and practice in relation to positioning of firearms officers in operations against properties (including consideration of the reactionary gap)
As set out above, in this case, Officer K was standing between 7 and 8 feet from the rear door of the property as Mr Fitzgerald left. He discharged his firearm within just over half a second of the door beginning to open. The jury found that he had acted lawfully, meaning that he had perceived a threat and had used force commensurate with the threat he perceived. They also found that he had acted reasonably in taking up the position which he took, given the briefing he had received. Nevertheless, the evidence at the inquest gave cause for concern in relation to the training and guidance given to firearms officers on how they should position themselves in operations against properties.
In the inquest, two experts in cognition and perception, ████████ and ████████, explained that close proximity to a potential source of danger can have a psychological impact, significantly elevating a person’s perception of threat and potentially increasing the likelihood that they will respond with force. The experts considered that, in this case, such proximity was likely to have heightened Officer K’s perception of threat.
The inquest heard evidence about the concept of the “reactionary gap”, a distance which officers are often trained to maintain between themselves and a subject who presents a threat. In evidence, ████████ discussed this concept, explaining that distance gives officers more time to assimilate information and respond to an approaching threat. ████████ explained that maintaining a reactionary gap prevents officers from being “closed down” by subjects. He said that officers are trained on the importance of distance in the context of containment tactics.
The firearms training and guidance materials considered in evidence made limited reference to positioning and the reactionary gap. The WMP training materials required students to demonstrate an appropriate reactionary gap in one training exercise and to explain its importance in another. The College of Policing’s Authorised Professional Practice on Armed Containment described the benefit of distance, but in terms of reducing stress, tension and the likelihood of a close quarter confrontation. None of the materials gave any detailed consideration to the risks presented by close proximity (including close proximity to entrances rather than subjects) in the context of armed containment of properties . None explained the potential impact of proximity on threat perception and the likelihood that an officer will respond with potentially lethal force .
I am concerned that the training and guidance given to firearms officers on how to position themselves, especially in operations against properties, does not include detailed consideration of the risks of taking up position in close proximity to entrances. It does not appear to address the effects of proximity on threat perception and the use of force .
As with the first matter of concern, I recognise that it should be for expert firearms training officers to decide how to deal with this subject in training and guidance, and that there will inevitably be situations where a firearms officer has to take up position very close to a doorway or other entrance when containing a property. However, there appears to be a need for further consideration of this issue in the interest of minimising the risks of mistake of fact shootings in the future.
Finally, I should stress that in raising this matter of concern, I am not detracting from the jury’s conclusions that Officer K’s use of force was lawful and that his decision on where to position himself was reasonable in light of the briefing and intelligence.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and consistent guidance and training on timing and factors for announcing “armed police” during containment and call-out operations
Wider context from the report “(1) Training and practice in relation to timing of any announcement of “armed police” in police firearms operations involving containment of properties
In the police operation in which Mr Fitzgerald was killed, the officers employed the tactic of “contain and call out with limited entry.” This involves firearms officers “containing” a property by surrounding it and providing firearms cover with their weapons; creating a breach by forcing entry; and “calling out” the subjects inside (directing them to leave through the point of breach), without the officers themselves entering. In evidence, it was explained that this is a very common tactic, which is used in a range of scenarios.
████████ a former senior firearms officer and armed policing lead within the College of Policing, gave evidence in the inquest. He explained that an integral part of the tactic is for officers to announce their presence by loud shouts of “armed police.” This warns those inside the property that it is the police forcing entry and informs them that the officers are armed. It was explained that this warning helps to avoid confusion and encourage compliance, thereby reducing the risk of harm to officers and occupants. The timing of the announcement is plainly important, and any potential for confusion or for making the announcement at the wrong time risks fatal consequences.
████████ said that the timing of any such announcement is not prescribed by national training or guidance, and that there is no “template” for when it should be done , although he understood that it would usually be made after achieving a breach (e.g. breaking down a door). The procedural and training documents (both national and from WMP) which were put in evidence in the inquest gave no detailed guidance on the subject . The Chief Firearms Instructor at WMP, ████████, gave evidence that WMP trains its officers to make the announcement after achieving a breach.
The evidence of the officers involved in the operation as to the recommended or standard practice was inconsistent. The Strategic Firearms Commander said that he expected officers to announce themselves as armed police as soon as they were in position. The Operational Firearms Commander said that the shout should first be made as soon as the chainsaw was being applied to the door and again as the breach was made. One further member of the team said that he thought best practice was to give the shout as the chainsaw was being applied, but acknowledged that he had not done so on this occasion. Several other members of the team thought that proper practice was only to make the announcement after the door had been breached.
The firearms briefing told the officers that method of entry would be conducted and “[o]nce breached, challenges will be made at the threshold and suspects will be handcuffed”. There was no further discussion or direction about when the officers should first announce their presence.
In the event, the officers at the front of the property did not shout “armed police” before breaking down the two doors at the front of the property. Before any announcement was made, Mr Fitzgerald left through the rear door of the premises and was shot by Officer K, who was providing rear containment.
In these circumstances, I am concerned that the guidance and training given to firearms officers on tactics of containing and entering properties (and specifically in relation to the containment and call out with limited entry tactic) does not ensure a clear and consistent understanding of when they should announce their presence, or what factors to consider in deciding when to make the announcement . I am also concerned that the topic was not the subject of more specific discussion or direction in the briefing.
It is important that officers conducting these kinds of highly challenging firearms operation should have proper guidance on this subject. If the approach of different officers is inconsistent, there is the clear potential for mistakes to be made and for the lives of officers and others to be put at risk. I appreciate that expert firearms training officers are best placed to produce any further guidance, and that it may not be possible to have a hard and fast rule. However, the inconsistent views of highly trained officers which were given in this inquest indicate that the subject ought to be further addressed in training and in formal guidance.
” Open source report
30 Oct 2024 Sebastian Benjamin OLIVER · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure to account for current and fluctuating capacity when closing incident logs View source Failure to seek clarification and communicate effectively with medical colleagues about fluctuating or lacking capacity View source Shortcomings in training for incidents involving fluctuating or lacking capacity and absconding from treatment centres 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
Sebastian Benjamin OLIVER · 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
Sebastian Benjamin Oliver was found unresponsive on 29 November 2023 after sustaining an incised wound to his left hand while climbing a spiked fence under the influence of drugs, and he later died in hospital. The report identified concerns about West Midlands Police closing a safe-and-well-check log after Mr Oliver absconded from hospital, relying on an earlier capacity assessment despite a later assessment that he lacked capacity, and about shortcomings in training and communication with ambulance staff.
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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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to account for current and fluctuating capacity when closing incident logs
Wider context from the report “3. WMAS notified West Midlands Police ("WMP") and requested a "safe and well check". After determining he was not at the last known location, the decision was made by officers of WMP to close the log because WMAS had earlier deemed him to have capacity (following the 22:18 call).
4. However, the decision to close the log was an error - as a person's capacity can fluctuate, it was inappropriate for WMP to rely upon a past capacity assessment taken hours earlier in the evening , particularly when a more recent capacity assessment indicated that he lacked capacity and where WMAS were concerned enough to request a "safe and well check".
5. I stress that the evidence was clear at inquest that even if WMP had not closed the log, they may not have been able to find Mr Oliver as it was not known where he went in the two hours or so after he left hospital, before being recorded on CCTV at 02:55 at ████████, and being subsequently found unresponsive at 06:21. On the balance of probabilities therefore, it cannot be said that Mr Oliver would have been found had the log not been closed.
6. However, I am concerned that the decision to not seek clarification from WMAS as to Mr Oliver's capacity represents shortcomings in training and/or a failure to ensure that WMP properly and effectively communicate with medical colleagues in WMAS when dealing with incidents where patients have fluctuating or lack capacity and abscond from treatment centres. It is not clear whether this was a "one-off" issue localised to a specific officer, or whether it represents a larger or institutional issue.
7. It is easy to anticipate a similar situation occurring in the future which leads to a death that is preventable, particularly those involving vulnerable persons and those lacking capacity.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to seek clarification and communicate effectively with medical colleagues about fluctuating or lacking capacity
Wider context from the report “3. WMAS notified West Midlands Police ("WMP") and requested a "safe and well check". After determining he was not at the last known location, the decision was made by officers of WMP to close the log because WMAS had earlier deemed him to have capacity (following the 22:18 call).
4. However, the decision to close the log was an error - as a person's capacity can fluctuate, it was inappropriate for WMP to rely upon a past capacity assessment taken hours earlier in the evening, particularly when a more recent capacity assessment indicated that he lacked capacity and where WMAS were concerned enough to request a "safe and well check".
5. I stress that the evidence was clear at inquest that even if WMP had not closed the log, they may not have been able to find Mr Oliver as it was not known where he went in the two hours or so after he left hospital, before being recorded on CCTV at 02:55 at ████████, and being subsequently found unresponsive at 06:21. On the balance of probabilities therefore, it cannot be said that Mr Oliver would have been found had the log not been closed.
6. However, I am concerned that the decision to not seek clarification from WMAS as to Mr Oliver's capacity represents shortcomings in training and/or a failure to ensure that WMP properly and effectively communicate with medical colleagues in WMAS when dealing with incidents where patients have fluctuating or lack capacity and abscond from treatment centres . It is not clear whether this was a "one-off" issue localised to a specific officer, or whether it represents a larger or institutional issue.
7. It is easy to anticipate a similar situation occurring in the future which leads to a death that is preventable, particularly those involving vulnerable persons and those lacking capacity.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Shortcomings in training for incidents involving fluctuating or lacking capacity and absconding from treatment centres
Wider context from the report “3. WMAS notified West Midlands Police ("WMP") and requested a "safe and well check". After determining he was not at the last known location, the decision was made by officers of WMP to close the log because WMAS had earlier deemed him to have capacity (following the 22:18 call).
4. However, the decision to close the log was an error - as a person's capacity can fluctuate, it was inappropriate for WMP to rely upon a past capacity assessment taken hours earlier in the evening, particularly when a more recent capacity assessment indicated that he lacked capacity and where WMAS were concerned enough to request a "safe and well check".
5. I stress that the evidence was clear at inquest that even if WMP had not closed the log, they may not have been able to find Mr Oliver as it was not known where he went in the two hours or so after he left hospital, before being recorded on CCTV at 02:55 at ████████, and being subsequently found unresponsive at 06:21. On the balance of probabilities therefore, it cannot be said that Mr Oliver would have been found had the log not been closed.
6. However, I am concerned that the decision to not seek clarification from WMAS as to Mr Oliver's capacity represents shortcomings in training and/or a failure to ensure that WMP properly and effectively communicate with medical colleagues in WMAS when dealing with incidents where patients have fluctuating or lack capacity and abscond from treatment centres. It is not clear whether this was a "one-off" issue localised to a specific officer, or whether it represents a larger or institutional issue.
7. It is easy to anticipate a similar situation occurring in the future which leads to a death that is preventable, particularly those involving vulnerable persons and those lacking capacity.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update training lesson plans and inputs on the Mental Capacity Act, capacity assessments and partner-agency assessments for all staff.
Verbatim wording from the response “(vii) Training lesson plans and inputs to ensure: that the Mental Capacity Act, capacity assessments and partner agency assessments are inputted to all staff.” Source location Response from West Midlands 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 officers to obtain, record and share treating-clinician rationale when partner risk assessments differ, with learning fed into relevant working groups.
Verbatim wording from the response “(iii) Collaboration with partners: Officers will be reminded that they must consider risk from the stakeholder/partner perspective and obtain the rationale of the treating clinician where there is a difference. This should then be recorded utilising WMP systems and fed back to WMP supervisors and shared with the reporting partner agency. Whilst WMP can professionally challenge partners it is more appropriate to follow the process in the best interest of the public and inaccuracies be fed back within working groups such as Joint Strategic Operation Groups (JSOG) to aid future learning.” Source location Response from West Midlands 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 Continue Re-THRIVE quality assurance and communications requiring rationalised decision-making in THRIVE records, with particular focus on dispatch.
Verbatim wording from the response “In the event of a question about resourcing a log could be escalated to supervision to allocate resource and dispatch. This happened in Mr Oliver’s case following the second call from WMAS requesting a “safe and well”. A decision was then made by a supervisor not to attend. After the supervisory review it was transferred out of dispatch into the ‘FCRTF’ which is a queue for cases to be reviewed and closed. WMAS were advised WMP would not attend. The decision to close a log would be an individual decision also applying the ‘THRIVE’/RE-THRIVE risk assessment principles and a consideration of any change in circumstances which may affect a risk profile. Where a grading is changed or reviewed, in this case the supervisor, should completed a ‘Re-THRIVE’. They should detail their rational for a change in the THRIVE assessment on the log and, preferably, also in a new THRIVE form.” Source location Response from West Midlands 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 Reinforce through training that staff must re-THRIVE and record a full rationale when recommending non-police attendance.
Verbatim wording from the response “(viii) Training to reinforce to staff to re-THRIVE: and a complete a full rationale if recommending non-Police attendance.” Source location Response from West Midlands 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 Develop a hospital-absconder question set and related Force Contact training to gather information supporting deployment decisions without treating medical capacity as determinative.
Verbatim wording from the response “The following measures will also be introduced within the Force Contact environment as part of the continuous improvement of the Force Contact function service within WMP. These will focus on supporting individual decision makers who are required to make decisions in cases such as Mr Oliver’s where there is a question of capacity.” Source location Response from West Midlands 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 Refresh force-wide communications instructing staff to use only the latest medical capacity assessment in decision making.
Verbatim wording from the response “(vi) To refresh communications across WMP: via corporate communications, relating to medical assessment capacity on logs to use only the latest assessment in decision making.” Source location Response from West Midlands 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 mandatory Right Care, Right Person training to Force Contact staff and relevant frontline officers, including decision-support materials and phase-specific training.
Verbatim wording from the response “Additional training has been provided to WMP Force Contact Call Handlers to ensure that the right deployment decisions are made when calls are received from members of the public or partners. This was in the form of a ‘Blackboard’ hybrid learning package containing informative videos, theory and knowledge checks in addition to a ‘flowchart’ decision tree to support Force Contact’s decision making; this is easily accessible to all both via a link within the ControlWorks (WMP’s command and control system) and within the WMP Intranet page. This includes consideration as to whether the call relates to an Article 2 (immediate risk to life) or Article 3 (immediate threat of serious harm) issue, and where these are present to deploy a police resource only where there is a clear policing role.” Source location Response from West Midlands Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police cannot determine deployment solely from capacity status because officers are not medically trained to assess its implications.
Verbatim wording from the response “(i) Capacity: Vulnerability Desk to support in implementing training within Force Contact that creates a question set for Contact Handling in relation hospital absconders to assist in gaining all the appropriate information to aid decision making. The term ‘capacity’ should NOT bear relevance to WMP’s decision making on an individual as we are not medically trained to determine the potential outcome for an individual who does or does not have capacity. We cannot definitively state that we would deploy in all instances where an individual lacks capacity or not deploy if they do. Therefore, it is more appropriate to move away from this terminology so that it is not an unnecessary focal point of decision making.” Source location Response from West Midlands Police
Open published response
12 Aug 2024 Mr Parminder Singh Sanghera · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Failure to conduct a full Mental Health Act assessment before release from hospital or custody View source Failure of hospital and police custody risk assessments to identify suicide or self-harm risk before release 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
Mr Parminder Singh Sanghera · 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
Mr Parminder Singh Sanghera was arrested after displaying erratic behaviour, including running naked, and was taken to hospital before being held in police custody. He was released without charge on 13 February 2023 and was later found deceased in a canal near the custody suite. The principal concern was that, despite his behaviour and vulnerability, no full mental health assessment was undertaken before his release and risk assessments did not identify a risk of suicide or self-harm.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a full Mental Health Act assessment before release from hospital or custody
Wider context from the report “1. During the course of the inquest, I heard evidence Mr Sanghera was deemed to be suffering from behavioural issues rather than a mental health crisis and no full Mental Health Act assessment took place either at New Cross Hospital or whilst in custody at Oldbury Police station .
2. The risk assessments performed in hospital and police custody identified no concerns of risk of suicide or self-harm from release. However, evidence at the inquest showed that he was suffering from a mental health crisis at the time.
3. My concern is that given the erratic behaviour he was displaying and his vulnerability, further consideration should have been given for a full mental health act assessment to take place before release . Therefore, you may wish to consider reviewing the arrangements and assessments required before discharge from hospital or being released from custody.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital and police custody risk assessments to identify suicide or self-harm risk before release
Wider context from the report “1. During the course of the inquest, I heard evidence Mr Sanghera was deemed to be suffering from behavioural issues rather than a mental health crisis and no full Mental Health Act assessment took place either at New Cross Hospital or whilst in custody at Oldbury Police station.
2. The risk assessments performed in hospital and police custody identified no concerns of risk of suicide or self-harm from release . However, evidence at the inquest showed that he was suffering from a mental health crisis at the time .
3. My concern is that given the erratic behaviour he was displaying and his vulnerability, further consideration should have been given for a full mental health act assessment to take place before release. Therefore, you may wish to consider reviewing the arrangements and assessments required before discharge from hospital or being released from custody.
” 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 Audit pre-release risk assessments monthly to monitor and improve their quality.
Verbatim wording from the response “(i) Over 90% of custody staff have completed the College of Policing vulnerability in custody training;
(ii) Pre-release risk assessments are now subject to monthly audits to ensure quality;
(iii) Detained persons now receive a leaflet signposting to support service pathways, a copy of which is enclosed with this response;
(iv) The Health Care Provider specification now includes a requirement for their staff to have access to Summary Care Records (Mitie became the service provider on 1 September 2024 and have access to these records, whereas the previous provider did not). When the name, date of birth and address of the detained person is entered the Summary Care Records entry would provide an NHS number, GP details and potentially a pharmacy number.” Source location Response from West Midlands Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The statutory criteria for continued detention to enable a full mental health assessment were not met.
Verbatim wording from the response “A decision was made by the investigation team that the offence Mr Sangera was arrested for would be subject to No Further Action (NFA). Therefore, the power to legally detain Mr Sangera in police custody under the provisions of PACE ceased. The criteria for continued detention to allow for a full assessment by an approved mental health professional and doctor under s136(2) of the Mental Health Act 1983 (MHA), namely that the person appears to be suffering from a mental disorder and in need of immediate care and control, was not met. In a custody setting, this assessment is made by a custody sergeant in consultation with a registered medical practitioner.” Source location Response from West Midlands Police
Open published response
3 Jun 2024 Tcherno Bari · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 12 Failure to ensure police access to the written risk assessment View source Failure to provide attending police officers with the written risk rating View source Failure to maintain an accurate and up-to-date missing person policy View source Lack of police officer awareness of the required risk rating View source Failure to communicate the RCRP challenge process to BSMHFT View source Delays in communicating police disagreement with the reported risk category View source Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise View source Lack of formal notification of police disagreement about risk category View source Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients View source Failure to inform BSMHFT when missing patient investigations are closed View source Failure to invite police representatives to daily appraisal meetings View source Failure of routine monitoring to ensure completion of the risk rating View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tcherno Bari · 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
Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.
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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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police access to the written risk assessment
Wider context from the report “(7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment , or require attending constables, or later the Locate team, to request a copy of the risk assessment . In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide attending police officers with the written risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy . I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’ , and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an accurate and up-to-date missing person policy
Wider context from the report “(5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP . I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer awareness of the required risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’ . Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’ .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the RCRP challenge process to BSMHFT
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT . Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it . However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process . Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Delays in communicating police disagreement with the reported risk category
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later , and WMP often close missing patient investigations without informing BSMHFT.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise
Wider context from the report “(8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. RCRP and APP appear to regard reports from mental health clinicians no differently to those from members of the public, and family and friends of the missing person . Context: police witnesses agreed that BSMHFT clinicians were the experts on mental health diagnosis, including identifying those conditions that carry an increased risk of suicide, and assessing the risk of suicide generally. However, this case demonstrates how in the heat of the moment an (inexperienced) attending constable can overlook that expertise and quickly dismiss it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal notification of police disagreement about risk category
Wider context from the report “(6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category . BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients , and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case, and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform BSMHFT when missing patient investigations are closed
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to invite police representatives to daily appraisal meetings
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case , and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’ .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of routine monitoring to ensure completion of the risk rating
Wider context from the report “(2) A ‘monitoring tool’ in the BSMHFT Missing Patient Policy requires routine monitoring to ensure nurses are completing ‘appendix A’ and ‘appendix B’, but not ‘appendix C – risk rating’ . Context: I was told this is under review, however I was concerned this is still outstanding 9 months following the death .
” 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 Update the WMP student training programme to emphasise clinician risk assessments, rationale, recording, and the challenge process.
Verbatim wording from the response “The WMP student training programme and input with regard to missing persons will also be updated to reflect the importance of this conversation, giving due weight to a clinician’s risk assessment and rationale and recording this so the challenge process can be enacted, if appropriate.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the WMP Missing Person Policy to address daily appraisal attendance, clinician risk assessments, recording, and investigation-closure notifications.
Verbatim wording from the response “BSMHFT and send an appropriate staff member, as required. The WMP missing persons policy will be updated to reflect this.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a process for officers to request electronic risk assessments through a central Locate Team inbox with overnight supervisory monitoring.
Verbatim wording from the response “WMP recognise the importance that the BSMHFT risk assessment is shared with officers (referred to as ‘Appendix C’ in the PFD report) and that attending constables know to request this. Whilst officers will be reminded, within the policy update, to request a copy of the risk assessment and to take possession of it they will also be given an email address to provide to BSMHFT. BSMHFT will be asked to provide the risk assessment (Appendix C) electronically to this email address. The risk assessment will be received into the central Locate Team inbox ensuring a hard copy document is not misplaced and enabling timely supervisory review, if required. The Locate Team inbox is only monitored until 10pm. Therefore, for overnight issues the Duty Sergeant will be asked to monitor the inbox and to escalate any issues through supervision where appropriate.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and disseminate the partner escalation process, including direct access to the Force Duty Manager for decision reviews.
Verbatim wording from the response “HM Coroner was made aware of an escalation process that has also been put in place for our partner agencies during the inquest, should partners be concerned that a WMP colleague has not made the correct decision. The telephone number for contacting the most senior WMP officer on duty in the Force Contact Department has been shared (see Exhibit 1 below). This number allows partners to speak to the WMP Force Duty Manager directly, who will immediately seek a review of the decisions made.” Source location Response from West Midlands 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 mental health trust cannot formally record differing risk opinions because it lacks access to police systems.
Verbatim wording from the response “The PFD Report also addresses the issue of difference between the WMP and BSMHFT risk categories. BSMHFT does not have access to WMP systems or to the COMPACT log which is used to record a missing person investigation so could not use this to formally indicate a difference in opinion. However, the WMP missing persons policy will be updated to remind all officers, when attending such calls to identify the mental health trust’s risk category and to recognise the importance of clinician’s expertise in determining the risk assessment. Officers will be reminded that they must consider risk from the stakeholder/partner perspective and obtain the rationale of the treating clinician where there is a difference. This should then be recorded on COMPACT and fed back to WMP supervisors and shared with the reporting partner agency.” Source location Response from West Midlands Police
Open published response
13 Mar 2024 Jacob Michael Nicholas BILLINGTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to record prisoners’ GP and CMHT details in an easily accessible format View source Failure to establish effective information sharing for prison discharge coordination View source Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties View source Unclear responsibilities and case remit for the prison discharge coordinator role View source Failure to coordinate interagency release management and share critical information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacob Michael Nicholas BILLINGTON · 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
Jacob Michael Nicholas Billington was unlawfully killed when he was stabbed in the neck during a night out in Birmingham on 6 September 2020. The concerns included inadequate coordination and information-sharing between agencies during the release of a high-risk prisoner with serious mental health difficulties, and a lack of clear cross-agency guidance and understanding of responsibilities.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record prisoners’ GP and CMHT details in an easily accessible format
Wider context from the report “2. Sysmone Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Sysmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to establish effective information sharing for prison discharge coordination
Wider context from the report “4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties
Wider context from the report “3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibilities and case remit for the prison discharge coordinator role
Wider context from the report “4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate interagency release management and share critical information
Wider context from the report “1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include the resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning any are not traced and treated assertively in the community.
” 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 Work with MAPPA partners to ensure the prison discharge coordinator role and policy are understood and cascaded to police MAPPA teams.
Verbatim wording from the response “The issue will be addressed by the partners who manage the prisoner coordinator role and who amend the new policy. West Midlands Police will work with our MAPPA partners to ensure both the role and policy are both understood and cascaded to all staff within the police MAPPA teams.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Visit managed offenders after prison release regardless of their MAPPA process status.
Verbatim wording from the response “Finally, as explained in evidence during the inquest: West Midlands Police’s approach to visiting managed offenders has changed since Mr Billington’s death. The position now is that a West Midlands Police officer will try to visit a managed offender when they are released from prison, regardless of the status of the MAPPA process.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with agencies to clarify key roles and systems, improve information sharing and management, and protect the public.
Verbatim wording from the response “We will work with all agencies to understand key roles and systems to better share information, manage individuals and protect the public.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue updating ViSOR records for each individual so information can be shared across agencies.
Verbatim wording from the response “Visor is the shared IT system accessible to numerous agencies. West Midlands Police will ensure we continue to update Visor records for each individual to ensure information can be shared across agencies.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide policing support to partners concerning high-risk prisoners with mental health difficulties released at sentence end.
Verbatim wording from the response “This issue will be addressed by HMPPS, however we will ensure we provide support from a policing perspective to partners in relation to high-risk prisoners with mental health difficulties at their sentence end date. From a policing perspective, it is important to note that the IT systems now in place (as described in evidence during the inquest) have changed meaning that there are now better opportunities to identify someone if they have been assessed as being at an increased risk to themselves or others.” Source location Response from West Midlands 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 HMPPS will address cross-agency guidance for releasing high-risk prisoners with mental health difficulties at sentence end.
Verbatim wording from the response “This issue will be addressed by HMPPS, however we will ensure we provide support from a policing perspective to partners in relation to high-risk prisoners with mental health difficulties at their sentence end date. From a policing perspective, it is important to note that the IT systems now in place (as described in evidence during the inquest) have changed meaning that there are now better opportunities to identify someone if they have been assessed as being at an increased risk to themselves or others.” Source location Response from West Midlands 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 Access to and amendment of SystmOne are outside policing functions because it is used by healthcare professionals.
Verbatim wording from the response “As Systmone is an IT system used by healthcare professionals, West Midlands Police did not (and do not) have access to this system.” Source location Response from West Midlands 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 Partners managing the prison discharge coordinator role will address the role and amend the related policy.
Verbatim wording from the response “The issue will be addressed by the partners who manage the prisoner coordinator role and who amend the new policy. West Midlands Police will work with our MAPPA partners to ensure both the role and policy are both understood and cascaded to all staff within the police MAPPA teams.” Source location Response from West Midlands Police
Open published response
29 Sep 2023 Steven Sanders · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to adequately mitigate illicit substance use, entry and distribution within SAH View source Presence and supply of highly potent synthetic opioids View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Steven Sanders · 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
Steven Sanders was a detained patient at St Andrew's Healthcare who was found unresponsive and not breathing on 20 November 2022 after returning from authorised leave, and was pronounced deceased at 23:04. A pathologist initially attributed his death to coronary artery disease, but later information raised suspicion that he may have taken an illicit substance. The principal concern was that illicit substances were entering and being distributed within the hospital, creating a risk to life among vulnerable detained patients.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately mitigate illicit substance use, entry and distribution within SAH
Wider context from the report “Initially there was no evidence that illegal drugs were more widely being used and supplied within SAH and the hospital provided evidence of its policies and procedures for searches to address this risk and asserted that these policies and procedures were in appropriate operation.
However, on the 24th July 2023 I was informed that during a routine room search of Hurst ward (another secure ward in SAH Birmingham) over the weekend of the 22nd/23rd July 2023 a quantity of drugs and a lighter were discovered in a patient’s room. The patient (Patient A) whose room these items were found in alleged that these drugs were given to him by Mr Steven Sanders when they were both patients on Hawksley ward. SAH has confirmed that the patient and Mr Sanders were cared for on Hawksley ward at the same time prior to Mr Sanders’ death. The following further information was then provided by SAH on the 27th July 2023: the room search occurred on 23rd July, ████████ found in Patient A’s room, Patient A disclosed the substance ████████ from Mr Sanders on the day he died (20th November 2022) after Mr Sanders returned from unescorted leave, Patient A got ████████ from another patient, Patient B, whilst on Hawksley Ward. Patient A also disclosed that Patient B had brought ████████ into Hawksley Ward.
Subsequently, on the 24th July 2023 Patient A was found with what appeared to be cocaine in his room and he had hidden it in his anus during the room search on the 23rd July.
I wrote to the CQC and WMP on the 28th July 2023 explaining my concerns. I have not yet received any update on the action taken to date by the CQC. It was agreed at a meeting with WMP on the 11th August 2023 that they would conduct some enquiries, but I have not had any update on those enquiries.
Today I have become aware that on the 24th September 2023 a report was made to West Midlands Police that a patient had been supplying drugs to other patients. The details were that he had been keeping ████████. Three patients had tested positive for ████████ and a further 5 patients were acting under influence.
Also, on the 24th September 2023 another detained patient (Patient C) was found deceased lying on his bed in unexplained and unexpected circumstances. A separate investigation is being undertaken into Patient C’s death and it remains to be ascertained whether his death was drug related.
I am deeply concerned that the risk of illicit substance use is not being adequately mitigated at SAH and there is an endemic problem. This risk creates an obvious risk to life not merely from the risk of death inherent in illicit substance use but also because the population of SAH is particularly vulnerable: many suffer from mental illness affecting their judgement and assessment of risk, there will be a history of drug use amongst many patients and those patients taking illicit substances may not have an accurate perception of their tolerance due to their time in detention. The risk of death is also increased by the current presence of ████████ (new and highly potent synthetic opioids) ████████ being supplied within the West Midlands.
There needs to be an urgent and thorough investigation into all these incidents to identify how drugs are entering and being distributed within SAH and how this risk can be mitigated as far as possible 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Presence and supply of highly potent synthetic opioids
Wider context from the report “Initially there was no evidence that illegal drugs were more widely being used and supplied within SAH and the hospital provided evidence of its policies and procedures for searches to address this risk and asserted that these policies and procedures were in appropriate operation.
However, on the 24th July 2023 I was informed that during a routine room search of Hurst ward (another secure ward in SAH Birmingham) over the weekend of the 22nd/23rd July 2023 a quantity of drugs and a lighter were discovered in a patient’s room. The patient (Patient A) whose room these items were found in alleged that these drugs were given to him by Mr Steven Sanders when they were both patients on Hawksley ward. SAH has confirmed that the patient and Mr Sanders were cared for on Hawksley ward at the same time prior to Mr Sanders’ death. The following further information was then provided by SAH on the 27th July 2023: the room search occurred on 23rd July, ████████ found in Patient A’s room, Patient A disclosed the substance ████████ from Mr Sanders on the day he died (20th November 2022) after Mr Sanders returned from unescorted leave, Patient A got ████████ from another patient, Patient B, whilst on Hawksley Ward. Patient A also disclosed that Patient B had brought ████████ into Hawksley Ward.
Subsequently, on the 24th July 2023 Patient A was found with what appeared to be cocaine in his room and he had hidden it in his anus during the room search on the 23rd July.
I wrote to the CQC and WMP on the 28th July 2023 explaining my concerns. I have not yet received any update on the action taken to date by the CQC. It was agreed at a meeting with WMP on the 11th August 2023 that they would conduct some enquiries, but I have not had any update on those enquiries.
Today I have become aware that on the 24th September 2023 a report was made to West Midlands Police that a patient had been supplying drugs to other patients. The details were that he had been keeping ████████. Three patients had tested positive for ████████ and a further 5 patients were acting under influence.
Also, on the 24th September 2023 another detained patient (Patient C) was found deceased lying on his bed in unexplained and unexpected circumstances. A separate investigation is being undertaken into Patient C’s death and it remains to be ascertained whether his death was drug related.
I am deeply concerned that the risk of illicit substance use is not being adequately mitigated at SAH and there is an endemic problem. This risk creates an obvious risk to life not merely from the risk of death inherent in illicit substance use but also because the population of SAH is particularly vulnerable: many suffer from mental illness affecting their judgement and assessment of risk, there will be a history of drug use amongst many patients and those patients taking illicit substances may not have an accurate perception of their tolerance due to their time in detention. The risk of death is also increased by the current presence of ████████ (new and highly potent synthetic opioids) ████████ being supplied within the West Midlands.
There needs to be an urgent and thorough investigation into all these incidents to identify how drugs are entering and being distributed within SAH and how this risk can be mitigated as far as possible in the future.
” Open source report
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Midlands 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 Midlands 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 Midlands 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
11 Jan 2023 Leroy Patrick HAMILTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of inpatient mental health beds View source Lack of an agreed multi-agency protocol for informal patients absconding from emergency departments View source Failure to undertake and appropriately classify risk assessments for missing persons View source Failure to classify reported people as missing persons View source Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed View source Lack of Psychiatric decisions unit spaces View source See 3 more concerns
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. 10
Action
Create a Support Desk with continuity of staffing, increased supervisory oversight, focused Locate training and ongoing support for service calls including missing persons.
Stated completedThe respondent said that this action was complete when they made their response on 16 January 2023. View source
Action
Review priority and internally generated log recording, conduct quality assurance audits, provide feedback, and deliver missing-person training to Force Contact staff.
Stated completedThe respondent said that this action was complete when they made their response on 16 January 2023. View source
Action
Run a pilot introducing early Inspector review, central control and progression for missing-person investigations, with escalation and ongoing initial-stage management.
Stated in progressThe respondent said that this action was in progress when they made their response on 16 January 2023. View source
Action
Add priority-response call escalations as a standing monthly agenda item for senior missing-person governance.
Stated completedThe respondent said that this action was complete when they made their response on 16 January 2023. View source
Action
Conduct detailed audits of missing-person call handling, risk assessment and compliance with the 12 key questions.
Stated completedThe respondent said that this action was complete when they made their response on 16 January 2023. View source
Action
Set up a multi-agency working group to design a joint protocol for informal patients absconding from emergency departments.
Stated in progressThe respondent said that this action was in progress when they made their response on 16 January 2023. View source
Action
Maintain and refresh the online missing-person training package, requiring officer completion and embedding it in student officer training.
Stated completedThe respondent said that this action was complete when they made their response on 16 January 2023. View source
Action
Develop a Locate learning portal with a missing-person toolkit and partner-agency information in consultation with stakeholders.
Stated in progressThe respondent said that this action was in progress when they made their response on 16 January 2023. View source
Action
Upgrade the COMPACT missing-person recording system to improve prevention interviews, risk documentation, information sharing and data insight.
Stated completedThe respondent said that this action was complete when they made their response on 16 January 2023. View source
Action
Consider establishing a specialist Force Contact desk for complex calls, including missing-person reports, with dedicated support and training.
Stated plannedThe respondent said that this action was planned when they made their response on 16 January 2023. View source See 7 more actions
×
AI-generated summary
Leroy Patrick HAMILTON · 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
Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient mental health beds
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU. Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed multi-agency protocol for informal patients absconding from emergency departments
Wider context from the report “3. Multi agency protocol for informal missing patients: The inquest heard how there is no agreed protocol to deal with informal patients who abscond from emergency departments . Consideration should be given to setting up an agreed protocol so that all agencies involved understand their respective roles and responsibilities.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and appropriately classify risk assessments for missing persons
Wider context from the report “5. WMP risk assessments for missing persons: When Mr Hamilton was first reported as missing no risk assessment was undertaken about his level of risk to himself . The call had confirmed he was at risk of harming himself . The leads to a concern that staff do not understand when and how to risk assesses incidents and when to identify high risk incidents .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to classify reported people as missing persons
Wider context from the report “4. WMP Missing person investigations: The inquest heard how on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr Hamilton as a missing person when he was reported as missing . On both occasions he should have been treated as a high risk missing person. This raises a serious concern that staff do not understand when people should be classified as missing . Consideration should be given to ensuring staff properly understand how to assess if someone should be treated as a missing person and WMP should consider whether further training is required.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed
Wider context from the report “2. Safe space: The inquest heard how it is often the case that due to the lack of inpatient beds and PDU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed . This means that acutely ill mental health patients are often left for long periods without any specialist care, support or observation . Consideration should be given to setting up a safe space where patients can wait for a bed or PDU space which is able to cater for their special needs and keep them safe.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of Psychiatric decisions unit spaces
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces : The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU . Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
” 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 Create a Support Desk with continuity of staffing, increased supervisory oversight, focused Locate training and ongoing support for service calls including missing persons.
Verbatim wording from the response “Fourth, following the full review, a ‘Support Desk’ was created. This entailed continuity of staff dealing with calls for service – including missing persons – with an increased number of supervisors in post to review and scrutinise the work of support staff. This provides a focused training opportunity for Locate staff, as well as on-going support.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review priority and internally generated log recording, conduct quality assurance audits, provide feedback, and deliver missing-person training to Force Contact staff.
Verbatim wording from the response “Third, a full review has been conducted concerning the recording of priority response logs and internally generated logs. This involved work with Force Contact, Force Response and Locate. While this was part of a wider review process, it incorporated missing persons at the front-end reporting stage and quality assurance activity. This was carried out through weekly audits and weekly senior leadership meetings to discuss individual cases or themes where the correct risks had not been identified during call handling. To support this development, feedback was provided, improvements were noted, and training was delivered to Force Contact staff by experienced Locate supervisors.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a pilot introducing early Inspector review, central control and progression for missing-person investigations, with escalation and ongoing initial-stage management.
Verbatim wording from the response “Seventh, a pilot scheme was recently implemented, led by the Chief Inspector Missing Lead for Force Response, which amends the response to missing person reports. This pilot scheme entails an early Inspector review to ensure that the right response is in place from the outset, that risk is correctly identified, and that there is ongoing management throughout the initial stages of investigation including any required escalation. The pilot scheme creates a central point of control and progression for all missing person investigations. This is an on-going project and a further update concerning the conclusion of the pilot scheme is awaited.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add priority-response call escalations as a standing monthly agenda item for senior missing-person governance.
Verbatim wording from the response “Second, the Missing Operational Group (MOG) has been in place for a significant period of time. This meeting provides governance at a senior leadership level for all aspects of the missing person process. There is representation from all stakeholders including Force Contact and Force Response. The MOG agenda entails feedback concerning individual cases where certain risk factors have not been identified, or where the response has not been appropriate. I anticipate that the concerns raised by HM Area Coroner concerning Mr Hamilton’s case will be addressed by MOG, resulting in corrective action, including targeted training. Further, priority response call escalations are now a standing agenda item each month at MOG.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct detailed audits of missing-person call handling, risk assessment and compliance with the 12 key questions.
Verbatim wording from the response “Sixth, detailed audits have been carried out which reveal a marked improvement from 2020 to 2022. While there is still work to do, the audit revealed 90% compliance with the ‘12 key questions’ and 100% of call calls audited accurately recorded, and correctly applied, the appropriate risk grading. Just 2% of all incidents audited in 2022 had no clear full risk assessment, compared to 66% in 2020.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set up a multi-agency working group to design a joint protocol for informal patients absconding from emergency departments.
Verbatim wording from the response “In relation to the Coroner’s third concern, relating to a multi-agency protocol to deal with informal patients who abscond from emergency departments, WMP is currently setting up a working group with key partner agencies, including mental health agencies and professionals, to discuss and design a joint missing person protocol. I anticipate that these discussions will take into account the circumstances of Mr Hamilton’s case, as well as the Authorised Professional Practice (APP) of the College of Policing, current national best practice, information sharing, the operation of lead agencies, communications (including with and to relevant partner agencies) and on-going governance. The department within West Midlands Police responsible for the investigation of missing person reports is called ‘Locate’.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and refresh the online missing-person training package, requiring officer completion and embedding it in student officer training.
Verbatim wording from the response “Eighth, the Locate learning portal is in the final stages of design. This resource will adopt a new approach to learning which will provide staff with a toolkit for their interactions with missing persons. The content is being produced in consultation with key stakeholders and will be extended to add partner information where appropriate. Relatedly, an online missing person package is currently available on WMP systems, which is regularly refreshed. Officers are requested to complete the package, which supports them in identifying missing persons and understanding primary actions to be taken. As of October 2022, more than” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Locate learning portal with a missing-person toolkit and partner-agency information in consultation with stakeholders.
Verbatim wording from the response “Eighth, the Locate learning portal is in the final stages of design. This resource will adopt a new approach to learning which will provide staff with a toolkit for their interactions with missing persons. The content is being produced in consultation with key stakeholders and will be extended to add partner information where appropriate. Relatedly, an online missing person package is currently available on WMP systems, which is regularly refreshed. Officers are requested to complete the package, which supports them in identifying missing persons and understanding primary actions to be taken. As of October 2022, more than” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Upgrade the COMPACT missing-person recording system to improve prevention interviews, risk documentation, information sharing and data insight.
Verbatim wording from the response “Ninth, WMP has completed an upgrade of its missing persons recording system (COMPACT). The main benefit of this upgrade is to ensure that the police prevention interview is more detailed, and that relevant information is passed to other agencies in order to support vulnerable persons in a holistic way. The upgrade to COMPACT prompts officers to consider things such as presentation and wider risk. This will improve the overall approach missing persons and ensure that information about history and risk are properly documented and accessible. Another beneficial feature of the upgrade is that it allows improved data insight into high demand missing locations and persons. This data will be used to understand where action and support is needed to support missing persons and reduce future threat, risk and harm.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider establishing a specialist Force Contact desk for complex calls, including missing-person reports, with dedicated support and training.
Verbatim wording from the response “Fifth, WMP is considering whether to establish a specialist desk within Force Contact that will entail the same staff dealing with more complex calls, such as missing persons. This will ensure that Force Contact staff receive the right support and training as a continuation of the ‘Support Desk’.” Source location Response from West Midlands 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 Commissioning and operating psychiatric decisions units falls outside the police force’s functions and authority.
Verbatim wording from the response “Whereas the third, fourth and fifth of the Coroner’s concerns are pertinent to West Midlands Police (WMP), the first and second concerns relating to the Psychiatric Decisions Unit (PDU) are, in my view, pertinent to other addressees of the report, namely: (i) the Birmingham and Solihull Mental health NHS Foundation Trust; (ii) the Birmingham and Solihull Integrated Care Board; (iii) University Hospital Birmingham NHS Foundation Trust; and (iv) the Secretary of State for Health. WMP has no involvement in the commissioning and operation of the PDU. For these reasons, this response focuses on the third, fourth and fifth concerns identified by the Coroner.” Source location Response from West Midlands 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 Responsibility for psychiatric decisions unit beds and spaces rests with the named health bodies and Secretary of State for Health.
Verbatim wording from the response “Whereas the third, fourth and fifth of the Coroner’s concerns are pertinent to West Midlands Police (WMP), the first and second concerns relating to the Psychiatric Decisions Unit (PDU) are, in my view, pertinent to other addressees of the report, namely: (i) the Birmingham and Solihull Mental health NHS Foundation Trust; (ii) the Birmingham and Solihull Integrated Care Board; (iii) University Hospital Birmingham NHS Foundation Trust; and (iv) the Secretary of State for Health. WMP has no involvement in the commissioning and operation of the PDU. For these reasons, this response focuses on the third, fourth and fifth concerns identified by the Coroner.” Source location Response from West Midlands Police
Open published response
3 Nov 2022 Raneem Oudeh and Khaola Saleem · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Insufficient staffing and resources for domestic abuse investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Raneem Oudeh and Khaola Saleem · 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
Raneem Oudeh and her mother, Khaola Saleem, were murdered outside Khaola’s home address just after midnight following an incident at a Birmingham shisha lounge. Both women died from multiple stab wounds. The report raises a concern that serious staff shortages in the domestic abuse team led to cases not being effectively investigated, placing repeat victims of domestic abuse and coercive control at serious risk.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing and resources for domestic abuse investigations
Wider context from the report “1. The inquest heard evidence that the domestic abuse team within the Public Protection Unit were seriously short staffed . The inquest was told that in Raneem's case the officer reviewing her case on 28/04/18 understood that more needed to be done however he filed the report due to having no staff to investigate the case . The officer stated that this problem continues . The inquest was told that cases are not being investigated due to lack of resources in the department . This leaves a very real and immediate concern that women like Raneem, who was a repeat victim of domestic violence and controlling and coercive control from a man who had made threats to kill her, are at serious risk due to a lack of effective investigation by the department responsible for investigating domestic abuse .
” 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 Maintain the restructured investigation arrangements, including Review and Allocation Team processing, Adult Complex teams and dedicated supervisory responsibilities.
Verbatim wording from the response “In our response dated the 28th December 2022, we detailed the work of the Review and Allocation Team (R&A) that was set up in the Public Protection Unit (PPU) department restructure in February 2019. The R&A team removes a significant proportion of the inbox management work that used to be completed by the Domestic Abuse Team supervisors, alongside their other duties. The R&A team currently manage 40-50% of the DA crime that in 2018, the investigation supervisors would have had to review and process.” Source location Response from West Midlands Police (2)
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 Operate a Review and Allocation Team to assess domestic abuse reports, verify risk grading, and allocate cases for investigation.
Verbatim wording from the response “Review and Allocation Team” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require Adult Investigation Team Sergeants to review, triage, set actions for, and allocate incoming crime reports each shift.
Verbatim wording from the response “Initial Investigative Reviews” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase staffing allocated to domestic abuse management and investigation across the West Midlands and Eastern area.
Verbatim wording from the response “The number of staff allocated to DA investigation has increased since August 2018. The strength of the Domestic Abuse Teams in August 2018 was 308 full time equivalent officers and police staff. The police staff included our Police Staff Investigating Officers (PSIO) and police staff within the Safeguarding Teams. For the Coventry and Solihull team it was 53 officers and staff.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Restructure domestic abuse investigations into Adult Investigation Teams and Adult Complex Investigation Teams.
Verbatim wording from the response “The Public Protection Department (PPU) was restructured in 2019. One of the reasons the new structure was put in place, was because it was identified that the Domestic Abuse Teams found it difficult to manage complex investigations alongside high volume DA reports and individuals in custody with the associated statutory time constraints.” Source location Response from West Midlands 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 new structure, resourcing, information technology and organisational processes manage domestic abuse demand in a controlled and safe manner.
Verbatim wording from the response “The new DA policy gives guidance to supervisors on what actions are expected for DA investigations and includes the investigative checklist that has already been mentioned. Whilst DA investigation remains a busy and complex area of work, the new structure, additional resourcing, improved IT and daily organisational means that the demand is managed in a controlled and safe manner.” Source location Response from West Midlands Police (2)
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 Current domestic abuse investigation staffing has increased substantially, and the relevant team’s workload is considered manageable.
Verbatim wording from the response “The number of staff allocated to DA investigation has increased since August 2018. The strength of the Domestic Abuse Teams in August 2018 was 308 full time equivalent officers and police staff. The police staff included our Police Staff Investigating Officers (PSIO) and police staff within the Safeguarding Teams. For the Coventry and Solihull team it was 53 officers and staff.” Source location Response from West Midlands 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 Investigation team staffing capacity is not a determining factor in decisions to file domestic abuse reports or pursue further action.
Verbatim wording from the response “The R&A team is made up of three teams that review each crime and use a bespoke template to determine the progress of the investigation. If there are further lines of investigation the report is allocated to one of the investigation teams to progress. In some cases, further information is required from the victim in order to inform the decision and the R&A team will facilitate this. The R&A team will check the Domestic Abuse Risk Assessment (DARA) grading and any history of previous incidents. This is to ensure the correct risk grade has been determined before a report is filed or allocated for further investigation. In addition, the R&A team can re-grade the risk where appropriate to do so.” Source location Response from West Midlands Police
Open published response
23 Jun 2022 Khalid Seneen Yousef · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Insufficient understanding of the L&D police custody suite model’s role and limitations View source Inadequate training of L&D practitioners View source Lack of clarity about responsibility for mentally unwell persons in custody View source Failure to learn sufficient lessons from the incident View source Inadequate experience of L&D practitioners View source Lack of commissioned psychiatrists within the L&D police custody suite model View source Inadequate supervision of L&D practitioners View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Khalid Seneen Yousef · 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
Khalid Seneen Yousef was decapitated during a sustained knife assault at a premises in Birmingham on 4 January 2018. The report identifies concerns that a Liaison and Diversion clinician failed to recognise the perpetrator’s psychosis and refer him for mental health assessment, and that the custody-suite model lacked commissioned psychiatrists, with wider concerns about responsibility, training and supervision.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the L&D police custody suite model’s role and limitations
Wider context from the report “3. West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for mentally unwell persons in custody
Wider context from the report “2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D services on who has responsibility for mentally unwell persons in custody .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to learn sufficient lessons from the incident
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate experience of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience , training and supervision of L&D practitioners .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned psychiatrists within the L&D police custody suite model
Wider context from the report “1. The L&D police custody suite model has not commissioned psychiatrists .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners .
” 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 Engage national Liaison and Diversion leads to raise the concern about the lack of psychiatric provision.
Verbatim wording from the response “In relation to the first concern, while the commissioning of the L&D model may be influenced by WMP (and other police forces) as stakeholders, the commissioning process itself is not something which WMP is ultimately responsible for or able to determine or carry out. Notwithstanding this, I can confirm that I have directed my head of custody to engage national L&D leads to make them aware of this concern. It is relevant to note that the lack of psychiatric provision in the West Midlands reflects the national position. Likewise, in relation to the fourth concern, it is understood that this pertains to a Root Cause Analysis report (RCA) commissioned by the Birmingham and Solihull Mental Health Trust (BSMHT). WMP had no involvement in the RCA, nor in the process of “lessons learnt” by BSMHT.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review mental-health training provided to custody officers and staff.
Verbatim wording from the response “For these reasons, in response to the second and third concerns identified by HM Area Coroner for Birmingham and Solihull, I have instructed that the following steps take place within six months of the date of this response:” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide frontline staff with clear advice on the nature, scope and limitations of the current Liaison and Diversion function.
Verbatim wording from the response “For these reasons, in response to the second and third concerns identified by HM Area Coroner for Birmingham and Solihull, I have instructed that the following steps take place within six months of the date of this response:” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Direct the head of custody to engage national Liaison and Diversion leads about the concern regarding psychiatric provision.
Verbatim wording from the response “In relation to the first concern, while the commissioning of the L&D model may be influenced by WMP (and other police forces) as stakeholders, the commissioning process itself is not something which WMP is ultimately responsible for or able to determine or carry out. Notwithstanding this, I can confirm that I have directed my head of custody to engage national L&D leads to make them aware of this concern. It is relevant to note that the lack of psychiatric provision in the West Midlands reflects the national position. Likewise, in relation to the fourth concern, it is understood that this pertains to a Root Cause Analysis report (RCA) commissioned by the Birmingham and Solihull Mental Health Trust (BSMHT). WMP had no involvement in the RCA, nor in the process of “lessons learnt” by BSMHT.” Source location Response from West Midlands Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide all frontline staff with clear advice about the nature, scope and limitations of the current Liaison and Diversion function.
Verbatim wording from the response “For these reasons, in response to the second and third concerns identified by HM Area Coroner for Birmingham and Solihull, I have instructed that the following steps take place within six months of the date of this response:” Source location Response from West Midlands 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 Detainee welfare does not require direct police recruitment of clinicians because locally commissioned healthcare provision should be available.
Verbatim wording from the response “In relation to the second concern, the mental and physical wellbeing of detainees is a matter for which the Chief Constable is ultimately responsible. This is a matter upon which both WMP and BSMHT are clear. However, it is important to note that this responsibility does not necessarily entail the direct recruitment of medical or mental health clinicians. As is common in custody provision across England, there is an expectation that locally commissioned health provision will be available to detainees in the same way that it would for members of the public who are not in detention. While it is my responsibility to maintain the welfare of detainees, this responsibility is discharged by establishing adequate processes and delivering appropriate training and direction to custody officers/staff about when and how to access clinical support.” Source location Response from West Midlands 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 West Midlands Police cannot determine or carry out commissioning of the Liaison and Diversion model.
Verbatim wording from the response “In relation to the first concern, while the commissioning of the L&D model may be influenced by WMP (and other police forces) as stakeholders, the commissioning process itself is not something which WMP is ultimately responsible for or able to determine or carry out. Notwithstanding this, I can confirm that I have directed my head of custody to engage national L&D leads to make them aware of this concern. It is relevant to note that the lack of psychiatric provision in the West Midlands reflects the national position. Likewise, in relation to the fourth concern, it is understood that this pertains to a Root Cause Analysis report (RCA) commissioned by the Birmingham and Solihull Mental Health Trust (BSMHT). WMP had no involvement in the RCA, nor in the process of “lessons learnt” by BSMHT.” Source location Response from West Midlands 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 Responsibility for reviewing the Root Cause Analysis, experience, training and supervision of Liaison and Diversion practitioners rests with Birmingham and Solihull Mental Health Trust.
Verbatim wording from the response “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.” Source location Response from West Midlands 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 Custody staff may rely on and defer to qualified healthcare practitioners for mental and physical health assessments.
Verbatim wording from the response “Turning to the third concern, following the evidence adduced at the inquest, it is acknowledged that the understanding of some WMP custody officers/staff in relation to the role and limitation of L&D requires improvement. Given that custody officers/staff are not medically trained, it is reasonable for them to be able to rely on, and defer to, the professional opinion of healthcare practitioners in relation to matters of mental and physical health. At the same time, it is accepted that custody officers/staff need to understand the differing levels of expertise of various clinicians and healthcare practitioners.” Source location Response from West Midlands 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 Responsibility for commissioning psychiatric provision is assigned to national Liaison and Diversion commissioners and other relevant bodies.
Verbatim wording from the response “Upon careful reflection, I consider that the second and third concerns are pertinent to WMP, whereas the first and fourth concerns are of relevance to other addressees of the Regulation 28 report, namely: (i) ████████ Chief Executive NHS England; (ii) ████████ Chief Executive Birmingham and Solihull Mental Health Trust and/or (iii) The Rt Hon Priti Patel MP, Home Secretary.” Source location Response from West Midlands 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 West Midlands Police cannot determine or carry out commissioning of the Liaison and Diversion model.
Verbatim wording from the response “In relation to the first concern, while the commissioning of the L&D model may be influenced by WMP (and other police forces) as stakeholders, the commissioning process itself is not something which WMP is ultimately responsible for or able to determine or carry out. Notwithstanding this, I can confirm that I have directed my head of custody to engage national L&D leads to make them aware of this concern. It is relevant to note that the lack of psychiatric provision in the West Midlands reflects the national position. Likewise, in relation to the fourth concern, it is understood that this pertains to a Root Cause Analysis report (RCA) commissioned by the Birmingham and Solihull Mental Health Trust (BSMHT). WMP had no involvement in the RCA, nor in the process of “lessons learnt” by BSMHT.” Source location Response from West Midlands 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 Birmingham and Solihull Mental Health Trust is responsible for the Root Cause Analysis and associated lessons learned.
Verbatim wording from the response “In relation to the first concern, while the commissioning of the L&D model may be influenced by WMP (and other police forces) as stakeholders, the commissioning process itself is not something which WMP is ultimately responsible for or able to determine or carry out. Notwithstanding this, I can confirm that I have directed my head of custody to engage national L&D leads to make them aware of this concern. It is relevant to note that the lack of psychiatric provision in the West Midlands reflects the national position. Likewise, in relation to the fourth concern, it is understood that this pertains to a Root Cause Analysis report (RCA) commissioned by the Birmingham and Solihull Mental Health Trust (BSMHT). WMP had no involvement in the RCA, nor in the process of “lessons learnt” by BSMHT.” Source location Response from West Midlands Police
Open published response
17 Nov 2021 Trevor Alton SMITH · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of a clear process for cascading relevant MARAC information to involved officers View source Failure of officers to understand the need for rescue breaths during resuscitation View source Failure to allocate a single coordinator for CPR when sufficient personnel are available View source Lack of clear processes for accurately recording information at MARAC 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
Trevor Alton 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
Trevor Smith died after being shot by a member of a police armed response unit during an attempted arrest at his home. The principal concerns were that information about an alleged previous overdose was not recorded or cascaded to the firearms team, and that officers were confused about CPR rescue breaths and coordination during resuscitation.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear process for cascading relevant MARAC information to involved officers
Wider context from the report “1. MARAC Information: Before firearms officers deployed to Mr Smith’s address a MARAC (Multi Agency Risk Assessment Conference) meeting took place on 12/03/19 when agencies shared information about the alleged victim of domestic violence and the alleged suspect Mr Smith. The evidence at the inquest confirmed that it was likely that Birmingham and Solihull Mental Health NHS Foundation Trust shared information that Mr Smith had taken an overdose of medication in January 2019. This information was not minuted by WMP nor reported back to the Senior Investigating Officer or the firearms team. As a result, they were unaware of this information and Mr Smith was not declared EMD (emotionally and mentally distressed). The evidence at the inquest confirmed that actions would have been the same even had Mr Smith been declared EMD. It was clear during the evidence that there was no clear guidance/process for accurately recording information at MARAC by WMP and no clear process for ensuring relevant information is cascaded to officers involved in the case . Consideration should be given to updating existing processes and policies to ensure accurate and relevant information is cascaded from MARAC.
2. CPR coordinator. The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies and procedures and training to ensure one person is allocated to coordinate CPR if it is required.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of officers to understand the need for rescue breaths during resuscitation
Wider context from the report “1. MARAC Information: Before firearms officers deployed to Mr Smith’s address a MARAC (Multi Agency Risk Assessment Conference) meeting took place on 12/03/19 when agencies shared information about the alleged victim of domestic violence and the alleged suspect Mr Smith. The evidence at the inquest confirmed that it was likely that Birmingham and Solihull Mental Health NHS Foundation Trust shared information that Mr Smith had taken an overdose of medication in January 2019. This information was not minuted by WMP nor reported back to the Senior Investigating Officer or the firearms team. As a result, they were unaware of this information and Mr Smith was not declared EMD (emotionally and mentally distressed). The evidence at the inquest confirmed that actions would have been the same even had Mr Smith been declared EMD. It was clear during the evidence that there was no clear guidance/process for accurately recording information at MARAC by WMP and no clear process for ensuring relevant information is cascaded to officers involved in the case. Consideration should be given to updating existing processes and policies to ensure accurate and relevant information is cascaded from MARAC.
2. CPR coordinator. The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation . The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies and procedures and training to ensure one person is allocated to coordinate CPR if it is required.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to allocate a single coordinator for CPR when sufficient personnel are available
Wider context from the report “1. MARAC Information: Before firearms officers deployed to Mr Smith’s address a MARAC (Multi Agency Risk Assessment Conference) meeting took place on 12/03/19 when agencies shared information about the alleged victim of domestic violence and the alleged suspect Mr Smith. The evidence at the inquest confirmed that it was likely that Birmingham and Solihull Mental Health NHS Foundation Trust shared information that Mr Smith had taken an overdose of medication in January 2019. This information was not minuted by WMP nor reported back to the Senior Investigating Officer or the firearms team. As a result, they were unaware of this information and Mr Smith was not declared EMD (emotionally and mentally distressed). The evidence at the inquest confirmed that actions would have been the same even had Mr Smith been declared EMD. It was clear during the evidence that there was no clear guidance/process for accurately recording information at MARAC by WMP and no clear process for ensuring relevant information is cascaded to officers involved in the case. Consideration should be given to updating existing processes and policies to ensure accurate and relevant information is cascaded from MARAC.
2. CPR coordinator. The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit . Consideration should be given to amending policies and procedures and training to ensure one person is allocated to coordinate CPR if it is required.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clear processes for accurately recording information at MARAC
Wider context from the report “1. MARAC Information: Before firearms officers deployed to Mr Smith’s address a MARAC (Multi Agency Risk Assessment Conference) meeting took place on 12/03/19 when agencies shared information about the alleged victim of domestic violence and the alleged suspect Mr Smith. The evidence at the inquest confirmed that it was likely that Birmingham and Solihull Mental Health NHS Foundation Trust shared information that Mr Smith had taken an overdose of medication in January 2019. This information was not minuted by WMP nor reported back to the Senior Investigating Officer or the firearms team. As a result, they were unaware of this information and Mr Smith was not declared EMD (emotionally and mentally distressed). The evidence at the inquest confirmed that actions would have been the same even had Mr Smith been declared EMD. It was clear during the evidence that there was no clear guidance/process for accurately recording information at MARAC by WMP and no clear process for ensuring relevant information is cascaded to officers involved in the case. Consideration should be given to updating existing processes and policies to ensure accurate and relevant information is cascaded from MARAC.
2. CPR coordinator. The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies and procedures and training to ensure one person is allocated to coordinate CPR if it is required.
” 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 Centralise MARAC coordination and administration and introduce trained minute takers, MARAC coordinators and a regional lead.
Verbatim wording from the response “The agency responsible for minute-taking and coordination in this case was Coventry Haven, who were commissioned to perform this duty up until the 31st March 2019, two weeks after the MARAC meeting in question took place. It was after this time that WMP took responsibility for the coordination and administration of all seven local authority areas, including Solihull, from 1st April 2019.” Source location 2021-0387-Response-from-West-Midlands-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 Provide ongoing regional MARAC training and require intensive training before minute takers work alone.
Verbatim wording from the response “Response: There is a regional MARAC Operating Protocol which has been in place since 1st April 2019. It governs WMP and wider agency engagement with the MARAC process and offers clear guidance on what is expected of them and what they can expect of Information Sharing within the process. Further, the MARAC Coordination team are responsible for ongoing MARAC training across the region which ensures that partners engaging in the process have staff trained and prepared to do so. In addition all MARAC minute takers are intensively trained when in role and are not permitted to take minutes alone until training is complete to the satisfaction of the local MARAC Coordinator.” Source location 2021-0387-Response-from-West-Midlands-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 Update firearms briefing sheets and brief commanders, advisors and officers to nominate a CPR coordinator where resources allow.
Verbatim wording from the response “In the meantime West Midlands Police:” Source location 2021-0387-Response-from-West-Midlands-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 Maintain a regional MARAC Operating Protocol governing agency engagement and information sharing.
Verbatim wording from the response “Response: There is a regional MARAC Operating Protocol which has been in place since 1st April 2019. It governs WMP and wider agency engagement with the MARAC process and offers clear guidance on what is expected of them and what they can expect of Information Sharing within the process. Further, the MARAC Coordination team are responsible for ongoing MARAC training across the region which ensures that partners engaging in the process have staff trained and prepared to do so. In addition all MARAC minute takers are intensively trained when in role and are not permitted to take minutes alone until training is complete to the satisfaction of the local MARAC Coordinator.” Source location 2021-0387-Response-from-West-Midlands-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 Review links between the MARAC system and wider police systems and departments to improve information capture and sharing.
Verbatim wording from the response “However, as all MARAC information is recorded on a system separate to Connect, which is where the vast majority of Police information is stored, this impacts upon transparency and speed of information sharing.” Source location 2021-0387-Response-from-West-Midlands-Police_Published
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 Conduct regular dip samples and audits of MARAC minutes to improve recording quality.
Verbatim wording from the response “Response: Since taking over responsibility for minuting MARAC meetings from 1st April 2019, WMP has recruited and trained a team of six dedicated minute takers who are experienced in the role and well-supported by supervision. As of summer 2021, MARAC minutes have been subject to regular dip samples and audits to ensure the continued improvement of staff involved in the recording process.” Source location 2021-0387-Response-from-West-Midlands-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 Continue developing MARAC minute-taking staff through ongoing quality auditing and dip-sampling.
Verbatim wording from the response “In addition to this, partner engagement with the MARAC process has improved significantly, with open communication channels for any challenge regarding the quality of minutes. Further, WMP is committed to the continued improvement and development of staff in the minute-taking role, including ongoing auditing and dip-sampling around the quality of recording.” Source location 2021-0387-Response-from-West-Midlands-Police_Published
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 Update the Medical Plan with directions for coordinating tactical medical care and positioning medical equipment.
Verbatim wording from the response “Medical Plan” Source location 2021-0387-Response-from-West-Midlands-Police_Published
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 Recruit and train a dedicated team of six MARAC minute takers supported by supervision.
Verbatim wording from the response “Response: Since taking over responsibility for minuting MARAC meetings from 1st April 2019, WMP has recruited and trained a team of six dedicated minute takers who are experienced in the role and well-supported by supervision. As of summer 2021, MARAC minutes have been subject to regular dip samples and audits to ensure the continued improvement of staff involved in the recording process.” Source location 2021-0387-Response-from-West-Midlands-Police_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A CPR coordinator may not be appointed where operational demands or available resources prevent an officer undertaking that role.
Verbatim wording from the response “2. Have ensured that all Strategic and Tactical Firearms Commanders (S&TFCs), Operational Firearms Commanders (OFCs), Firearms Tactical Advisors (FTAs) and all Authorised Firearms Officers (AFOs) are aware of this recommendation. All officers have been reminded of the importance of nominating a CPR coordinator where resources allow. There may be circumstances where the operational need and level of resourcing at an incident do not allow an officer to perform the role of coordinator. This will be a dynamic assessment for the officers at the scene. All team briefing sheets have been updated and version controlled and now include reference to the coordinator role. These briefing sheets are used as a template in firearms briefings which are recorded.” Source location 2021-0387-Response-from-West-Midlands-Police_Published
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 Coventry Haven was responsible for minute-taking and coordination at the relevant MARAC meeting.
Verbatim wording from the response “The agency responsible for minute-taking and coordination in this case was Coventry Haven, who were commissioned to perform this duty up until the 31st March 2019, two weeks after the MARAC meeting in question took place. It was after this time that WMP took responsibility for the coordination and administration of all seven local authority areas, including Solihull, from 1st April 2019.” Source location 2021-0387-Response-from-West-Midlands-Police_Published
Open published response
3 Nov 2021 Saskia Jones and 2 others · Prevention of Future Deaths report London City
View report summary
Concerns raised 24 Failure to inform MAPPA panels about regularity and form of overt offender-management contact View source Insufficient consideration of extremist offenders’ dishonest self-presentation View source Failure to share and consider counter-terrorism police intelligence in MAPPA management View source Failure to properly reason and record offender-manager licence-condition approvals View source Failure to provide MAPPA panels important prison-history information View source Failure to provide MAPPA panels direct input from the preparing forensic psychologist View source Failure to communicate between offender managers and event organisers before extremist offenders attend events View source Insufficient risk assessment and management for prison higher education programmes involving post-release offender contact View source Sudden disruption of DDP mentoring arrangements View source Sudden loss of supervised internet access for employment searches View source Failure to complete the full structured assessment before changing an OASys risk rating View source Failure to properly consider security-sensitive information in MAPPA decisions View source Lack of precautionary search capability for terrorist offenders on licence View source Failure to detect Class A drug use by terrorist offenders on licence View source Unavailability of offender risk-profile information to prison-based higher education providers View source Failure to ensure all MAPPA meeting attendees receive meeting minutes View source Failure to ensure direct forensic psychologist involvement in ERG 22+ assessment reports View source Failure to assess risks of continuing close contact between serious offenders and young students View source Excessive reliance on compliance in management of extremist offenders View source Failure to communicate high-risk event attendance to host venues View source Failure to directly address risks when approving licence-condition changes View source Lack of formal risk assessment for higher education events held outside university premises View source Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes View source Failure to record proper rationale for changes to OASys risk ratings View source See 21 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Saskia Jones and 2 others · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 29 November 2019, Usman Khan carried out a terrorist attack at Fishmongers’ Hall, fatally stabbing Saskia Jones and Jack Merritt before being fatally shot by firearms officers on London Bridge. The report raised concerns about risk assessment and communication for events involving high-risk offenders, and about the assessment, information-sharing, supervision and management of terrorist offenders released into the community.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to inform MAPPA panels about regularity and form of overt offender-management contact
Wider context from the report “The facts of this case give cause for concern that MAPPA panels responsible for managing terrorist offenders may be unaware of the regularity and form of contact with police officers responsible for overt offender management .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient consideration of extremist offenders’ dishonest self-presentation
Wider context from the report “The facts of this case give rise to concern that probation officers may give insufficient regard to instances of dishonesty in self-presentation by extremist offenders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to share and consider counter-terrorism police intelligence in MAPPA management
Wider context from the report “This case gives cause for concern that counter-terrorism police may be in possession of intelligence or information which may be useful to the management of an offender by the MAPPA panel, but that such intelligence or information may not be brought to the knowledge of or taken into account by MAPPA agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to properly reason and record offender-manager licence-condition approvals
Wider context from the report “This case gives rise to concern that offender managers may take significant decisions to give approvals under licence conditions without those decisions being properly reasoned and recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MAPPA panels important prison-history information
Wider context from the report “The facts of this case give cause for concern that some members of MAPPA panels responsible for managing extremist offenders may not be aware of important information from the offender’s time in prison .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MAPPA panels direct input from the preparing forensic psychologist
Wider context from the report “It is a matter for concern that MAPPA panels managing even the most serious offenders may not have the benefit of hearing directly from a forensic psychologist who has prepared an ERG report shortly prior to the offender’s release .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate between offender managers and event organisers before extremist offenders attend events
Wider context from the report “This case gives rise to concern that an extremist offender may be permitted to attend an event or venue without there having been proper communication between the probation and police officers responsible for managing the offender and the event organisers and/or venue hosts .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient risk assessment and management for prison higher education programmes involving post-release offender contact
Wider context from the report “Consideration should be given to whether further measures of risk assessment and management can be introduced for any higher education programmes running in prisons which involve continued contact with offenders after their release into the community .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Sudden disruption of DDP mentoring arrangements
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Sudden loss of supervised internet access for employment searches
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to complete the full structured assessment before changing an OASys risk rating
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to properly consider security-sensitive information in MAPPA decisions
Wider context from the report “The facts of this case give cause for concern that security sensitive information may not be properly taken into account in decision-making by MAPPA panels concerning the management of terrorist offenders.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of precautionary search capability for terrorist offenders on licence
Wider context from the report “The facts of this case gave cause for concern that those involved in managing terrorist offenders on licence may lack a valuable means of addressing risks they pose, namely an ability to carry out a search on a precautionary basis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to detect Class A drug use by terrorist offenders on licence
Wider context from the report “The facts of this case give cause for concern that a terrorist offender on licence, who was subject both to strict licence conditions and to a priority investigation, could obtain and use Class A drugs without that being detected .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of offender risk-profile information to prison-based higher education providers
Wider context from the report “It is a matter of concern that Learning Together could operate courses in prisons in the way it did without being given information about the risk profiles of offenders joining courses .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure all MAPPA meeting attendees receive meeting minutes
Wider context from the report “Based on the evidence in this case, there is cause for concern that effective procedures are not in place to ensure that all MAPPA meeting attendees receive meeting minutes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure direct forensic psychologist involvement in ERG 22+ assessment reports
Wider context from the report “Notwithstanding the measures which the NPS has put in place since the attack, there remains cause for concern that ERG 22+ assessment reports may be prepared by a CTPO without the direct involvement of a forensic psychologist .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to assess risks of continuing close contact between serious offenders and young students
Wider context from the report “It is a matter of concern that focussed consideration was not given to the risks of serious offenders being placed in close and continuing contact with young students .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Excessive reliance on compliance in management of extremist offenders
Wider context from the report “Based on the facts of this case, there is cause for concern that probation officers may attach excessive weight in their management of extremist offenders to “compliance” (i.e. absence of evidence of breach of licence conditions and police behaviour).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate high-risk event attendance to host venues
Wider context from the report “It is a matter of concern that a major event could be held by a University at a livery company hall in London without clear communication of the fact that it would be attended by serving and recently released serious offenders .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to directly address risks when approving licence-condition changes
Wider context from the report “This case gives cause for concern that an offender manager and/or MAPPA panel participants could approve a permission, variation or relaxation in relation to a licence condition without directly addressing the potential risks involved .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal risk assessment for higher education events held outside university premises
Wider context from the report “It is a matter of concern that there was no such risk assessment for Learning Together events as set out above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes
Wider context from the report “The facts of this case give rise to concern that important decisions on approvals, variations and relaxations in relation to licence conditions may be taken without clearly reasoned discussion and decision-making in MAPPA panels .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to record proper rationale for changes to OASys risk ratings
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale .
” Open source report
×
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 Recruit a dedicated minute taker and have MAPPA minutes reviewed by the Chair before dissemination.
Verbatim wording from the response “12. A dedicated Minute Taker (Probation Service National Security Division) will be recruited to provide consistency and continuity in note-taking, and final minutes are reviewed by the MAPPA Chair prior to dissemination, to ensure accuracy. Additionally, where events are urgent and require a more timely response, emergency MAPPA panels can be arranged at short notice with documented records made of decisions and rationale. These improvements, fully supported by a senior CTWM Manager, have enabled the MAPPA panel to operate in a more efficient and structured way and ensured that notes taken can more accurately reflect the more focussed discussion taking place.” Source location 2021-0362-Response-from-West-Midlands-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 Use Core Groups to examine case detail and recommend decisions to MAPPA panels for final approval.
Verbatim wording from the response “10. As the Coroner is aware, West Midlands Police has had a CT MAPPA arrangement in place for some years. It has included regular discussions around proposed licence conditions and any variations through the MAPPA process. Licence conditions are now firmly a matter for HMPPS but if MAPPA’s input is required, as CTPHQ describe at paragraph 7 above, there is a clear process for this to take place in a structured way. Since the attacks at Fishmongers’ Hall, developments have also taken place to improve the structure and quality of decision-making, including the introduction of Core Groups which consider the operational detail of a particular case, and enable detailed discussion by key professionals involved in that case. These Core Groups make recommendations to the MAPPA panel for debate and final sign off.” Source location 2021-0362-Response-from-West-Midlands-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 Vet CT MAPPA Chairs and specialist offender-management staff, and use Joint Extremist Unit support to bring intelligence into MAPPA meetings.
Verbatim wording from the response “34. CT MAPPA chairs are now Develop Vetted, and that the key staff (CTNM & National Security Division) who actively manage the offenders, have specialist roles, are also vetted to a level suitable for CT and work together outside of the formal MAPPA meetings. The Chairs now work with the Joint Extremist Unit to facilitate intelligence” Source location 2021-0362-Response-from-West-Midlands-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 Escalate delayed prison Form F submissions, challenge variable quality, and seek additional analytical support for security information.
Verbatim wording from the response “26. Where there are delays in receipt of the Form F, these are escalated as a matter of urgency to the prison concerned. The quality of the Form F can be variable, and locally the West Midlands MAPPA chair is challenging this position, and seeking a greater level of analytical support from the JCTPPH around security information, to better support MAPPA decisions.” Source location 2021-0362-Response-from-West-Midlands-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 Feed offender-visit activity into MAPPA panels to synchronise visits across agencies and account for MAPPA requirements.
Verbatim wording from the response “41. CTP West Midlands now feed this into the MAPPA panel to ensure synchrony of visits across agencies, and to take account of any MAPPA requirements.” Source location 2021-0362-Response-from-West-Midlands-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 Fund and deploy specially trained CT Nominal Management officers, with accountable senior regional roles for terrorist-risk offender management.
Verbatim wording from the response “16. Furthermore, CTPHQ has since invested c.£12million per year in dedicated and specially trained CT Nominal Management officers who will attend all CT specialist MAPPA (Category 4) meetings. Their training includes proper communication between those managing the offender and event organisers and/or venue hosts. Additionally, CTPHQ are committed to ensuring terrorist offenders are managed by trained officers, with appropriate guidance, and senior roles have been assigned in each region of the CTP network to provide accountability for the management of all terrorist risk nominals, including specialist CT MAPPA arrangements in line with the Independent Review and recommendations on ‘core group’ joint case work.” Source location 2021-0362-Response-from-West-Midlands-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 Require relevant assessments and information to be available and incorporated into risk-management planning for allocated offenders.
Verbatim wording from the response “22. A Joint Counter Terrorism Prison and Probation Hub (‘JCTPPH’) has been formed. This is a collaboration between HMPPS, CTPHQ and the Security Service. One of its core functions is to enhance the flow of intelligence and information between covert and overt functions, noting that there is an obvious and necessary ‘firewall’ between the two. MAPPA chairs will consider how core groups will contribute in each case. The creation of core groups will ensure a secure and clear pathway for the sharing of sensitive intelligence/information into MAPPA. CTPHQ have provided guidance through their Manual of Guidance to require CTP Nominal Management specialist officers and Lead Responsible Officers to ensure that all relevant information is at hand to develop effective risk management plans for their allocated nominals, including those managed under MAPPA.” Source location 2021-0362-Response-from-West-Midlands-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 Arrange emergency MAPPA panels with documented decisions and rationales when urgent matters require timely responses.
Verbatim wording from the response “12. A dedicated Minute Taker (Probation Service National Security Division) will be recruited to provide consistency and continuity in note-taking, and final minutes are reviewed by the MAPPA Chair prior to dissemination, to ensure accuracy. Additionally, where events are urgent and require a more timely response, emergency MAPPA panels can be arranged at short notice with documented records made of decisions and rationale. These improvements, fully supported by a senior CTWM Manager, have enabled the MAPPA panel to operate in a more efficient and structured way and ensured that notes taken can more accurately reflect the more focussed discussion taking place.” Source location 2021-0362-Response-from-West-Midlands-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 Design risk-based home-visit regimes and provide MAPPA panels with visibility of police activity supporting risk-management plans.
Verbatim wording from the response “Response from NCTPHQ” Source location 2021-0362-Response-from-West-Midlands-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 Operate the Joint Counter Terrorism Prison and Probation Hub to improve secure intelligence and information sharing into MAPPA.
Verbatim wording from the response “22. A Joint Counter Terrorism Prison and Probation Hub (‘JCTPPH’) has been formed. This is a collaboration between HMPPS, CTPHQ and the Security Service. One of its core functions is to enhance the flow of intelligence and information between covert and overt functions, noting that there is an obvious and necessary ‘firewall’ between the two. MAPPA chairs will consider how core groups will contribute in each case. The creation of core groups will ensure a secure and clear pathway for the sharing of sensitive intelligence/information into MAPPA. CTPHQ have provided guidance through their Manual of Guidance to require CTP Nominal Management specialist officers and Lead Responsible Officers to ensure that all relevant information is at hand to develop effective risk management plans for their allocated nominals, including those managed under MAPPA.” Source location 2021-0362-Response-from-West-Midlands-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 Develop and operationalise the covert-overt bridge for reviewing, revealing and appropriately sharing sensitive intelligence with MAPPA.
Verbatim wording from the response “31. The JCTPPH will ensure the right information gets to the right place at the right time. A major focus, in its first year, has been the development and operationalisation of a covert-overt bridge framework. This provides an effective, safe, process through which sensitive intelligence can be revealed and subsequently, appropriately, disclosed to support defensible decision making regarding risk management. Originally focused on supporting better disclosure into the Parole Board process learning has been taken and applied to MAPPA where the bridge has already been tested on five cases bringing to the attention of MAPPA information previously only known to the security service.” Source location 2021-0362-Response-from-West-Midlands-Police_Published
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 ERG findings need not have a dedicated minutes section because the CTPO presents them to the panel and documents them in the relevant section.
Verbatim wording from the response “30. ERG assessments are shared with CT Police NMs, and the ERG is discussed at MAPPA Panel to allow a full understanding of a nominal risk and to ensure CT Police risk management plans reflect this information. There is no specific section in the minutes for the ERG summaries however the Counter Terrorism Probation Officer (CTPO) would talk the panel through the findings once the ERG had completed within prison and therefore documented in their section.” Source location 2021-0362-Response-from-West-Midlands-Police_Published
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 Licence conditions are a matter for HMPPS, with police supporting MAPPA discussions when its input is required.
Verbatim wording from the response “7. Licence conditions are a matter for HMPPS but if it is determined a discussion at MAPPA would be helpful then Local CT policing will support this through new specialist CT MAPPA arrangements. The Probation Service National Security Division have specialist administrators to support the new operating model for specialist CT MAPPA and to ensure effective minute taking and sharing which are set out in more detail at paragraph 12 below.” Source location 2021-0362-Response-from-West-Midlands-Police_Published
Open published response
21 Jan 2020 Jason Paul DEVOTI · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 6 Failure to resource and attend P2 incidents within 60 minutes during increased demand View source Failure to provide sufficient and appropriate control-room training for escalation and increased demand View source Failure to deal with P2 incident logs within the required time View source Inaccurate and incomplete monitoring of open and overdue P2 incident logs View source Insufficient control-room staff to process P2 incident logs View source Insufficient police officers to resource and attend P2 incidents View source See 3 more concerns
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. 17
Action
Establish THRIVE, integrated with the National Decision Model, as agreed policy for incident-risk assessment and decision-making.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Implement a Log Closure Doctrine to support dispatcher decision-making and focus resources on calls requiring greatest need.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Implement a control-room shift pattern aligned with contact-handling colleagues to improve understanding and joint training opportunities.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Transfer incident logs between control rooms to share demand across available staff.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Refresh the escalation process, reduce decision-making rank requirements, and subject its use to regular audits and feedback.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Implement the new Command and Control system, embedding THRIVE and improving incident, risk, and demand management.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Involve the Force Incident Manager during particularly busy response shifts to redeploy resources from outside the area or to another policing area.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Use the closest available resource to support front-end incident-log demand.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Use Force Support Unit staff to manage legacy demand.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Introduce a performance analysis tool providing incident and resource-demand data at 15-minute intervals.
Stated plannedThe respondent said that this action was planned when they made their response on 8 February 2020. View source
Action
Operate the revised dispatch model with a dedicated triage terminal, supervisory incident reviews, and 24-hour reassessment and transfer of unresolved incidents.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Improve contact handling by identifying lower-risk or non-policing incidents that do not require higher-priority control-room responses.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Provide initial control-room training, mentoring, and competence portfolios over a six-month training period.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 February 2020. View source
Action
Develop process-change training for the THRIVE policy and prepare it for delivery to teams.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 February 2020. View source
Action
Transfer logs more than 24 hours old to a different team so dispatchers can focus on critical calls.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Replace the incident snapshot presentation and establish an online dashboard to support understanding of available resources.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source
Action
Allocate logs unresolved at 96 hours to an appropriate Neighbourhood Policing Unit resource for ownership until finalisation.
Stated completedThe respondent said that this action was complete when they made their response on 8 February 2020. View source See 14 more actions
×
AI-generated summary
Jason Paul DEVOTI · 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
Jason Devoti had a history of mental health issues and alcohol dependency and was found deceased in accommodation on 9 October 2018 after West Midlands Police failed to attend a P2 welfare-check request for more than 22 hours. The inquest heard that he died from acute ethyl alcohol poisoning, although the time of death could not be established. The principal concerns were police control-room backlogs, inadequate escalation and training, and the risk that vulnerable people subject to P2 incidents would not receive a timely response during periods of increased demand.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to resource and attend P2 incidents within 60 minutes during increased demand
Wider context from the report “(5) I am concerned at how overwhelmed those working in the Bournville control room had been by the increased demand on resources, and how their views about any improvement in the situation in the months following Jason's death did not appear to match what I was told by ████████ I was also concerned about the lack of awareness of and implementation of whatever escalation process may have been in place in the control room at the time of these events; this suggests a lack of appropriate training. Whilst I understand that the West Midlands force is undergoing a period of transition so far as their control rooms are concerned, I am not satisfied that measures to have yet been put in place to ensure that all those working in control rooms have received sufficient and appropriate training to deal with situations of increased demand.
(6) I therefore remain concerned that in times of increased demand, and particularly unanticipated demand, there is a risk that West Midlands Police will be unable to resource and attend a P2 incident within the 60 minute period that is their stated aim , and that in turn will create a risk of death of the subject of such a P2 incident, if vulnerable and at some risk of harm as Jason Devoti undoubtedly was.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficient and appropriate control-room training for escalation and increased demand
Wider context from the report “(5) I am concerned at how overwhelmed those working in the Bournville control room had been by the increased demand on resources, and how their views about any improvement in the situation in the months following Jason's death did not appear to match what I was told by ████████ I was also concerned about the lack of awareness of and implementation of whatever escalation process may have been in place in the control room at the time of these events ; this suggests a lack of appropriate training . Whilst I understand that the West Midlands force is undergoing a period of transition so far as their control rooms are concerned, I am not satisfied that measures to have yet been put in place to ensure that all those working in control rooms have received sufficient and appropriate training to deal with situations of increased demand.
(6) I therefore remain concerned that in times of increased demand, and particularly unanticipated demand, there is a risk that West Midlands Police will be unable to resource and attend a P2 incident within the 60 minute period that is their stated aim, and that in turn will create a risk of death of the subject of such a P2 incident, if vulnerable and at some risk of harm as Jason Devoti undoubtedly was.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to deal with P2 incident logs within the required time
Wider context from the report “(2) The four police Dispatchers working in the Bournville control room gave evidence to the inquest that:
(a) At the time of these events a very large number ( 150-200 ) of P2 incident logs would regularly be outstanding at the beginning of a shift ;
(b) That many of those logs would be "overdue" – which meant not only that they had passed the one hour deadline, but in fact that more than 6 hours had passed since the log was last looked at;
(c) That those operating the terminals which would have to try to deal with these logs were overwhelmed by the number of logs they had to deal with;
(d) That if there was an escalation process in force at the time, then:
(i) Either dispatchers were not sufficiently aware of the process so as to be able to act in accordance with it; or
(ii) They were being given the impression by supervisors that there was little point in escalating overdue logs to them, as there was little that could be done;
(e) That the reason for the large number of logs being overdue was mainly because there were insufficient officers to deploy to incidents, but also because there were not enough staff in the control room to work through the logs;
(f) That measures taken to reduce the number of overdue logs ( known as ████████ ) would provide only temporary respite before the number of overdue logs built up again;
(g) That at various times since these events, there had been little improvement in the situation: in January 2019 the situation was "still overwhelming" ( ████████ ); in June 2019 there would always be a lot of overdue logs ( ████████ ); in October 2019 there were still too many P2 logs that were not being dealt with in time ( ████████ ); the current situation is "a little better" in that "more robust decisions are being taken by call takers", but there are still problems now, and "the crux is that we don't have enough police officers on the streets to deal with incidents" ( ████████ ).
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and incomplete monitoring of open and overdue P2 incident logs
Wider context from the report “(4) In order to try to assist with understanding the figures involved, I was provided with a number of tables designed to give a "snapshot" of current logs and available police resources at particular times, viz. 8-9 October 2018, 8 October 2019 and 7 October 2020. In my view, this provided limited assistance as (a) the column giving the total of logs open appeared to be incorrect as it did not tally with the figures within other columns, and (b) it was not possible to see how many of the open logs were overdue , and in particular how many of the P2 logs had passed the critical one hour mark without a response .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient control-room staff to process P2 incident logs
Wider context from the report “(2) The four police Dispatchers working in the Bournville control room gave evidence to the inquest that:
(a) At the time of these events a very large number ( 150-200 ) of P2 incident logs would regularly be outstanding at the beginning of a shift;
(b) That many of those logs would be "overdue" – which meant not only that they had passed the one hour deadline, but in fact that more than 6 hours had passed since the log was last looked at;
(c) That those operating the terminals which would have to try to deal with these logs were overwhelmed by the number of logs they had to deal with ;
(d) That if there was an escalation process in force at the time, then:
(i) Either dispatchers were not sufficiently aware of the process so as to be able to act in accordance with it; or
(ii) They were being given the impression by supervisors that there was little point in escalating overdue logs to them, as there was little that could be done;
(e) That the reason for the large number of logs being overdue was mainly because there were insufficient officers to deploy to incidents, but also because there were not enough staff in the control room to work through the logs ;
(f) That measures taken to reduce the number of overdue logs ( known as ████████ ) would provide only temporary respite before the number of overdue logs built up again;
(g) That at various times since these events, there had been little improvement in the situation: in January 2019 the situation was "still overwhelming" ( ████████ ); in June 2019 there would always be a lot of overdue logs ( ████████ ); in October 2019 there were still too many P2 logs that were not being dealt with in time ( ████████ ); the current situation is "a little better" in that "more robust decisions are being taken by call takers", but there are still problems now, and "the crux is that we don't have enough police officers on the streets to deal with incidents" ( ████████ ).
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient police officers to resource and attend P2 incidents
Wider context from the report “(2) The four police Dispatchers working in the Bournville control room gave evidence to the inquest that:
(a) At the time of these events a very large number ( 150-200 ) of P2 incident logs would regularly be outstanding at the beginning of a shift;
(b) That many of those logs would be "overdue" – which meant not only that they had passed the one hour deadline, but in fact that more than 6 hours had passed since the log was last looked at;
(c) That those operating the terminals which would have to try to deal with these logs were overwhelmed by the number of logs they had to deal with;
(d) That if there was an escalation process in force at the time, then:
(i) Either dispatchers were not sufficiently aware of the process so as to be able to act in accordance with it; or
(ii) They were being given the impression by supervisors that there was little point in escalating overdue logs to them, as there was little that could be done;
(e) That the reason for the large number of logs being overdue was mainly because there were insufficient officers to deploy to incidents , but also because there were not enough staff in the control room to work through the logs;
(f) That measures taken to reduce the number of overdue logs ( known as ████████ ) would provide only temporary respite before the number of overdue logs built up again;
(g) That at various times since these events, there had been little improvement in the situation: in January 2019 the situation was "still overwhelming" ( ████████ ); in June 2019 there would always be a lot of overdue logs ( ████████ ); in October 2019 there were still too many P2 logs that were not being dealt with in time ( ████████ ); the current situation is "a little better" in that "more robust decisions are being taken by call takers", but there are still problems now, and "the crux is that we don't have enough police officers on the streets to deal with incidents" ( ████████ ).
” 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 Establish THRIVE, integrated with the National Decision Model, as agreed policy for incident-risk assessment and decision-making.
Verbatim wording from the response “11. Staff across the control rooms continue to be supported in the use of the escalation process. There are a number of processes being implemented to ensure that this is the case:” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Log Closure Doctrine to support dispatcher decision-making and focus resources on calls requiring greatest need.
Verbatim wording from the response “b. Instituting a “Log Closure Doctrine” to encourage bolder decision-making from dispatchers dealing with emergency calls to ensure resources are focussed on those calls requiring greatest need.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a control-room shift pattern aligned with contact-handling colleagues to improve understanding and joint training opportunities.
Verbatim wording from the response “f. In June 2019 a new shift pattern was implemented for control rooms, this was in part due to there being no dedicated training days in the previous pattern and to align with Contact handling colleagues to improve understanding and opportunities for joint training.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transfer incident logs between control rooms to share demand across available staff.
Verbatim wording from the response “d. Load sharing across control rooms to match demand with resource. Logs are now transferred to another control room to ensure that demand is equally managed across all staff.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh the escalation process, reduce decision-making rank requirements, and subject its use to regular audits and feedback.
Verbatim wording from the response “a. Escalation process - Whilst this was in place at the time of the death of Mr Devoti, this has been refreshed with all staff and is now subject of regular audits and feedback. The ‘rank’ involved in this decision making has been reduced to make the decision process quicker and has been explained to the wider organisation.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the new Command and Control system, embedding THRIVE and improving incident, risk, and demand management.
Verbatim wording from the response “b. THRIVE is now embedded into the new Command and Control system and was delivered to all Force Contact staff as part of the training for the system ‘go live’.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Involve the Force Incident Manager during particularly busy response shifts to redeploy resources from outside the area or to another policing area.
Verbatim wording from the response “16. Before and since the events leading up to Mr Devoti’s death, West Midlands Police has taken steps to ensure that the Response resources it has available are allocated as swiftly and efficiently as possible to all emergency calls. In addition to those measures set out above the following steps have also been taken:” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the closest available resource to support front-end incident-log demand.
Verbatim wording from the response “b. Use of the closest available resource to support with front end log demand.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Force Support Unit staff to manage legacy demand.
Verbatim wording from the response “8. It was presented during the inquest that the reason for the number of outstanding incident logs was due to resourcing challenges because of austerity and the availability of officers to deploy. This has been addressed in a number of ways since the incident involving Mr DEVOTI:” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a performance analysis tool providing incident and resource-demand data at 15-minute intervals.
Verbatim wording from the response “6. There is acceptance that there is still work more to do, including the introduction of a new Command and Control System and a performance analysis tool which provides incident and resource demand data at 15 minutes periods in order that this can be easily identified and responded to. This has continued to improve the position demonstrated by the snapshots presented as evidence and described at Point 4 above.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the revised dispatch model with a dedicated triage terminal, supervisory incident reviews, and 24-hour reassessment and transfer of unresolved incidents.
Verbatim wording from the response “b. Changes to control room model - The model that is used within dispatch is continually reviewed to ensure that it delivers the most effective approach. Changes were implemented in the summer of 2019 in order to manage incoming demand and the risk contained within existing logs. This includes the introduction of a dedicated triage terminal. This terminal does not hold legacy demand, therefore is able to review every new incident log sent to” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve contact handling by identifying lower-risk or non-policing incidents that do not require higher-priority control-room responses.
Verbatim wording from the response “e. This has been combined with a focus within Contact handling, around the policing purpose for incidents. Historically there were incidents being created as a P2 that were lower risk and should have been graded as a P3, or where there was no policing response required. This has further reduced unnecessary demand on control rooms.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide initial control-room training, mentoring, and competence portfolios over a six-month training period.
Verbatim wording from the response “12. The role by its very nature is one of managing competing demands, assessing risk and identifying appropriate resources to deploy against this assessment. The initial training is over a six month period involving initial training, mentoring and the completion of a portfolio for competence and capability in being able to operate in this high pressured role. To support staff in delivering against these demands, all of these systems and processes are now in place to support staff appropriately.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop process-change training for the THRIVE policy and prepare it for delivery to teams.
Verbatim wording from the response “a. THRIVE, which is a tool used to gather information to assess risk incorporated with the National Decision Model (NDM), supporting decision making on how an incident should be managed. This is now an agreed policy and the process change training is being developed ready for delivery to teams.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transfer logs more than 24 hours old to a different team so dispatchers can focus on critical calls.
Verbatim wording from the response “c. Reducing the number of logs held by each dispatcher. Logs more than 24 hours old are now dealt with by a different team so that dispatchers can concentrate on the most critical calls without the distraction of managing older logs.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace the incident snapshot presentation and establish an online dashboard to support understanding of available resources.
Verbatim wording from the response “10. In relation to point 4 of HM Coroners’ areas of concern, it is accepted that there were some issues with how the ‘snapshot’ was completed. This has been addressed and as seen during the inquest, this snapshot has been changed to simplify what is being presented and an online dashboard is now in place to support the understanding of resources.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate logs unresolved at 96 hours to an appropriate Neighbourhood Policing Unit resource for ownership until finalisation.
Verbatim wording from the response “c. Support from Neighbourhood Policing Unit senior leaders to allocate logs unresolved at 96 hours to the most appropriate resource to own until finalised.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Resource constraints limit the ability to respond to emergency calls within an appropriate time, despite prioritisation and efficient allocation of available resources.
Verbatim wording from the response “14. It is right to reflect the positive news of an uplift to police resources over the next three years, recently announced by the Government and these are welcomed. It is necessary to acknowledge the impacts of austerity through the funding formula over the last five years particularly on West Midlands Police and the challenge this has created in managing increasing demand levels.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing systems and processes are considered sufficient to support control-room staff in managing competing demands, assessing risk and deploying resources.
Verbatim wording from the response “13. In relation to the lack of resources to deal with incidents, the introduction of the escalation process allows for the use of any resource to respond to an incident where the risk dictates. It has taken time to embed this process and we are now seeing this supporting delivery. This has become more focused during Force TRM, held three times a day, where decisions are made to move additional resources according to demand.” Source location 2020-0017-Response-from-West-Midlands-Police_Redacted
Open published response
22 Oct 2019 Nigel Byron Abbott · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 10 Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community View source Failure to learn and correct identified unsafe beliefs about section 135 warrants View source Mental health professionals operating caseloads well in excess of recommended levels View source Failure of agencies to work together effectively View source Failure to use section 4 for urgent cases View source Failure to provide section 140 beds View source Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments View source Chronic shortage of psychiatric beds View source Failure of agencies to work together effectively on mental health detention processes View source Misunderstanding between agencies about urgent section 135 warrant requirements View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Nigel Byron Abbott · 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 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to learn and correct identified unsafe beliefs about section 135 warrants
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected .
My on-going concern is that the agencies involved in this area are not working together effectively. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Mental health professionals operating caseloads well in excess of recommended levels
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to work together effectively
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to use section 4 for urgent cases
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used .
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide section 140 beds
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT .
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments .
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Chronic shortage of psychiatric beds
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds .
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to work together effectively on mental health detention processes
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process , reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected.
My on-going concern is that the agencies involved in this area are not working together effectively . The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding between agencies about urgent section 135 warrant requirements
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation . This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available . All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected.
My on-going concern is that the agencies involved in this area are not working together effectively. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report
12 Aug 2019 Karen Jane Burns · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Insufficient resources to deal with the volume of calls, particularly at night View source Failure to grade calls correctly View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Karen Jane Burns · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Karen Jane Burns was found hanging from a basketball net at a park in Birmingham at 06.15 on 23 March 2019, after her ex-partner had reported that she had threatened to kill herself. The inquest concluded that her death was suicide. A serious concern was raised about West Midlands Police resources, particularly at night, and the incorrect grading and non-response of the call reporting the threat.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient resources to deal with the volume of calls, particularly at night
Wider context from the report “1. I heard evidence at the inquest that this call was graded incorrectly. It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response). The evidence confirmed that nearly all the P2 and P3 calls went unanswered that night . This raises a serious concern about the amount of resources available to West Midlands Police. Urgent attention is needed to address the resources available, particularly at night, as current resources are unable to deal with the large volume of cases the Force is expected to deal with .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to grade calls correctly
Wider context from the report “1. I heard evidence at the inquest that this call was graded incorrectly . It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response). The evidence confirmed that nearly all the P2 and P3 calls went unanswered that night. This raises a serious concern about the amount of resources available to West Midlands Police. Urgent attention is needed to address the resources available, particularly at night, as current resources are unable to deal with the large volume of cases the Force is expected to deal with.
” 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 Capture learning from the incident and provide training to the involved call handlers.
Verbatim wording from the response “6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource dispatch, allowing for improved identification of resource availability and response times.” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review THRIVE+ training for staff using learning from the incident.
Verbatim wording from the response “6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource dispatch, allowing for improved identification of resource availability and response times.” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Involve the Force Incident Manager during exceptionally busy response shifts to enable redeployment of resources from outside the area where possible.
Verbatim wording from the response “5. Before and since the events leading up to Ms Burns’ death, West Midlands Police has taken steps to ensure that the response resources it has are allocated as swiftly and efficiently as possible to all emergency calls. These steps include:” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate calls raising particular concerns to supervisors so resources can be prioritised where possible.
Verbatim wording from the response “5. Before and since the events leading up to Ms Burns’ death, West Midlands Police has taken steps to ensure that the response resources it has are allocated as swiftly and efficiently as possible to all emergency calls. These steps include:” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a new Command and Control platform to improve identification of resource availability and response times.
Verbatim wording from the response “6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource dispatch, allowing for improved identification of resource availability and response times.” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Change the dispatch model, including seating and interactions, to improve call handling efficiency.
Verbatim wording from the response “e. Changing the dispatch model, including where people sit and how they interact, to promote more efficient handling of calls.” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ongoing further training to all control room staff to reduce call-grading errors.
Verbatim wording from the response “training for all control room staff is ongoing to ensure such errors are eliminated as far as possible. It is clear from the Coroner’s findings that the wrong grading of this call made no difference to the deceased in this case since even a correctly graded P2 call would not have been responded to due to pressure on resources on the night of 22/23 March 2019.” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce dispatcher log volumes by transferring logs over 24 hours old to another team.
Verbatim wording from the response “d. Reducing the number of logs held by each dispatcher. Logs more than 24 hours old are now dealt with by another team so dispatchers can concentrate only on the most critical calls without the distraction of managing older logs. Numbers of logs held by each dispatcher has decreased from around 160 (as on the night of 22/23 March 2019) to around 60.” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Change shift patterns to improve team relationships and the efficient handling and transfer of calls between shifts.
Verbatim wording from the response “f. Changing shift patterns to build better relationships between teams and to promote more efficient handling of calls and transfer of calls between shifts.” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a Log Closure Doctrine to support bolder dispatcher decisions and focus resources on calls with the most pressing needs.
Verbatim wording from the response “5. Before and since the events leading up to Ms Burns’ death, West Midlands Police has taken steps to ensure that the response resources it has are allocated as swiftly and efficiently as possible to all emergency calls. These steps include:” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor call response times, resolution, resource levels and performance to assess whether appropriate resources remain available.
Verbatim wording from the response “6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource dispatch, allowing for improved identification of resource availability and response times.” Source location 2019-0273-Response-by-West-MIdlands-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 Finite resources limit the ability to respond to all emergency calls within the appropriate time, despite prioritisation.
Verbatim wording from the response “3. The second and key issue that the Coroner raises is the risk created by the lack of resources available to West Midlands Police. On the night of 22/23 March 2019 most calls graded P2, and even some calls graded P1 (response time of 15 minutes), could not be reached due to the high level of demand and resources available.” Source location 2019-0273-Response-by-West-MIdlands-Police
Open published response
22 Jul 2019 Richard Patrick Carlon · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Unavailability of approved Mental Health practitioners for Mental Health Act assessments View source Failure to advise BSMHT when a person is found safe and well at home View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Richard Patrick Carlon · 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
Richard Patrick Carlon, who had paranoid schizophrenia and a history of relapsing after taking illicit substances, was detained under the Mental Health Act after stating that he would kill himself. He later left care, was found at his father’s home, and subsequently stepped in front of a lorry; he died in hospital from polytrauma following the road traffic collision. The concerns included the lack of an approved Mental Health practitioner to conduct an assessment and failures in communication between the police and mental health services after he was found safe and well.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of approved Mental Health practitioners for Mental Health Act assessments
Wider context from the report “1. No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr Carlon on 14/11/18. I was told this was an ongoing problem and was delaying assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to advise BSMHT when a person is found safe and well at home
Wider context from the report “2. When Mr Carlon was found safe and well at home WMP did not advise BSMHT . This was a missed opportunity for Mental health to re-engage with Mr Carlon and make a further assessment of his condition. Consideration need to be given to how agencies can improve communication.
” Open source report
12 Jul 2019 David Jonathon Jukes · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure to follow through plans made to discuss and assess patients View source Failure to maintain accurate records of contacts, decisions and risk assessments View source Failure of the system to carry out necessary psychiatric assessments in police custody View source Failure to use all available means to locate patients requiring assessment View source Failure to ensure staff compliance with record-keeping duties is detected View source Failure to provide material arrest information for mental health assessments in custody View source Failure to attempt timely assessment after a high-risk patient re-establishes contact View source Failure to pass reliable information between mental health services View source Insufficient HTT capacity to maintain progress notes and risk assessments View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Jonathon Jukes · 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
David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to follow through plans made to discuss and assess patients
Wider context from the report “5. It was planned that Mr. Jukes would be discussed at a team meeting on the 3rd October 2018 after the psychologist raised concerns on the 2nd. There is no credible evidence he was discussed or a plan made to locate and assess him . No explanation was provided in evidence for why evidence given of a strategy to guard against this occurring in future. Therefore there continues to be a risk that plans to discuss patients in meetings will not be followed through which puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate records of contacts, decisions and risk assessments
Wider context from the report “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes . Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment . There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited. Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the system to carry out necessary psychiatric assessments in police custody
Wider context from the report “3. Despite not being informed by the BCPFT liaison and diversion nurse that Mr Jukes was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018. She also gave some information about the circumstances of his arrest, further information about the incident and police involvement had been reported to Street Triage during the night and was noted in the RIO notes. Despite this, no psychiatrist visited or attempted to visit Mr. Jukes in custody which it was stated in evidence was the usual practice of the team. It is not known why this was. Not having a robust and effective system to carry out necessary assessments whilst a patient is detained in police custody puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to use all available means to locate patients requiring assessment
Wider context from the report “4. Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was treating suicide and harm to others, on the 2nd October 2018 the HTT’s only recorded attempt to contact Mr. Jukes before the 9th October 2018 was a single call (which probably mistakenly went to his wife’s phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication to Mr. Jukes (although he had communicated this way with the team before and provided them with his email address) nor a call to his wife to ask her for assistance . There was evidence at inquest from the RCA Author that there should have been more effort to contact him at least from the 4th onwards if not before. Failure to utilise all means of locating a patient whereabouts are unknown, who requires assessment and who is not making contact with the team puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff compliance with record-keeping duties is detected
Wider context from the report “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes. Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment. There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited . Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide material arrest information for mental health assessments in custody
Wider context from the report “1. The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr. Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody . She was provided with a print out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft, threatened suicide and harm to others and not come out in response to police negotiators. This information was not included in a verbal handover according to the nurse’s evidence and there is no record of it being handed over to her. She stated in evidence that if she had been aware of the extent of the events overnight on the 27th into the 28th she would have arranged a Mental Health Act assessment when he did not engage with her. There is a risk to life if assessments of mental health in custody are not informed by material information about circumstances connected with arrest.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt timely assessment after a high-risk patient re-establishes contact
Wider context from the report “6. On the 9th October 2018 an HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018 . By this time he was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances, had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week. This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact . The staff involved maintained in evidence that they acted appropriately, evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk . No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to pass reliable information between mental health services
Wider context from the report “2. The above psychiatric liaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based at Perry Barr custody suite and was informed that Mr. Jukes was not known to the service. She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of his previous evening. It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred . Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn’t explain why the nurse was left with the impression that he was not known to services. It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise . If reliable information is not being passed there is a risk to life from ill-informed decision making.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient HTT capacity to maintain progress notes and risk assessments
Wider context from the report “8. Evidence was given at the inquest that the reason HTT may not be maintaining good record keeping was due to insufficient capacity arising from a combination of too few staff arising from under-funding of the service and unnecessary referrals being made to the team . Evidence was given that there is work underway to introduce a systems to prevent inappropriate referrals and that funding has been granted for a further two CPNS for HTTs within BSMHT. However the evidence was that this will not be enough to enable staff to have the time to comply with their obligations to update progress notes and risk assessments . If funding is not sufficient to enable staff to fulfil their professional obligations to their patients, lives are at risk.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing custody record and available information access adequately inform Liaison and Diversion assessments, so no future-death risk exists.
Verbatim wording from the response “Therefore, it is submitted that some information was readily available on the custody record.” Source location 2019-0329-Response-by-Staffordshire-and-West-Midlands-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 An adequate system records arrest circumstances and gives Liaison and Diversion practitioners access to relevant custody information.
Verbatim wording from the response “The Liaison and Diversion team can make verbal requests for further information. This would include access to the full custody record which is available in custody and would extend to call out logs and ‘crime investigation logs that can be obtained by the custody staff. It would however be unlikely to extend to all the logs.” Source location 2019-0329-Response-by-Staffordshire-and-West-Midlands-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 No action is required because the existing system addresses the identified risk in this case.
Verbatim wording from the response “It is our position that there is an adequate system in place which ensures that the circumstances of an arrest are accurately recorded on the custody record and that a Liaison and Diversion practitioner has access to a wide range of information within the custody setting. Therefore, it is submitted that there is no risk of future death to be addressed and no action is required in this case.” Source location 2019-0329-Response-by-Staffordshire-and-West-Midlands-Police
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 West Midlands 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 West Midlands 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
9 Nov 2016 Mark Adam Yafai · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 2 Failure to require Health Care Professional assessment after disclosed recent drug consumption View source Lack of clear and consistent drug-related risk assessment and observation guidance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mark Adam Yafai · 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
Mark Adam Yafai was arrested in the early hours of 1 July 2015 after disclosing recent cocaine use, and was found convulsing and frothing at the mouth in his cell. He suffered cardiac arrest and died at hospital; the stated cause of death was acute cocaine toxicity. The report raised concerns that custody policies used unclear terminology and gave too much discretion over healthcare assessment, risk assessment and observation for detainees who had disclosed drug use.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to require Health Care Professional assessment after disclosed recent drug consumption
Wider context from the report “i. The Safer Detention Policy and Handling of Person in Custody Composite Policy as updated August 2014 was replaced by the WMP Detention and Custody Policy Inc. Standard Operating Procedure with effect from the 22nd December 2015. The earlier policy was in operation at the time Mark Yafai died. The earlier policy lacked clarity or guidance in how the phrase “under the influence” must be interpreted. The phrase is unsuitable since it confers a very broad discretion upon a custody officer to not have the detainee examined by a Health Care Professional, despite a detainee has disclosed recently consuming drugs. The impact upon risk assessment and levels of observation is clear and significant. A broad discretion of an officer when determining risk concerning medical matters including drug use is inadequate. The jury made a determination in similar terms.
ii. The evidence was the policy is accessible. Accordingly, it is paramount that the policy must provide clear unambiguous guidance/ direction to custody officers particularly in relation to drugs which can have serious consequences for an individual who has consumed. The circumstances of this inquest touching upon the death of Mark Yafai accentuated this point. The evidence was that cocaine can have toxic effects even from small quantities (as little as 0.03g). Consumption can be via a number of means and the effects delayed depending upon the method of ingestion. There is no antidote to cocaine toxicity. The evidence was custody officers range of knowledge about drugs and the effects can and do differ and this can have a bearing upon risk assessment given the terminology in the policy and broad discretion officers have.
iii. The 2015 policy retains that same unclear terminology i.e. “believed to be under the influence of drugs or withdrawing from drugs” and “will be seen by a Health Care Professional (HCP) as a matter of course”.
iv. It does not deal with the instances in which a detainee irrespective of presentation (which is not itself any easy assessment when a detainee is being observed by an officer most likely for the first time with no information against which a comparison may be made as whether their current presentation is indeed “normal”) has disclosed the recent consumption of drugs. What is “a line” or any quantitative opinion on drugs consumed is a very subjective assessment by the detainee and/ or the custody officer.
v. An assessment as to the effect of any drugs is best assessed a by a Heath Care Professional. That was the evidence and information that emerged in the inquest. Standard medical observations can be undertaken ranging from a check as body temperature to elevated heart rate or blood pressure which may be indicators that drugs are having an adverse effect upon the body.
vi. Earlier identification of these matters may prevent death particularly since treatment for many drugs, particularly cocaine, is symptomatic. Close observation of a detainee is clearly significant since early treatment of symptoms can have an impact upon an individual’s survivability.
vii. The policy in other respects does use directional/ non discretion type terminology in some respects when dealing with drug issues. It is thus currently inconsistent in this respect on this topic and in interrelation with Risk assessment and appropriate observation levels which are a focus of custody personnel.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clear and consistent drug-related risk assessment and observation guidance
Wider context from the report “i. The Safer Detention Policy and Handling of Person in Custody Composite Policy as updated August 2014 was replaced by the WMP Detention and Custody Policy Inc. Standard Operating Procedure with effect from the 22nd December 2015. The earlier policy was in operation at the time Mark Yafai died. The earlier policy lacked clarity or guidance in how the phrase “under the influence” must be interpreted. The phrase is unsuitable since it confers a very broad discretion upon a custody officer to not have the detainee examined by a Health Care Professional, despite a detainee has disclosed recently consuming drugs. The impact upon risk assessment and levels of observation is clear and significant. A broad discretion of an officer when determining risk concerning medical matters including drug use is inadequate. The jury made a determination in similar terms.
ii. The evidence was the policy is accessible. Accordingly, it is paramount that the policy must provide clear unambiguous guidance/ direction to custody officers particularly in relation to drugs which can have serious consequences for an individual who has consumed. The circumstances of this inquest touching upon the death of Mark Yafai accentuated this point. The evidence was that cocaine can have toxic effects even from small quantities (as little as 0.03g). Consumption can be via a number of means and the effects delayed depending upon the method of ingestion. There is no antidote to cocaine toxicity. The evidence was custody officers range of knowledge about drugs and the effects can and do differ and this can have a bearing upon risk assessment given the terminology in the policy and broad discretion officers have.
iii. The 2015 policy retains that same unclear terminology i.e. “believed to be under the influence of drugs or withdrawing from drugs” and “will be seen by a Health Care Professional (HCP) as a matter of course”.
iv. It does not deal with the instances in which a detainee irrespective of presentation (which is not itself any easy assessment when a detainee is being observed by an officer most likely for the first time with no information against which a comparison may be made as whether their current presentation is indeed “normal”) has disclosed the recent consumption of drugs. What is “a line” or any quantitative opinion on drugs consumed is a very subjective assessment by the detainee and/ or the custody officer.
v. An assessment as to the effect of any drugs is best assessed a by a Heath Care Professional. That was the evidence and information that emerged in the inquest. Standard medical observations can be undertaken ranging from a check as body temperature to elevated heart rate or blood pressure which may be indicators that drugs are having an adverse effect upon the body.
vi. Earlier identification of these matters may prevent death particularly since treatment for many drugs, particularly cocaine, is symptomatic. Close observation of a detainee is clearly significant since early treatment of symptoms can have an impact upon an individual’s survivability.
vii. The policy in other respects does use directional/ non discretion type terminology in some respects when dealing with drug issues. It is thus currently inconsistent in this respect on this topic and in interrelation with Risk assessment and appropriate observation levels which are a focus of custody personnel.
” Open source report
8 Nov 2016 Ozeilivo Andrew AKERELE · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Failure to follow up a recommendation for a more thorough search View source Failure to ensure the Police Search Advisor is aware of recommendations for a more thorough search View source Failure to search a disused graveyard near the last sighting at or about the time of disappearance View source Failure of the search to locate a missing person despite an intensive search near the last confirmed sighting View source Failure to ensure the Police Search Advisor is aware of the cursory nature of a graveyard search View source Failure of the search team to locate a missing person when searching a defined graveyard area View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ozeilivo Andrew AKERELE · 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
Ozeilivo Andrew Akerele disappeared, and his body was found 15 months later in a disused graveyard close to the last confirmed sighting of him. The concerns relate to failures to search the area adequately and promptly, failure to follow up a recommendation for a more thorough search, and gaps in communication with the Police Search Advisor. The inquest concluded with a finding of misadventure.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up a recommendation for a more thorough search
Wider context from the report “(3) The recommendation by ████████ for a more thorough search was not followed up.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure the Police Search Advisor is aware of recommendations for a more thorough search
Wider context from the report “(4)The Police Search Advisor was unaware of the recommendation for a more thorough search by ████████
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to search a disused graveyard near the last sighting at or about the time of disappearance
Wider context from the report “(2) failure to search the disused graveyard at or about the time of his disappearance . where Mr Akerele was eventually discovered 15 months later by children.- the graveyard was only a few metres away from the last sighting of him on CCTV on 31 January 2015 .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the search to locate a missing person despite an intensive search near the last confirmed sighting
Wider context from the report “(1) failure to find the body of Mr Akerele despite an intensive search when in fact his body was found very close to the last confirmed sighting of him .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure the Police Search Advisor is aware of the cursory nature of a graveyard search
Wider context from the report “(5) The Police Search Advisor was unaware of the (cursory) nature of the search of the graveyard in February 2015
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of the search team to locate a missing person when searching a defined graveyard area
Wider context from the report “(2) failure of the search team to find Mr Akerele when they did eventually search the disused graveyard in approximately late February 2015 despite the graveyard being approximately 60m x 30m .
” Open source report
26 Nov 2014 Amanda Hawkins · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 4 Failure to contact healthcare professionals during missing-person risk assessment View source Failure to direct hospital appointment correspondence to a person able to manage it View source Failure to maintain adequate support during moves, funding changes and step-down of services View source Failure to identify missed essential appointments and provide follow-up View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Amanda Hawkins · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Amanda Hawkins, aged 44, had schizophrenia and experienced multiple moves to accommodation with reduced levels of care and changes in care co-ordination. She was last seen on 30 May 2014 and reported missing that evening; her naked, decomposed body was found on 22 July 2014, and the cause of death was unascertained. Concerns included increased vulnerability following the moves and inadequate follow-up of essential hospital appointments because care co-ordination workers were not informed of missed appointments.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to contact healthcare professionals during missing-person risk assessment
Wider context from the report “(1) When Amanda was reported missing she was classified as medium risk. No contact was made with her healthcare professionals. Had such contact been made earlier in the enquiry her risk profile may well have changed to high risk at an earlier point. This in turn may have led to a different approach in the search for her.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to direct hospital appointment correspondence to a person able to manage it
Wider context from the report “(2) Hospital appointments were sent to Amanda at her home address when she did not have sufficient understanding to deal with correspondence. Care co-ordination workers were not made aware of missed appointments and there was therefore no follow up. Lack of follow up for essential appointments led to her increased vulnerability.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate support during moves, funding changes and step-down of services
Wider context from the report “(1) The moves following closure of various homes or changes in funding and step down in-services offered to Amanda resulted in her increased vulnerability .
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to identify missed essential appointments and provide follow-up
Wider context from the report “(2) Hospital appointments were sent to Amanda at her home address when she did not have sufficient understanding to deal with correspondence. Care co-ordination workers were not made aware of missed appointments and there was therefore no follow up . Lack of follow up for essential appointments led to her increased vulnerability.
” Open source report
25 Jun 2014 Lloyd Edward Butler · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to control custody staff behaviour View source Failure to maintain a professional and safe custody-suite culture View source Lack of leadership by custody sergeants View source Insufficient guidance and training for custody staff on acceptable behaviour View source Failure of custody staff to behave professionally and with discipline View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lloyd Edward Butler · 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
Lloyd Edward Butler was arrested for being drunk and incapable and detained at Stechford Police Station, where he was found struggling to breathe and subsequently died after suffering cardiac arrest. The report describes untimely observations and rousing, staff distraction and unprofessional behaviour, and concerns about inadequate leadership, training, and the wider culture in custody suites.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to control custody staff behaviour
Wider context from the report “(1) The lack of professionalism and leadership in the custody suite was striking. There was no leadership by the custody sergeant and no control of the behaviour of any of the staff . Evidence heard at the inquest indicated this sort of banter and practice was common and continuing. Many detainees in the custody block are vulnerable, often have mental health difficulties and other social problems and may be in varying degrees of intoxication. The custody staff are responsible for those detainees and should carry this responsibility out in a professional and disciplined manner.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a professional and safe custody-suite culture
Wider context from the report “(3) There was evidence at the inquest that the CCTV footage of Mr Butler’s time in custody was representative of the general approach and culture within custody suites in the West Midlands . West Midlands Police should consider how this culture might be addressed and changed.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of leadership by custody sergeants
Wider context from the report “(1) The lack of professionalism and leadership in the custody suite was striking. There was no leadership by the custody sergeant and no control of the behaviour of any of the staff. Evidence heard at the inquest indicated this sort of banter and practice was common and continuing. Many detainees in the custody block are vulnerable, often have mental health difficulties and other social problems and may be in varying degrees of intoxication. The custody staff are responsible for those detainees and should carry this responsibility out in a professional and disciplined manner.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance and training for custody staff on acceptable behaviour
Wider context from the report “(2) There was insufficient evidence at the inquest that any guidance or training had been conducted for custody staff regarding what was acceptable behaviour in a custody suite following the events in question.
” 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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Failure of custody staff to behave professionally and with discipline
Wider context from the report “(1) The lack of professionalism and leadership in the custody suite was striking. There was no leadership by the custody sergeant and no control of the behaviour of any of the staff. Evidence heard at the inquest indicated this sort of banter and practice was common and continuing . Many detainees in the custody block are vulnerable, often have mental health difficulties and other social problems and may be in varying degrees of intoxication. The custody staff are responsible for those detainees and should carry this responsibility out in a professional and disciplined manner .
” 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 Incorporate the national Code of Ethics into all training courses and deliver associated training to supervisors, Sergeants and Inspectors.
Verbatim wording from the response “The local implementation of the Code of Ethics, overseen by the Deputy Chief Constable, will underpin WMP’s continued focus on professionalism amongst our staff. The principles within the Code are being incorporated into all WMP training courses, including those relating to custody. All first and second line supervisors, Sergeants and Inspectors, are attending one day training courses, which have already commenced, covering the Code and its requirements. This commitment of resources hopefully evidences the force’s determination to promote a positive culture of professionalism within the organisation.” Source location 2014-0281-Response-by-West-Midlands-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 Central Justice Services managers to sample custody records and, where appropriate, CCTV to monitor the quality of custody care.
Verbatim wording from the response “It is hoped that the measures detailed above will offer reassurance that WMP has addressed the ‘Matters of Concern’ since 2010 and continues to do so. Whilst recognising the potential for under-reporting, the level of complaints made by detainees is relatively low; with only 71 complaints being made in relation to detention in custody in 2013-2014 out of approximately 65000 people who were detained. Nevertheless, to ensure the quality of care provided to those in custody, CJS managers are expected to dip sample custody records and, where appropriate, CCTV.” Source location 2014-0281-Response-by-West-Midlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide all custody staff with one day of continuous professional development every 20 weeks to refresh procedures, disseminate learning and reinforce standards.
Verbatim wording from the response “It also covers the practical application of these principles to the custody role, such as ensuring that initial and ongoing risk assessments are conducted, cells are inspected for damage and cleanliness, and that adequate meals, clean clothing and bedding is available. In addition to this initial training, all custody staff receive one day’s continuous professional development every 20 weeks. These one day courses refresh staff knowledge on custody procedure and policy, make staff aware of new guidance and legislation, provide an opportunity for operational learning to be disseminated, and help to reinforce the professional standards expected of all custody staff.” Source location 2014-0281-Response-by-West-Midlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Pride in our Police campaign to promote professional standards and personal responsibility across the organisation.
Verbatim wording from the response “WMP has invested in ensuring that there is a culture of professionalism, not only in all of the custody facilities, but more widely across the workforce. In June 2013, WMP launched the ‘Pride in our Police’ campaign. This internal campaign aims to promote a culture of high professional standards and personal responsibility across the organisation. The areas of focus are identified by panels of first and second line supervisors and are then addressed at a local level, supported by an internal media campaign and with oversight by the Head of Professional Standards. The campaign has already covered topics including uniform and appearance, personal” Source location 2014-0281-Response-by-West-Midlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide new custody officers and staff with the Role of the Custody Officer lesson covering duty of care, detainee needs and custody standards.
Verbatim wording from the response “WMP agree that training and guidance for custody staff is a crucial part of maintaining high standards in the custody environment and it is unfortunate that insufficient evidence was presented at the inquest to offer reassurance of our commitment in this regard. All new custody officers and staff, since 2010, have undertaken a specific lesson entitled, ‘The Role of the Custody Officer’, as part of their training for their role. This lesson incorporates key aspects from the force values, including acting with, ‘integrity, compassion, courtesy and patience’, and explores what is meant by ‘duty of care’ in the custody environment; emphasising the importance of being attentive towards the needs of detainees and having due regard for their human rights.” Source location 2014-0281-Response-by-West-Midlands-Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Centralise custody facility and staff management under Central Justice Services and reduce the number of custody suites.
Verbatim wording from the response “Since 2010, management of custody facilities and staff has been brought under a central force department, Central Justice Services (CJS) and the number of custody suites reduced from 21 to 11. The creation of this department has allowed for greater accountability and clearer leadership. WMP recognises that Custody Sergeants have a key role in ensuring that proper standards are implemented on a day to day basis and recognises how the lack of front line leadership shown in the care of Mr Butler would give cause for wider concern.” Source location 2014-0281-Response-by-West-Midlands-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 Poor practice shown in the case is not representative of the general conduct or culture in current custody suites.
Verbatim wording from the response “While recognising that evidence given at the inquest suggested that the conduct evident in the case of Mr Butler has not necessarily been eliminated entirely, WMP believe that it is not representative, in any way of the general conduct or culture of WMP Custody Sergeants, officers and staff today. This position is based on the governance structures now in place, the training and guidance provided to staff, the systems and processes that have been implemented, and the culture of WMP as a whole.” Source location 2014-0281-Response-by-West-Midlands-Police
Open published response
11 Mar 2014 Saleh Ali Dalie · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Lack of appropriate crossing measures on a residential road View source Lack of parking restrictions on a residential road View source Lack of road calming measures on a residential road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Saleh Ali Dalie · 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
Saleh Ali Dalie was hit by a van while crossing Kyotts Lake Road to attend his local mosque and later died from his injuries in hospital. The report raised concerns about the safety of the residential road, noting several incidents and two fatalities, and that requested road-calming, parking restrictions and crossing measures had not been introduced.
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 Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate crossing measures on a residential road
Wider context from the report “(1) There have been several incidents and 2 fatalities on this road. Residents have campaigned for road calming measures and parking restrictions and appropriate crossing measures which have not been introduced . I am concerned about the safety of this road given it is a residential area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of parking restrictions on a residential road
Wider context from the report “(1) There have been several incidents and 2 fatalities on this road. Residents have campaigned for road calming measures and parking restrictions and appropriate crossing measures which have not been introduced . I am concerned about the safety of this road given it is a residential area.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Midlands Police; that does not assign responsibility.
PFD Monitor interpretation Lack of road calming measures on a residential road
Wider context from the report “(1) There have been several incidents and 2 fatalities on this road. Residents have campaigned for road calming measures and parking restrictions and appropriate crossing measures which have not been introduced . I am concerned about the safety of this road given it is a residential area.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations