7 Oct 2025 Ann Sabrina LASKOWSKY · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 4 Lack of dissemination and promotion of the Partner Triage Line to operational police officers View source Lack of clear training on assessing whether a person is responsive or unresponsive View source Lack of specific policy, guidance or training on using the Partner Triage Line View source Lack of clear training on assessing whether a person is breathing normally View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ann Sabrina LASKOWSKY · 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
Ann Sabrina Laskowsky was found unresponsive at home on 5 October 2024 after police attended when an inactivity alarm was triggered. She was taken to hospital later that day and died on 6 October 2024 from naturally occurring disease contributed to by self-neglect and exacerbated by longstanding alcohol dependence. The principal concerns were the adequacy and clarity of police first-aid training, including recognising abnormal breathing and unresponsiveness, and officers’ knowledge, use and training regarding the Partner Triage Line.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of dissemination and promotion of the Partner Triage Line to operational police officers
Wider context from the report “2. The knowledge, use and training in respect of available resources
In the course of the Inquest, I heard evidence in respect of a resource or service, known as the ’Partner Triage Line’. This is a service which has been provided for a number of years by the Yorkshire Ambulance Service which provides a direct line for police officers to speak to a medical practitioner at the emergency operations centre, to seek advice, with the facility for the Officer to send photographs to the practitioner to help inform their advice and an ability for the practitioner to conduct a live video assessment.
Differing evidence was heard at inquest in terms of the knowledge of individual officers in respect of that service, with one officer being unaware that there was a service or resource.
In the course of my investigation, I received further evidence confirming that the telephone number for the ‘Partner Triage Line’ is visible and accessible in the contact environment and is then sent to officers on request, but that it is not known or promoted to those officers carrying out operational duties , who are those who are likely to need it the most.
I have significant concerns in relation to the knowledge of this valuable resource and its overall lack of use and promotion amongst those Officer who might need it the most. In particular my concerns relate to the following:-
a. The lack of knowledge and use of the service throughout West Yorkshire Police given the lack of dissemination and promotion amongst all of the officers to whom it would be of benefit , providing them with the tools to enable them to properly and effectively carry out their duties; and
b. The lack of specific policy, guidance or training for Officers in respect of how the service can be used to support them in carrying out their duties, enabling them to keep members of the public safe. This is of particular concern, given that the service has now been available for a number of years.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clear training on assessing whether a person is responsive or unresponsive
Wider context from the report “1. The adequacy of First Aid Training provided by West Yorkshire Police
The body worn camera footage which was played during the course of the inquest, clearly shows that when the Officers arrived, they found Ann lying slumped on the sofa, appearing pale with an increased respiratory rate. Ann was profoundly unwell and required urgent medical attention.
The attending Officers did not recognise the severity of Ann's condition and instead considered that Ann was asleep but could not be woken. This of itself, raises significant concerns in respect of the nature and adequacy of the training that had been provided to the officers at the time.
Expert evidence received during the course of the Inquest concluded that even if the Officers had sought medical attention when they attended, given the severity of her condition, such treatment would not have prevented her death.
During the course of the Inquest, evidence was received from a variety of sources, in respect of nature and quality of the First Aid Training provided to Officers, in both their initial training and their annual refresher training.
This evidence demonstrated an overwhelming lack of clarity in terms of the way in which officers are trained to assess whether an individual is alive, breathing and conscious , something which it is expected that Officers can assess, in line with their authorised professional practice. The very nature of this evidence was such as to raise significant concerns as to the impact of this training upon the preservation of life.
There were two main areas in which the lack of clarity and consequent inadequacy of training were of particular concern:-
a. The assessment of whether a person is breathing normally and how this is to be assessed; and
b. Whether an individual is responsive or unresponsive, particularly in cases where there may be some involuntary movements from the individuals concerned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of specific policy, guidance or training on using the Partner Triage Line
Wider context from the report “2. The knowledge, use and training in respect of available resources
In the course of the Inquest, I heard evidence in respect of a resource or service, known as the ’Partner Triage Line’. This is a service which has been provided for a number of years by the Yorkshire Ambulance Service which provides a direct line for police officers to speak to a medical practitioner at the emergency operations centre, to seek advice, with the facility for the Officer to send photographs to the practitioner to help inform their advice and an ability for the practitioner to conduct a live video assessment.
Differing evidence was heard at inquest in terms of the knowledge of individual officers in respect of that service, with one officer being unaware that there was a service or resource.
In the course of my investigation, I received further evidence confirming that the telephone number for the ‘Partner Triage Line’ is visible and accessible in the contact environment and is then sent to officers on request, but that it is not known or promoted to those officers carrying out operational duties, who are those who are likely to need it the most.
I have significant concerns in relation to the knowledge of this valuable resource and its overall lack of use and promotion amongst those Officer who might need it the most. In particular my concerns relate to the following:-
a. The lack of knowledge and use of the service throughout West Yorkshire Police given the lack of dissemination and promotion amongst all of the officers to whom it would be of benefit, providing them with the tools to enable them to properly and effectively carry out their duties; and
b. The lack of specific policy, guidance or training for Officers in respect of how the service can be used to support them in carrying out their duties , enabling them to keep members of the public safe. This is of particular concern, given that the service has now been available for a number of years.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of clear training on assessing whether a person is breathing normally
Wider context from the report “1. The adequacy of First Aid Training provided by West Yorkshire Police
The body worn camera footage which was played during the course of the inquest, clearly shows that when the Officers arrived, they found Ann lying slumped on the sofa, appearing pale with an increased respiratory rate. Ann was profoundly unwell and required urgent medical attention.
The attending Officers did not recognise the severity of Ann's condition and instead considered that Ann was asleep but could not be woken. This of itself, raises significant concerns in respect of the nature and adequacy of the training that had been provided to the officers at the time.
Expert evidence received during the course of the Inquest concluded that even if the Officers had sought medical attention when they attended, given the severity of her condition, such treatment would not have prevented her death.
During the course of the Inquest, evidence was received from a variety of sources, in respect of nature and quality of the First Aid Training provided to Officers, in both their initial training and their annual refresher training.
This evidence demonstrated an overwhelming lack of clarity in terms of the way in which officers are trained to assess whether an individual is alive, breathing and conscious , something which it is expected that Officers can assess, in line with their authorised professional practice. The very nature of this evidence was such as to raise significant concerns as to the impact of this training upon the preservation of life.
There were two main areas in which the lack of clarity and consequent inadequacy of training were of particular concern:-
a. The assessment of whether a person is breathing normally and how this is to be assessed ; and
b. Whether an individual is responsive or unresponsive, particularly in cases where there may be some involuntary movements from the individuals concerned.
” 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 Remind officers during initial and annual refresher first aid training that they can use the YAS Partner Triage Line.
Verbatim wording from the response “Finally, Trainers will remind officers whilst on their First Aid Training Courses (including yearly refresher courses) that they can utilise the YAS Partner Triage Line if they need advice from a clinically trained practitioner.” Source location Response from West Yorkshire 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 Teach officers that failure to obtain a suitable AVPU response means the casualty is unresponsive and requires an ambulance call.
Verbatim wording from the response “The First Aid Trainers now teach Officers that when they are looking for a response using AVPU (Alert, Voice, Pain, Unresponsive) that if they are unable to obtain a ‘suitable response’ from the casualty using Voice or to Pain then the casualty is unresponsive, and they should call for an ambulance.” Source location Response from West Yorkshire 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 clarification of normal breathing rates, visible breathing effort and distress to first aid training.
Verbatim wording from the response “To assess your concerns about the assessment of whether a person is breathing normally, the Trainers will now include a discussion and clarification and confirmation of 12-20 breaths per minute (they should be taking a minimum of 2 breaths in 10 seconds). If it appears as though they are in distress or it is taking visible effort to breath, this is not normal breathing.” Source location Response from West Yorkshire 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 an unresponsive-sleeper scenario to develop officers’ decision-making about calling an ambulance.
Verbatim wording from the response “Trainers now invite Officers to question and discuss “what is a suitable response”. A scenario based on a person who appears to be asleep who the Officers are unable to wake up will be used to invite discussion between the Trainer and the Officers to support effective decision making. Officers will now be taught that if someone is asleep and they are unable to wake them using painful stimuli and they do not respond to their voice then this is not normal, and an ambulance should be called.” Source location Response from West Yorkshire 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 Invite officers to discuss what constitutes a suitable response during first aid training.
Verbatim wording from the response “Trainers now invite Officers to question and discuss “what is a suitable response”. A scenario based on a person who appears to be asleep who the Officers are unable to wake up will be used to invite discussion between the Trainer and the Officers to support effective decision making. Officers will now be taught that if someone is asleep and they are unable to wake them using painful stimuli and they do not respond to their voice then this is not normal, and an ambulance should be called.” Source location Response from West Yorkshire 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 Communicate the YAS Partner Triage Line to staff through force-wide messages, briefings and online learning.
Verbatim wording from the response “The YAS Partner Triage Line was launched to WYP on 18th January 2021 and was communicated to all staff through force wide messages, briefings and an online learning package.” Source location Response from West Yorkshire 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 Post an intranet briefing, update operational briefings and training materials, and provide force-wide intranet access to the Partner Triage Line information.
Verbatim wording from the response “Following the conclusion of the inquest into Ann’s death an intranet briefing has been posted to remind everyone of the facility and details of the facility have been included in operational briefings and training and guidance material has been updated to include reference to the Partner Triage Line, which all members have the force have access to via the force intranet. The Right Care Right Person team have been tasked with monitoring the usage of the facility as part of our partnership work with YAS.” Source location Response from West Yorkshire 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 Teach officers to distinguish involuntary limb, head or facial movements from a suitable response and call an ambulance.
Verbatim wording from the response “Trainers now teach Officers to be aware of involuntary movements of limbs, head or face and that these are not to be mistaken for a suitable response. The Trainer now emphasises the need to call for an ambulance.” Source location Response from West Yorkshire 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 Practise breathing assessment using acting casualties in face-up, face-down and seated positions.
Verbatim wording from the response “The above will be put into practice by using acting casualties who are found in a variety of positions such as face up on the floor, face down on the floor and, also in a sitting position.” Source location Response from West Yorkshire Police
Open published response
25 May 2025 Paul Andrew Alexander · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of an agreed emergency-services response to welfare concerns arising under RCRP View source Reliance on call takers to bring cross-agency welfare concerns to operational managers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Andrew Alexander · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Andrew Alexander, who had a long-standing history of mental illness and was under the care of community mental health services, entered the water at Aspley Marina on 4 February 2024 and died from cold-water immersion. A welfare call to police was redirected to the ambulance service, which did not attend, and no emergency services were dispatched. The principal concern was a gap in how emergency services respond to welfare calls under the Right Care Right Person framework.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed emergency-services response to welfare concerns arising under RCRP
Wider context from the report “In the course of the evidence, it became apparent the police had introduced RCRP in September 2023. RCRP is a police initiative arising out of a national agreement but to be implemented by individual police forces. Little or no consultation with other agencies had taken place prior to the implementation of RCRP in September 2023.Whilst I heard evidence that meetings with other agencies now do take place, the specifics of Paul’s case and the broader issues it raises have not been discussed nor is there any understanding/agreement in place as to how such a situation would now be addressed . As much as the court was advised was that if a similar situation arose today, there may be a discussion between operational managers in the respective police and ambulance call centres, but that this would be reliant upon the matter being brought to the attention of those respective managers by the call taker. The evidence from the RCRP lead at the ambulance service indicated the scenario that arose with Paul was not an isolated example. As such there appears to be a lacuna in how emergency services will respond to such a situation when it was accepted this was a call expressing concern for Paul’s welfare.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Reliance on call takers to bring cross-agency welfare concerns to operational managers
Wider context from the report “In the course of the evidence, it became apparent the police had introduced RCRP in September 2023. RCRP is a police initiative arising out of a national agreement but to be implemented by individual police forces. Little or no consultation with other agencies had taken place prior to the implementation of RCRP in September 2023.Whilst I heard evidence that meetings with other agencies now do take place, the specifics of Paul’s case and the broader issues it raises have not been discussed nor is there any understanding/agreement in place as to how such a situation would now be addressed. As much as the court was advised was that if a similar situation arose today, there may be a discussion between operational managers in the respective police and ambulance call centres, but that this would be reliant upon the matter being brought to the attention of those respective managers by the call taker . The evidence from the RCRP lead at the ambulance service indicated the scenario that arose with Paul was not an isolated example. As such there appears to be a lacuna in how emergency services will respond to such a situation when it was accepted this was a call expressing concern for Paul’s welfare.
” 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 Train contact-centre staff, supervisors, and managers on Right Care Right Person and escalation procedures through peer training and updated training packages.
Verbatim wording from the response “• Contact Focus Group established (November 2023) trained to deliver peer to peer training on RCRP – delivered updated training across Contact teams (July 2024)” Source location Response from West Yorkshire 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 publish the Welfare Checks Deployment Procedure, jointly revised with Yorkshire Ambulance Service.
Verbatim wording from the response “2.1.2 An accompanying ‘Welfare Checks Deployment Procedure’ policy was implemented and was published on WYP website - Welfare Checks Deployment Procedure - Force Policy | West Yorkshire Police” Source location Response from West Yorkshire 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 and operate a widened WYP–YAS escalation process with approved procedures, digital documentation, daily review, and monthly partnership learning meetings.
Verbatim wording from the response “4.1.5 This updated policy reflects discussions with partnership agencies, including a revised escalation process which was discussed with YAS in September 2024. Since this date, WYP have been in regular contact with YAS to develop and introduce an improved escalation process to streamline and widen the scope of escalation to support in cases where the RCRP threshold to deploy is not met.” Source location Response from West Yorkshire 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 Yorkshire Police states RCRP did not change existing processes, which were already governed by established welfare and escalation policies.
Verbatim wording from the response “4.1.1 There has been an existing ‘Escalation Policy’ in force prior to the launch of RCRP, contained within the ‘Welfare check deployment criteria’ Policy, which was updated in consultation with YAS in August 2022.” Source location Response from West Yorkshire Police
Open published response
11 Mar 2025 NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Failure to coordinate detention and medical staff roles during a medical emergency View source Failure to appreciate the importance of early CPR View source Delays in commencing CPR during a medical emergency in a cell View source Failure of communication between detention and medical staff to facilitate prompt CPR commencement View source Lack of protocols defining detention and medical staff roles during a medical emergency in a cell 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
NICHOLAS OLIVER JAMES GEDGE · 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
Nicholas Oliver James Gedge was found unresponsive in a police station cell on 14 November 2022 and was pronounced deceased at hospital later that day. The principal concerns were the delay in commencing CPR, the lack of a shared understanding and coordinated roles among detention and medical staff, and uncertainty about protocols for responding to medical emergencies in cells.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate detention and medical staff roles during a medical emergency
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person . There did not appear to be a co-ordinated approach to assisting Nicholas , with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook .
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate the importance of early CPR
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated , or that the communication between detention and medical staff did not facilitate its prompt commencement.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Delays in commencing CPR during a medical emergency in a cell
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between detention and medical staff to facilitate prompt CPR commencement
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols defining detention and medical staff roles during a medical emergency in a cell
Wider context from the report “(1) From the point when the Detention Officer first entered Nicholas' cell to when CPR was commenced, 8 minutes and 12 seconds elapsed without CPR being given. Within that timeframe, two Detention Officers and a nurse were present in the cell after 75 seconds had passed.
(2) On the evidence, there did not appear to be any shared understanding between the three people in the cell with Nicholas of the urgency of starting CPR on an unresponsive person. There did not appear to be a co-ordinated approach to assisting Nicholas, with the Detention Officers and the nurse not appearing to have defined roles which they understood and undertook.
(3) It was not clear whether there were any protocols in place to define the respective roles of detention staff and medical staff attending a medical emergency in a cell. The passage of time before CPR was commenced gives rise to a concern either that the importance of early CPR was not appreciated, or that the communication between detention and medical staff did not facilitate its prompt commencement.
” 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 Review custody contracts, policies and procedures with Leeds Community Healthcare to clarify emergency roles for Detention Officers and Healthcare Professionals.
Verbatim wording from the response “3. Nevertheless, the Chief Constable intends to review the contracts, policies and procedures that are in place between Leeds Community Healthcare and the Force, in partnership with Leeds Community Healthcare, to ensure that the respective roles of the Detention Officers and Healthcare Professionals in custody in an emergency situation are sufficiently clear.” Source location Response from West Yorkshire Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing training and emergency procedures appropriately require Detention Officers to provide Basic Life Support and follow Healthcare Professional direction.
Verbatim wording from the response “(i) Until the custody Healthcare Professional attends, they are to follow their training and provide Basic Life Support, including giving CPR to people who are not breathing.” Source location Response from West Yorkshire Police
Open published response
14 Jan 2025 Anugrah Abraham (“Anu”) · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Unclear imminent adjustments for police officers disclosing suicidal thoughts before occupational health assessment View source Failure to investigate the quality of occupational health care after a death View source Lack of specialist Registered Mental Health nurses in the occupational health unit View source Failure to maintain accurate documented information on PCDA student officer progression View source Failure to learn from deaths and reflect on occupational health care processes View source Stress associated with the Police Constable Degree Apprenticeship route View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anugrah Abraham (“Anu”) · 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
Anugrah Abraham (“Anu”), a serving West Yorkshire police officer, died by hanging on 4 March 2023 after leaving home the previous afternoon; the inquest recorded a conclusion of suicide. The report identified concerns about the management of his mental health, including delayed and inadequate Occupational Health responses, unclear action when he disclosed suicidal thoughts, poor information sharing, and aspects of the PCDA and Regulation 13 processes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Unclear imminent adjustments for police officers disclosing suicidal thoughts before occupational health assessment
Wider context from the report “3. The court heard as to the increase in mental health issues amongst Police Officers nationally. Despite this, the question of what imminent adjustments should be made or considered once an officer discloses suicidal thoughts, was unclear . This is before an OHU appointment . In this case Anu’s mental deterioration was reportedly directly linked to his role as a police officer. It is acknowledged that this is a difficult issue and there will be issues such as confidentiality to consider.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the quality of occupational health care after a death
Wider context from the report “2. Following Anu’s death there was no investigation into the quality of care afforded to him by the OHU within WYP . Hence at the time of the inquest, there had been no reflection by practitioners as to the quality of care provided and no learning in respect of processes and procedures. It was accepted that following the inquest there were matters which would be considered. The lack of investigation meant learning from deaths in order to prevent future deaths was not addressed.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of specialist Registered Mental Health nurses in the occupational health unit
Wider context from the report “1. The court heard that most OHU referrals within police forces now relate to mental health issues as opposed to physical health issues. Despite this, there are no specialist Registered Mental Health nurses recruited into WYP OHU . Indeed the court heard the situation within WYP may be indicative of the national picture.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate documented information on PCDA student officer progression
Wider context from the report “5. Ensuring there is a full understanding across Police forces as to the PCDA and the sharing of accurate information with all those involved in the management of student officers so there is clear documented records and understandings as to how a student officer is progressing and whether they are likely to become an efficient constable .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from deaths and reflect on occupational health care processes
Wider context from the report “2. Following Anu’s death there was no investigation into the quality of care afforded to him by the OHU within WYP. Hence at the time of the inquest, there had been no reflection by practitioners as to the quality of care provided and no learning in respect of processes and procedures . It was accepted that following the inquest there were matters which would be considered. The lack of investigation meant learning from deaths in order to prevent future deaths was not addressed .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Stress associated with the Police Constable Degree Apprenticeship route
Wider context from the report “4. Whilst the court heard there are now different routes into policing and there is no longer a requirement to undertake a degree. The court heard from a significant number of officers who had undertaken the PCDA. Many of the witnesses told the court of the impact this route into policing had on them at the time, including the levels of stress they incurred . The PCDA does continue to operate .
” 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 Embed recording of suicidal-ideation frequency and informal team risk advice in the Assessment of Suicide and Self Harm protocol.
Verbatim wording from the response “2. An informal post-incident briefing was held with relevant members of the OH team at the time. It should be noted that the OHU did not undertake formal serious incident analysis (SIA) until after the inquest on the guidance of the IOPC. The learning that was identified in the SIA related to the addition of recording frequency of suicidal ideation, and the recording of informal team advice/conversations. As a consequence, the Assessment of Suicide and Self Harm protocol was updated to include this learning, and it is now embedded into normal practice. There has also been the introduction of a recorded message informing callers where to obtain crisis support on initial telephone contact with the OH team.” Source location Response from West Yorkshire 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 Undertake an independent external audit of Occupational Health provision, operating model and resourcing.
Verbatim wording from the response “It is important to confirm that the West Yorkshire Police Occupational Health function will be subject to an independent external audit of service provision, the operating model, etc., to understand whether the function remains appropriately resourced and modelled to meet current and future service delivery demands. The review is being undertaken by Acorn Occupational Health Ltd who are a Safe Effective Quality Occupational Health Service accredited organisation. This audit is expected to be completed by April 2025. Ultimately, the findings of the review will be considered by the Force’s Service Delivery & Change Group (SDCG) which comprises the Force’s most senior leaders and is chaired by the Deputy Chief Constable.” Source location Response from West Yorkshire 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 People presenting in physical or mental health crisis are expected to seek treatment from primary care or the local NHS Emergency Department.
Verbatim wording from the response “It must be reinforced that the Occupational Health department (“OH”) is a specialist advice service relating to the impact of work on health and health on work. It is not a treatment service and the normal expectation for anyone with a crisis presentation, whether physical or mental health is that they present to primary care or the Emergency Department of the local NHS provider. Because treatment for mental health conditions is not a service provided by OH, they do not employ specialist treatment providers such as registered mental health nurses. If” Source location Response from West Yorkshire 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 Occupational Health provides work-related health advice, not mental health treatment, so treatment provision is outside its service function.
Verbatim wording from the response “1. There has been an increase in the ratio of mental health related issues to physical health issues being referred to our Occupational Health department, but these fall within the expertise of occupational health clinicians who are trained to provide advice to both employees and employers regarding these conditions.” Source location Response from West Yorkshire Police
Open published response
25 Oct 2024 Martin Ian Stubbs · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Delays in concluding internal disciplinary proceedings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Martin Ian Stubbs · 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
Martin Ian Stubbs was a serving police officer who was arrested, suspended from duty and remained on bail until his death. He died by suicide by hanging at his home on 26 August 2024. The principal concern was the prolonged delay in concluding the internal disciplinary process, which the family believed contributed to his death and might reflect wider resource or management issues.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Delays in concluding internal disciplinary proceedings
Wider context from the report “Mr Stubbs’ father (a former officer himself and still a civilian police employee) expressed his firm belief that the length of time he had been suspended from duty had played a significant part in his son’s decision to take his life. It is a concern that someone subject to an internal disciplinary process has a legitimate expectation that that process will be dealt with expeditiously in the interests of all parties, and that legitimate expectation was not met in Mr Stubbs’ case . Mr Stubbs’ family do not understand whether the delay in concluding the process reflects resource issues or an institutionalised practice of allowing such matters to drift without proactive management to bring them to a conclusion . Anecdotally, Mr Stubbs’ family are aware of other long outstanding internal disciplinary proceedings and fear other families may have to go through an experience similar to theirs.
” 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 Review gross-misconduct investigations annually to ensure they are conducted promptly and have sufficient resources.
Verbatim wording from the response “Following receipt of your Prevent Future Death Report, WYP has conducted a full review of the investigation and discussed the concerns you have raised with the IO. To address the concerns you have raised, WYP has implemented the following changes with immediate effect:” Source location Response from West Yorkshire 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 Meet quarterly with IOPC senior leaders to review investigation resources and welfare provisions.
Verbatim wording from the response “Following receipt of your Prevent Future Death Report, WYP has conducted a full review of the investigation and discussed the concerns you have raised with the IO. To address the concerns you have raised, WYP has implemented the following changes with immediate effect:” Source location Response from West Yorkshire 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 gross-misconduct investigations quarterly to assess whether they have sufficient resources.
Verbatim wording from the response “Following receipt of your Prevent Future Death Report, WYP has conducted a full review of the investigation and discussed the concerns you have raised with the IO. To address the concerns you have raised, WYP has implemented the following changes with immediate effect:” Source location Response from West Yorkshire Police
Open published response
21 Aug 2023 David Joseph Celino · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Lack of authoritative guidance on permitted front-of-house drug testing View source Failure of festival staff and volunteers to proactively identify and assist people showing signs of adverse drug reactions View source Lack of reliable records of drug-related festival casualties View source Lack of governing oversight of music festivals View source Lack of accurate information about the number of under-18 festival attendees 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
David Joseph Celino · 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 Joseph Celino, aged 16, took tablets sold as an illicit drug at Leeds Festival in August 2022, developed an adverse reaction, and died after being treated at the festival field hospital and in hospital. The concerns included inadequate information about the number of under-18 attendees, the absence of national oversight and reliable data on drug-related casualties at music festivals, insufficient action to deter drug supply, and a failure by festival staff to identify and assist David as his condition deteriorated.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of authoritative guidance on permitted front-of-house drug testing
Wider context from the report “(6) Various witnesses raised the issue of “Front of House” drug testing, expressing views as to the benefits and disadvantages of this being permitted. It would help all those involved in the management of events similar to the Leeds Festival to have authoritative guidance on this subject, from the Home Office , along with clarification as to exactly what is permitted .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure of festival staff and volunteers to proactively identify and assist people showing signs of adverse drug reactions
Wider context from the report “(5) Evidence at the inquest indicated David Celino had walked about the Leeds Festival site between approximately 7pm and 8.45pm on the evening of Saturday 27 August 2022. As the signs of his adverse drug reaction developed, he was unable to walk straight, was pale, sweating profusely and agitated. In the latter stages he needed help from two other 16-year-olds to prevent him falling over. In this period, he passed through at least one check point manned by stewards or security staff. It is likely he encountered other festival staff and/or volunteers in this period also. Lamentably, no staff or volunteers spotted the need to intervene to ask about his well-being or offer assistance. This history suggests further instruction or training for festival staff and volunteers is required as to the need to be proactive, particularly in view of the prevalence of illicit drugs and teenagers. As it was, David Celino’s friends only obtained advice as to his condition from the drug dealer they happened to encounter, who reassured them that his reaction as “normal”.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of reliable records of drug-related festival casualties
Wider context from the report “(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties , which might reveal the extent of the problem.
(3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of governing oversight of music festivals
Wider context from the report “(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties, which might reveal the extent of the problem.
(3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of accurate information about the number of under-18 festival attendees
Wider context from the report “(1) Neither the organiser of the festival (Festival Republic) nor Leeds City Council which licenced the event had accurate information about the number of people under 18 who were attending the festival. It was estimated to be 20% of the 90,000 attending, so about 18,000. In consequence, the magnitude of the problem of potentially vulnerable, naïve teenagers exposed to possible exploitation by drug dealers, was not appreciated.
” 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 Assign another night Duty Detective Inspector to attend hospital with an ill person, allowing the festival-based inspector to focus on the crime scene and suspects.
Verbatim wording from the response “After listening to the concerns raised by David’s family, WYP have reflected on how the initial stages of the investigation were dealt with and, in future, would ask another night Duty Detective Inspector to attend the hospital with the person who had become ill, allowing the night Duty Inspector at the festival to focus on the crime scene, potential suspects etc.” Source location Response from West Yorkshire Police
Open published response
Concerns raised 3 Failure to condition firearms licensing delegation on adequate training View source Absence of a mandatory requirement for role-specific firearms licensing training View source Lack of nationally accredited training for firearms licensing staff View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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 Yorkshire 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 Yorkshire 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 Yorkshire 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
3 Mar 2022 Andrew David Kitson · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 3 Insufficiently refined parameters and guidance for spontaneous police pursuits in residential areas View source Lack of statistical evidence and analytical feedback for evaluating the risks and effectiveness of spontaneous police pursuits View source Unreliable availability of complete real-time information to pursuit managers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew David Kitson · 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
Andrew David Kitson was walking on the pavement of the A61 Leeds Road on 9 June 2020 when a Peugeot being pursued by police lost control, mounted the pavement and struck him. He sustained multiple injuries and was pronounced dead at the scene. The concerns related to insufficient statistical evidence for evaluating spontaneous police pursuits and the burden placed on police personnel when assessing the safety of continuing high-speed pursuits in residential areas.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficiently refined parameters and guidance for spontaneous police pursuits in residential areas
Wider context from the report “(2) The rules governing spontaneous police pursuits in residential areas place an onerous burden upon police standards review continuously the safety of proceeding whilst at the same time driving at high speed . The pursuit manager who authorises the continuance of a pursuit is dependant upon fragments of verbal messages relayed over the radio, due to the perceived need to leave airtime for other TPAC units to input information. The Inquest heard evidence to the effect that real time camera pictures from the police vehicle are not always available due to IT issues. This means the pursuit manager must largely trust the judgement of the police driver.
In order to lessen the burden upon the police driver in having to weigh numerous factors in a continuing, complex judgement, consideration should be given to a refinement of the parameters in which pursuits in residential areas are permitted . Such guidance to pursuit managers (informed by data regarding the effectiveness and risks arising in previous pursuits) would help to promote consistency and lessen the dependence upon a case-by-case judgement made in a pressured timescale.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of statistical evidence and analytical feedback for evaluating the risks and effectiveness of spontaneous police pursuits
Wider context from the report “(1) The evidence taken at the inquest revealed insufficient statistical evidence was available to guide an evaluation of the proportion of spontaneous police pursuits which
(a) involve driving at high speeds through residential areas;
(b) result in the apprehension of an offender;
(c) result in personal injury to other road users or property damage;
(d) are aborted without the alleged offender being caught;
without such analytical feedback (ideally prepared on a national basis) the risks inherent in such pursuits, balanced against their effectiveness, cannot adequately be reviewed .
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Unreliable availability of complete real-time information to pursuit managers
Wider context from the report “(2) The rules governing spontaneous police pursuits in residential areas place an onerous burden upon police standards review continuously the safety of proceeding whilst at the same time driving at high speed. The pursuit manager who authorises the continuance of a pursuit is dependant upon fragments of verbal messages relayed over the radio , due to the perceived need to leave airtime for other TPAC units to input information. The Inquest heard evidence to the effect that real time camera pictures from the police vehicle are not always available due to IT issues . This means the pursuit manager must largely trust the judgement of the police driver.
In order to lessen the burden upon the police driver in having to weigh numerous factors in a continuing, complex judgement, consideration should be given to a refinement of the parameters in which pursuits in residential areas are permitted. Such guidance to pursuit managers (informed by data regarding the effectiveness and risks arising in previous pursuits) would help to promote consistency and lessen the dependence upon a case-by-case judgement made in a pressured timescale.
” 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 Liaise with national pursuit and driving standards leads to assess compliance with national standards.
Verbatim wording from the response “Following receipt of the Regulation 28 report, we undertook to re-evaluate our local arrangements at West Yorkshire Police and also to liaise with the NPCC National leads for Pursuit and Driving Standards to assess our compliance with National Standards.” Source location Response from West Yorkshire 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 Assess trends in pursuit outcomes and their links to driver training and national standards.
Verbatim wording from the response “The ongoing assessment of trends in pursuit outcomes and the link to driver training (national standards) has been raised with ████████ (national lead for Pursuit).” Source location Response from West Yorkshire 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 Collaborate with the National Pursuit Group on routine pursuit debriefing and adapt local practice accordingly.
Verbatim wording from the response “Collaboration with the National Pursuit Group regarding whether all Forces routinely debrief pursuit activity (incorporating airmax/ watchguard) and to adapt as local practice is ongoing.” Source location Response from West Yorkshire 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 Discuss reconfiguring Chronicle to record whether pursuits result in arrests.
Verbatim wording from the response “There is currently no system-retrievable data which directly correlates whether a suspect is detained as a result of a pursuit. Additional de-briefing reports (the command and control system incident log, supervisor shift reports) do routinely explain pursuit activity and arrests made. Chronicle can only be configured on a national level to include whether an arrest(s) is made or not. Discussions are to be undertaken with the National Pursuit Group to explore the re-configuration of Chronicle to include specific arrest information.” Source location Response from West Yorkshire 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 Record all pursuits in Chronicle and provide the data quarterly to the National Pursuits Group.
Verbatim wording from the response “West Yorkshire Police has recorded data relating to pursuits since 2017. From April 2019, the mechanisms for recording data changed and as such for the period between April 2019 and July 2020, the data remains available but only manually retrievable from RT18 forms. This particular format is not easily useable or searchable. However, since July 2020 all pursuits are recorded on a Force system called Chronicle (an electronic database) and this data is passed through to the National Pursuits Group (NPROII) on a quarterly basis. The data includes whether the pursuit was spontaneous, the reason for the pursuit, time/date, whether the pursuit was discontinued, the reason for discontinuance and the location.” Source location Response from West Yorkshire 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 Re-evaluate local pursuit arrangements.
Verbatim wording from the response “Following receipt of the Regulation 28 report, we undertook to re-evaluate our local arrangements at West Yorkshire Police and also to liaise with the NPCC National leads for Pursuit and Driving Standards to assess our compliance with National Standards.” Source location Response from West Yorkshire 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 Redefining pursuit parameters using statistical data requires national-level discussion to ensure consistency across police forces.
Verbatim wording from the response “In order to lessen the burden upon the police driver in having to weigh numerous factors in continuing, complex judgement, consideration should be given to a refinement of the parameters in which pursuits in residential areas are permitted. Such guidance to pursuit managers (informed by data regarding the effectiveness and risks arising in previous disputes) would help to promote consistency and lessen dependence upon a case-by-case judgement made in a pressured timescale” Source location Response from West Yorkshire Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing dynamic risk assessment, trained decision-makers and ground commander primacy are retained rather than imposing more limited pursuit parameters.
Verbatim wording from the response “It is an operational reality that every pursuit has different and distinct dynamics which relate to: environmental factors; suspect identity, capability and intent; suspect vehicle capability; police officer capability; police vehicle capability; offence severity; and the ongoing risk assessment. Taking these into account, and in order to provide the best possible decision-making capability, West Yorkshire Police’s Driver Training utilises Authorised Professional (National) Practice, in conjunction with robust training around the use of the National Decision Model, which outlines the relevant roles and responsibilities as below.” Source location Response from West Yorkshire Police
Open published response
Concerns raised 4 Failure to classify people presenting indicators of vulnerability as vulnerable persons rather than absconding suspects View source Inconsistent understanding of risk of harm among police duty sergeants View source Failure to make a further NPAS helicopter request when a person who has absconded may be at risk of harm View source Lack of shared understanding between police forces and NPAS about what each may expect of the other View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tyrone Lock · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Tyrone Lock left a hotel wearing only boxer shorts and socks on a cold, windy night and was found deceased two days later in a pond. The jury concluded that he should have been classified as a vulnerable person rather than an absconder, and that a second helicopter request should have been made; it identified police failings contributing to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to classify people presenting indicators of vulnerability as vulnerable persons rather than absconding suspects
Wider context from the report “(1) The jury concluded that Tyrone should have been assessed differently from the first male and should have been classified as a vulnerable person and not as a suspect that was absconding .
(2) The jury believed that a second request for a helicopter should have been issued and that it would have been deployed and that in this case there would have been a chance to find Tyrone in a survivable state.
(3) Collectively there was information available to the police from the OIS logs, what was said to them by the night manager and from their own observations that Tyrone’s departure could be described as “hallucinating, foaming/frothing at the mouth, spaced out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks only. It was very cold, 4 degrees, it was windy and he ran out into open ground with water courses with somebody out to get him and on the police log according to the night manager an ambulance probably would be a good idea.” It was on this evidence that the jury concluded that Tyrone should have been classified as a vulnerable person .
(4) On that information witnesses from the National Police Air Service (NPAS) confirmed that they would have classified Tyrone as a vulnerable person and would have made every effort to deploy a helicopter to the scene. NPAS further indicated that because one request in the same incident had met with a refusal that did not mean a second request would also be refused. Each request would be dealt with on its own merits. Here a second call would have been treated as a top priority job. NPAS would not be concerned with why someone was running away from the police, their concern would be, having run away, that was he at risk of harm.
(5) Contrary to the NPAS evidence the police officers concerned believed that, regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request. Further two duty sergeants involved on the Saturday and Monday mornings had different views as to what risk of harm meant. One thought it meant risk of suicide only, the other that it would extend to non-fatal or accidental harm.
(6) As NPAS serves all police forces in England and Wales they are included in this report so that:
a. They may liaise with West Mercia Police as to any lack of understanding as to what one may expect of the other.
b. To review whether any other police force may also have a similar lack of understanding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Inconsistent understanding of risk of harm among police duty sergeants
Wider context from the report “(1) The jury concluded that Tyrone should have been assessed differently from the first male and should have been classified as a vulnerable person and not as a suspect that was absconding.
(2) The jury believed that a second request for a helicopter should have been issued and that it would have been deployed and that in this case there would have been a chance to find Tyrone in a survivable state.
(3) Collectively there was information available to the police from the OIS logs, what was said to them by the night manager and from their own observations that Tyrone’s departure could be described as “hallucinating, foaming/frothing at the mouth, spaced out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks only. It was very cold, 4 degrees, it was windy and he ran out into open ground with water courses with somebody out to get him and on the police log according to the night manager an ambulance probably would be a good idea.” It was on this evidence that the jury concluded that Tyrone should have been classified as a vulnerable person.
(4) On that information witnesses from the National Police Air Service (NPAS) confirmed that they would have classified Tyrone as a vulnerable person and would have made every effort to deploy a helicopter to the scene. NPAS further indicated that because one request in the same incident had met with a refusal that did not mean a second request would also be refused. Each request would be dealt with on its own merits. Here a second call would have been treated as a top priority job. NPAS would not be concerned with why someone was running away from the police, their concern would be, having run away, that was he at risk of harm.
(5) Contrary to the NPAS evidence the police officers concerned believed that, regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request. Further two duty sergeants involved on the Saturday and Monday mornings had different views as to what risk of harm meant . One thought it meant risk of suicide only, the other that it would extend to non-fatal or accidental harm .
(6) As NPAS serves all police forces in England and Wales they are included in this report so that:
a. They may liaise with West Mercia Police as to any lack of understanding as to what one may expect of the other.
b. To review whether any other police force may also have a similar lack of understanding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to make a further NPAS helicopter request when a person who has absconded may be at risk of harm
Wider context from the report “(1) The jury concluded that Tyrone should have been assessed differently from the first male and should have been classified as a vulnerable person and not as a suspect that was absconding.
(2) The jury believed that a second request for a helicopter should have been issued and that it would have been deployed and that in this case there would have been a chance to find Tyrone in a survivable state.
(3) Collectively there was information available to the police from the OIS logs, what was said to them by the night manager and from their own observations that Tyrone’s departure could be described as “hallucinating, foaming/frothing at the mouth, spaced out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks only. It was very cold, 4 degrees, it was windy and he ran out into open ground with water courses with somebody out to get him and on the police log according to the night manager an ambulance probably would be a good idea.” It was on this evidence that the jury concluded that Tyrone should have been classified as a vulnerable person.
(4) On that information witnesses from the National Police Air Service (NPAS) confirmed that they would have classified Tyrone as a vulnerable person and would have made every effort to deploy a helicopter to the scene . NPAS further indicated that because one request in the same incident had met with a refusal that did not mean a second request would also be refused. Each request would be dealt with on its own merits. Here a second call would have been treated as a top priority job . NPAS would not be concerned with why someone was running away from the police, their concern would be, having run away, that was he at risk of harm.
(5) Contrary to the NPAS evidence the police officers concerned believed that, regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request . Further two duty sergeants involved on the Saturday and Monday mornings had different views as to what risk of harm meant. One thought it meant risk of suicide only, the other that it would extend to non-fatal or accidental harm.
(6) As NPAS serves all police forces in England and Wales they are included in this report so that:
a. They may liaise with West Mercia Police as to any lack of understanding as to what one may expect of the other.
b. To review whether any other police force may also have a similar lack of understanding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to West Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between police forces and NPAS about what each may expect of the other
Wider context from the report “(1) The jury concluded that Tyrone should have been assessed differently from the first male and should have been classified as a vulnerable person and not as a suspect that was absconding.
(2) The jury believed that a second request for a helicopter should have been issued and that it would have been deployed and that in this case there would have been a chance to find Tyrone in a survivable state.
(3) Collectively there was information available to the police from the OIS logs, what was said to them by the night manager and from their own observations that Tyrone’s departure could be described as “hallucinating, foaming/frothing at the mouth, spaced out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks only. It was very cold, 4 degrees, it was windy and he ran out into open ground with water courses with somebody out to get him and on the police log according to the night manager an ambulance probably would be a good idea.” It was on this evidence that the jury concluded that Tyrone should have been classified as a vulnerable person.
(4) On that information witnesses from the National Police Air Service (NPAS) confirmed that they would have classified Tyrone as a vulnerable person and would have made every effort to deploy a helicopter to the scene. NPAS further indicated that because one request in the same incident had met with a refusal that did not mean a second request would also be refused. Each request would be dealt with on its own merits. Here a second call would have been treated as a top priority job. NPAS would not be concerned with why someone was running away from the police, their concern would be, having run away, that was he at risk of harm.
(5) Contrary to the NPAS evidence the police officers concerned believed that, regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request. Further two duty sergeants involved on the Saturday and Monday mornings had different views as to what risk of harm meant. One thought it meant risk of suicide only, the other that it would extend to non-fatal or accidental harm.
(6) As NPAS serves all police forces in England and Wales they are included in this report so that:
a. They may liaise with West Mercia Police as to any lack of understanding as to what one may expect of the other .
b. To review whether any other police force may also have a similar lack of understanding.
” Open source report
24 Jun 2016 Beverley Anne Devanney · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1 Lack of formal police training for officers facing such circumstances 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
Beverley Anne Devanney · 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
Beverley Anne Devanney, who had a history of mental ill health and drug and alcohol misuse, jumped from Burdock Way flyover in Halifax on 19 January 2016 after officers attended reports of her standing on the wrong side of the barrier. The inquest concluded that the death was suicide, and raised a concern that there was no formal police training for officers facing such circumstances.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of formal police training for officers facing such circumstances
Wider context from the report “During the course of the inquest although it was apparent that ████████
████████areful and measured approach to Miss Devanney was beyond reproach, he informed me that there was no formal police training to cover Officers when faced with such circumstances .
• I would request West Yorkshire police to give consideration to the appropriateness of such training.
” Open source report
3 Mar 2016 Adam RICE · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5 Failure to maintain a trained and experienced reserve of custody staff for rapid deployment View source Failure to communicate outstanding investigations or treatment to police after a patient self-discharges View source Failure to recruit suitably capable custody staff View source Inadequate custody staffing levels during periods of high demand View source Lack of comprehensive knowledge of custody law and procedures among custody staff View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Adam RICE · 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
Adam RICE was taken to hospital after being found asleep in a skateboard park, later self-discharged without a CT head scan, and was subsequently detained at a police station after being arrested. He exhibited signs of alcohol withdrawal, collapsed and died in his cell on 12 May 2014. The report identified concerns about communication between hospital staff and police, custody staffing and training, welfare checks, observation levels, handovers and monitoring practices.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a trained and experienced reserve of custody staff for rapid deployment
Wider context from the report “3b To ensure that they have a bank of staff who might ordinarily be engaged in other duties but who are trained and have experience in Custody work who can be drafted in at short notice during such periods of high demand when it becomes obvious that the existing staff cannot cope with the demands being placed upon 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate outstanding investigations or treatment to police after a patient self-discharges
Wider context from the report “1. When a patient self-discharges against medical advice and it is known or it is highly likely that the Police will immediately thereafter become involved and it can be foreseen that the patient will be taken into Custody .
2. Then the Clinician(s) involved should inform the Police that the person has self-discharged against advice and should give brief details of any desired and outstanding investigations or treatment (eg. Reference to a possible head injury would suffice and the desire to carry out a CT head scan). This I suggest would not breach patient confidentiality.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to recruit suitably capable custody staff
Wider context from the report “2. That West Yorkshire Police only recruit Custody staff of the highest calibre to carry out this vital role involving some of the most vulnerable members of society.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate custody staffing levels during periods of high demand
Wider context from the report “3a To ensure that there are adequate staffing levels of all ranks and grades to fulfil this vital role particularly during periods of high demand when it is known that Custody facilities will be extremely busy and in particular on Fridays, Saturdays and Sundays.
” 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive knowledge of custody law and procedures among custody staff
Wider context from the report “1. To ensure that Custody staff to which I mean Police Officers of all ranks, Civilian Detention Officers and Nursing staff have a full and comprehensive knowledge of the Police and Criminal Evidence Act and the relevant Codes of Practice and the relevant provisions of the College of Policing Authorised Professional Practice Provisions in respect of Detention and Custody and Custody Management Planning .
” Open source report
27 May 2015 Nicholas Gary Stocks · Prevention of Future Deaths report West Yorkshire (West)
View report summary
Concerns raised 12 50 mph speed limit at the incident junction approaches View source Inconsistent highway inspection practices View source Failure to undertake risk assessments and determine urgency of remedial work after road traffic collisions View source Failure to follow up remedial work assigned to other agencies View source Potentially inadequate street lighting at road junction approaches View source Failure to identify and report defective road markings for repair View source Lack of ongoing training and assessment of Safety Inspectors View source Absence of visible signs or road markings at an approaching Give Way junction View source Failure to appropriately assess and act on public reports of highway defects View source Unclear allocation of responsibility for inspecting road junctions View source Failure to fully report matters of concern identified at road traffic collision scenes View source Unavailability of an appropriately manned emergency reporting route View source See 9 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
Nicholas Gary Stocks · 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
Nicholas Gary Stocks was struck and fatally injured by a vehicle after a collision at the junction of Dry Hill Lane and the A635 Barnsley Road in Huddersfield on 27 September 2012. The report raised concerns about damaged and poorly maintained give-way signs and road markings, inadequate reporting and repair systems, highway inspection practices, risk assessment, and coordination between West Yorkshire Police and Kirklees Council.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation 50 mph speed limit at the incident junction approaches
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph . I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Inconsistent highway inspection practices
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway .. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake risk assessments and determine urgency of remedial work after road traffic collisions
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up remedial work assigned to other agencies
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council , so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Potentially inadequate street lighting at road junction approaches
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and report defective road markings for repair
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired . In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of ongoing training and assessment of Safety Inspectors
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Absence of visible signs or road markings at an approaching Give Way junction
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction . In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately assess and act on public reports of highway defects
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council , some months prior to this incident occurring. Although Kirklees Council records show no further action required . I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Unclear allocation of responsibility for inspecting road junctions
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads .
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to fully report matters of concern identified at road traffic collision scenes
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council .
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response. I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time, I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an appropriately manned emergency reporting route
Wider context from the report “West Yorkshire Police
(1) I am concerned with the system that was in place to ensure that matters of concern identified by Officers of West Yorkshire Police who attend the scene of Road Traffic Collision in November 2011 were not fully reported to Kirklees Council.
I would ask you to review the system presently in place to ensure that all future reports are made and fully reported
(2) On the afternoon of the 27th September 2012 following the earlier road traffic incident, a Police Officer identified the need for a repair to the Give Way sign which had been demolished. The Police Officer in attendance would have been able to also identify that the road markings at the scene were no longer visible and therefore any road user who was travelling along Dry Hill Lane would have had no visible signs or road markings on the approaching Give Way junction. In essence the Officer would have been able to undertake a risk assessment and identify the level of urgency for remedial repair works to be undertaken.
I would invite West Yorkshire Police to liaise with the relevant department of Kirklees Council and undertake a new review and consider whose responsibility it should be to undertake a risk assessment at the scene of a road traffic collision in order to determine the level of urgency of remedial work which is required to be carried out so as to ensure the safety of road users and to develop a system so as to ensure that risk assessment process is implemented and carried out.
(3) I would also ask you to liaise with the relevant departments of Kirklees Council in order to carry out investigations to determine which departments of Kirklees Council was contacted on the afternoon on 27th September 2012 to report the damage to the give way sign. I heard evidence that Kirklees Council Customer Services, the relevant department which should have been contacted, and who are contactable between the hours of 8.00 and 18 hours. Outside of these hours an answer machine message provides an emergency contact number. If the control room unit had contacted the customer service centre then this telephone line should have been manned and a response received rather than sending an email which was acknowledged by an automated response . I wish to ensure that firstly West Yorkshire Police have the relevant contact number which needs to be used in the future and secondly if the Customer Service centre at Kirklees Council was contacted it clearly was not manned at the appropriate time , I wish to ensure this is rectified.
Kirklees Council
(1) I have concerns with the regard to the wide variation of how road inspections are undertaken by your Safety Inspectors. During the course of the enquiries undertaken by West Yorkshire Police a number of interviews were conducted with a number of safety inspectors. I have reviewed those interviews and note that there was a wide variation on how Safety Inspectors undertook inspections of a highway.. One Inspector indicated that they would inspect one side of the road one month, and when inspecting the road the following month would inspect the other side of the carriageway. Another Inspector indicated that they would inspect the whole of the carriageway on each inspection. Another Safety Inspector stated that the driver also had a role to place in inspecting the road in addition to driving the vehicle which transported the Safety Inspector who would be seated in the front passenger seat.
(2) I have concerns with regard to how Safety Inspectors identify issues at the junction of two roads and which inspection has responsibility to consider matters at the actual junction. There appeared to have been vague and unclear responses from the Inspectors who gave evidence, as to whose responsibility it would be to actually inspect the junction of the two roads.
(3) I was concerned that neither of the two Safety Inspectors who gave evidence, considered that the lack of road markings at the junction of Barnsley Road and Dry Hill Lane, and upon Dry Hill Lane itself posed a safety risk to road users and applying appropriate risk assessment should have been repaired I heard evidence from a highly qualified independent expert who was fully familiar with the Kirklees inspection policy and who stated that the lack of road markings at the junction with Barnsley Road and upon Dry Hill Lane itself, were identifiable and reportable defects applying Kirklees Council Policy criteria and should have been reported by the Safety Inspectors and repaired. In addition the independent expert stated that the poor state of the road markings would have been present for a considerable and significant period of time. Certainly, when each of the roads had last been inspected by a Safety Inspector from Kirklees Council.
(4) I also have concern that there is no ongoing training and assessment of Safety Inspectors after initial training has been given so as to ensure consistency and appropriate standard levels of inspections are maintained.
I would invite Kirklees Council to undertake a comprehensive review of the training of all of their Safety Inspectors and consider what further retraining requirements are required now and in the future.
(5) I would refer you to the comments I have made in the West Yorkshire Police section of this report in respect of the operation of Kirklees Council’s Customer Service Centre. I would ask you to liaise directly with West Yorkshire Police and review and ensure the Customer Centre Service facility is fully operational at all relevant times
(6) I would also ask you to liaise with West Yorkshire Police in respect of the comments made in the West Yorkshire Police Section of this report concerning risk assessments when a road traffic collision occurs and West Yorkshire Police in attendance and identify the need for repair works to be undertaken, so as to ensure that an immediate risk assessment is undertaken to safeguard members of the public.
(7). From details provided in the course of this investigation, it appears that remedial work was required to be undertaken by Yorkshire Water at the junction with Barnsley Road and Dry Hill Lane. This work was to identified on 13th March 2010 and the 5th March 2012, but there was no record that such work had been undertaken, and no follow up was implemented by Kirklees Council, so as to ensure that this work was carried out. I would invite you to review your systems so as to ensure that work is undertaken by other agencies and checks made to ensure that all necessary works are completed.
(8) Evidence at the inquest also revealed that members of the public had reported the lack of road markings to Kirklees Council, some months prior to this incident occurring. Although Kirklees Council records show no further action required. I am concerned with regard to this finding in light of the evidence provided to me by the independent expert who confirmed that the lack of road markings was clearly a defect which fell within the Councils existing guidance as an identifiable defect which required rectification. I would invite you to review the present system that Kirklees Council has in place with addressing complaints made by members of the public in respect of the roads and highways which fall within your designated area.
9. I understand that major road works have been undertaken by Kirklees Council at the scene of this incident. However, at the inquest it was clear that the speed limit still remains to be 50 mph. I would invite you to review the speed limit not only on Dry Hill Lane, but also Barnsley Road and Lower Denby Lane.
I would request you to review the street lighting along Lower Denby Lane and Dry Hill Lane at their approach to the junction with Barnsley Road and whether any additional lighting is required.
” Open source report
14 Mar 2014 David Robert Oldfield · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2 Failure to restrict tasering by firearms officers to appropriate and justifiable circumstances View source Risk of serious injury or death from tasering in certain circumstances View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Robert Oldfield · 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 Robert Oldfield sustained fatal stab wounds to the jugular vessels in his neck during an incident at his home on 5 October 2012. He was tasered by firearms officers after emergency services attended and died shortly afterwards. Concerns included whether the tasering was appropriate and justifiable, and uncertainty about the circumstances immediately preceding it.
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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict tasering by firearms officers to appropriate and justifiable circumstances
Wider context from the report “(1) There is no evidence that the act of tasering the Deceased caused or contributed to his death; however, there is evidence that tasering can, in certain circumstances, cause serious injury and/or death to a person;
(2) The tasering of a person by firearms officers should only take place in appropriate and justifiable circumstances , and a failure to do so unnecessarily increases the risk of a loss of life ;
(3) On the basis of evidence adduced in the course of the Inquest it is unlikely that the events immediately preceding the tasering of the Deceased occurred in the manner stated by one or more of the attending firearms officers;
(4) Therefore, it is of concern as to precisely what were the circumstances which preceded the act of tasering the Deceased, whether such was appropriate and justifiable in all the circumstances and, if not, whether similar circumstances could arise 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 Yorkshire Police; that does not assign responsibility.
PFD Monitor interpretation Risk of serious injury or death from tasering in certain circumstances
Wider context from the report “(1) There is no evidence that the act of tasering the Deceased caused or contributed to his death; however, there is evidence that tasering can, in certain circumstances, cause serious injury and/or death to a person ;
(2) The tasering of a person by firearms officers should only take place in appropriate and justifiable circumstances, and a failure to do so unnecessarily increases the risk of a loss of life;
(3) On the basis of evidence adduced in the course of the Inquest it is unlikely that the events immediately preceding the tasering of the Deceased occurred in the manner stated by one or more of the attending firearms officers;
(4) Therefore, it is of concern as to precisely what were the circumstances which preceded the act of tasering the Deceased, whether such was appropriate and justifiable in all the circumstances and, if not, whether similar circumstances could arise in the future.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Safe Taser usage and use in appropriate, justifiable circumstances require no additional response; they are highlighted only for awareness.
Verbatim wording from the response “The further comments we received from you in relation to the first two (the safe usage of Taser and the importance of its use in appropriate and justifiable circumstances) made it clear that these required no additional response from us, but were to highlight issues for our awareness. I will however return to these at the conclusion of the letter.” Source location 2014-0117-Response-by-West-Yorkshire-Police
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations