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 Wiltshire 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 Wiltshire 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 Wiltshire 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
13 Feb 2023 Michael POULTON · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Lack of money for people taken into Police custody to return to their home address View source Lack of means for people taken into Police custody to communicate with family View source Lack of ready access to transport for people taken into Police custody to return to their home address View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael POULTON · 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
Michael POULTON was released from police custody on 22 June 2019, with arrangements for police transport to a family member’s home, but there was a delay and he left the custody suite. He was found suspended by a ligature in a field the following day; concerns related to people in police custody lacking money, communication with family, or ready access to transport home, and to arrangements for facilitating their return.
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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of money for people taken into Police custody to return to their home address
Wider context from the report “(1) People are being taken into Police custody, some distance from their home address, without having any money or means of communicating with family, or ready access to transport from the custody suite, to their home address.
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of means for people taken into Police custody to communicate with family
Wider context from the report “(1) People are being taken into Police custody, some distance from their home address, without having any money or means of communicating with family , or ready access to transport from the custody suite, to their home address.
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of ready access to transport for people taken into Police custody to return to their home address
Wider context from the report “(1) People are being taken into Police custody, some distance from their home address, without having any money or means of communicating with family, or ready access to transport from the custody suite, to their home address .
” 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 Provide training on the schemes to all new Custody Sergeants.
Verbatim wording from the response “Training on these schemes will be given to all new Custody Sergeants.” Source location Response from Wiltshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Ring B4 U Bring Scheme to capture detainees’ essential return-home information from arrest onward.
Verbatim wording from the response “In anticipation of the closure of Melksham Custody in February 2023, Wiltshire Police (‘the Force’) have developed and implemented a scheme entitled the Vulnerable Detainee Transportation Scheme.” Source location Response from Wiltshire Police
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Vulnerable Detainee Transportation Scheme, including risk-based public transport assessment, funded taxis and police transport home for the most vulnerable detainees.
Verbatim wording from the response “In anticipation of the closure of Melksham Custody in February 2023, Wiltshire Police (‘the Force’) have developed and implemented a scheme entitled the Vulnerable Detainee Transportation Scheme.” Source location Response from Wiltshire 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 Implemented detainee transportation schemes fully address the identified safety issues, so no additional measures are proposed.
Verbatim wording from the response “In anticipation of the closure of Melksham Custody in February 2023, Wiltshire Police (‘the Force’) have developed and implemented a scheme entitled the Vulnerable Detainee Transportation Scheme.” Source location Response from Wiltshire Police
Open published response
23 Mar 2020 Lewis Charles Francis · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum View source Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lewis Charles Francis · 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
Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.
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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the special needs and vulnerabilities of prisoners within the autistic spectrum
Wider context from the report “(2) Evidence at the inquest suggested that there was an insufficient understanding of the special needs and vulnerabilities of those prisoners who are within the autistic spectrum
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for ready transfer of people in police custody suspected of or charged with serious crime to a medium secure mental health facility for assessment or treatment
Wider context from the report “(1) At present there is no mechanism for the ready transfer of a person in police custody within the police areas of Devon and Cornwall, Avon and Somerset, Wiltshire and Gloucestershire from police custody to a medium secure mental health facility for assessment / treatment under sections 2 and 3 of the Mental Health Act 1983 where such a person is suspected of or charged with a serious crime. Such an arrangement exists in the West Midlands where a Memorandum of Understanding has been developed and agreed between relevant agencies.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with other force areas and the South West Provider Collaborative to develop a Memorandum of Understanding.
Verbatim wording from the response “It has been identified there is an issue with the pathways within Mental Health Services and not within the Police Service. There are limited options using criminal justice powers and the Police are reliant on the NHS to divert from those. In line with Recommendation 6 (2) of the Coroner’s Regulation 28 report, Wiltshire Police is working with other force areas and the South West Provider Collaborative to develop the proposed Memorandum of Understanding.” Source location 2020-0074-Response-from-Wiltshire-Police_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mental health service pathways are outside the Police Service’s remit.
Verbatim wording from the response “It has been identified there is an issue with the pathways within Mental Health Services and not within the Police Service. There are limited options using criminal justice powers and the Police are reliant on the NHS to divert from those. In line with Recommendation 6 (2) of the Coroner’s Regulation 28 report, Wiltshire Police is working with other force areas and the South West Provider Collaborative to develop the proposed Memorandum of Understanding.” Source location 2020-0074-Response-from-Wiltshire-Police_Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Police rely on the NHS to provide diversion from limited criminal justice options.
Verbatim wording from the response “It has been identified there is an issue with the pathways within Mental Health Services and not within the Police Service. There are limited options using criminal justice powers and the Police are reliant on the NHS to divert from those. In line with Recommendation 6 (2) of the Coroner’s Regulation 28 report, Wiltshire Police is working with other force areas and the South West Provider Collaborative to develop the proposed Memorandum of Understanding.” Source location 2020-0074-Response-from-Wiltshire-Police_Redacted
Open published response
9 Apr 2019 Aidan David Ridley · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 8 Inadequate supervision of Police call handlers View source Limited use of three-way calls between the public, Police call handlers and the ambulance service View source Failure to provide safe advice about turning a person over View source Failure to direct members of the public to ambulance-service advice or medically trained people at the scene View source Inadequate induction and ongoing training on three-way calls View source Failure to intervene in or correct unsafe call-handler advice View source Inadequate training of Police call handlers View source Inadequate guidance for Police call handlers View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Aidan David Ridley · 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
Aidan David Ridley was struck by a car while crossing a road on 12 February 2016 and died three days later from hypoxic brain injury caused by how he landed, which obstructed his airway. Concerns included police call-handler advice not to turn him over, insufficient direction to seek ambulance advice or defer to medically trained bystanders, and inadequate call-handler training, guidance and supervision.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of Police call handlers
Wider context from the report “(3) The guidance, training and supervision of the Police call handler was inadequate to enable the call to dealt with effectively.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Limited use of three-way calls between the public, Police call handlers and the ambulance service
Wider context from the report “(5) The system that has been introduced since Aidan's death, of allowing 3 way calls between the member of the public, the police call handler and the ambulance service appears on the evidence heard at the Inquest, to have had little if any use . To what extent does the induction training and the ongoing training of Control room call operators refer to it or demonstrate it in action?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safe advice about turning a person over
Wider context from the report “(1) The advice by the Police call handler not to turn Aidan over .
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to direct members of the public to ambulance-service advice or medically trained people at the scene
Wider context from the report “(2) The Police call handler did not advise members of the public at the scene to seek advice from the ambulance service or to defer to members of the public present with medical training .
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate induction and ongoing training on three-way calls
Wider context from the report “(5) The system that has been introduced since Aidan's death, of allowing 3 way calls between the member of the public, the police call handler and the ambulance service appears on the evidence heard at the Inquest, to have had little if any use. To what extent does the induction training and the ongoing training of Control room call operators refer to it or demonstrate it in action?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to intervene in or correct unsafe call-handler advice
Wider context from the report “(4) There was a failure to intervene in or correct the advice given by the call handler not to turn Aidan over .
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of Police call handlers
Wider context from the report “(3) The guidance, training and supervision of the Police call handler was inadequate to enable the call to dealt with effectively.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate guidance for Police call handlers
Wider context from the report “(3) The guidance , training and supervision of the Police call handler was inadequate to enable the call to dealt with effectively.
” 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 Implement protocols, staff communication and training requiring police call handlers to avoid first-aid advice and refer medical emergencies to ambulance call handlers.
Verbatim wording from the response “As events unfolded and it became clearer there was a casualty the call remained with the police as the BT operator had ended their call, there was no facility to transfer the call to ambulance on a priority line. Police call handlers are not trained in first aid and do not receive any training to provide first aid advice. Following this incident clarity on the point of Police call handlers providing first aid was sought from ████████. The National Police Chiefs Council (NPCC) lead for First Aid. The reply from ████████ was they should not provide first aid. This has been communicated to all staff within the Crime & Communication Centre where the call handlers work, and updated protocols now exist between the police and ambulance call centers and are now established which I will detail in a separate report.” Source location 2019-0173-Response-by-Wiltshire-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 Train new call handlers, issue staff briefings and reminders, and regularly test the three-way police-ambulance conferencing process.
Verbatim wording from the response “The functionality of this system is a standard telephony conferencing. This is trained to all of our new starters as is all other Cortex / Telephony processes. It is fair to say that the set of circumstances relating to the road traffic collision report involving Aidan remain unusual.” Source location 2019-0173-Response-by-Wiltshire-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 Revise the force procedure for managing calls to reinforce the policy on police call handlers’ medical-advice responsibilities.
Verbatim wording from the response “A variety of training materials (including e-mail reminders about the police sent to staff) were provided by Wiltshire Police as part of the inquest; please let me know if you require further copies of these. Furthermore, as indicated during the inquest, further revisions of the relevant Force procedure on managing calls have now taken place in order to underline the policy to staff.” Source location 2019-0173-Response-by-Wiltshire-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 Police call handlers should not provide first-aid advice; ambulance call-centre staff are responsible for providing that advice.
Verbatim wording from the response “The fact that medical advice was provided by the call handler in this incident has been the subject of clarification as we sought national guidance from ████████. The advice we received back was that the police call handlers should not provide first aid advice or guidance as they received no formal training for this.
This advice has been communicated to all the staff working in the Crime & Communication Centre that handles all the calls and crime reports they will not provide first aid advice or guidance during a call and that they will utilise established protocols to refer the calls on to the ambulance call center who have the training, databases and established protocols to provide first aid advice to the people reporting medical emergencies.” Source location 2019-0173-Response-by-Wiltshire-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 Routine monitoring of every call is not achievable because supervisors have other responsibilities and the control room manages numerous live incidents.
Verbatim wording from the response “As mentioned, incoming calls are not all routinely monitored by supervisors. The layout of the call center means the Force Incident Manager (Inspector) has responsibility for up to seventeen members of staff who are either taking calls or dispatching units. The inspector may hear one half of the conversation as the operator is speaking. The inspector and supervisors have the ability to dip sample calls of call handlers but also have other roles and responsibilities which include assessing the current active logs across the county.
A supervisor could review or monitor the call requested by the call handler.
It is routine within the Crime & Communication Centre to have up to 30 live incidents across the county over five different radio channels which places demands on all the staff.” Source location 2019-0173-Response-by-Wiltshire-Police
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A minor road-traffic-collision report, as initially understood, would not require supervisor oversight under existing procedures.
Verbatim wording from the response “This call was initially reporting a road traffic collision and this quickly developed into a medical emergency call that was not identified as such at the point the call came to the police. The training given to call handlers enables them to take control of the call and extract relevant information from the caller and remaining calm and reassuring. As information developed a call was made to ambulance by a colleague to ensure an ambulance was attending the scene which was within procedure.” Source location 2019-0173-Response-by-Wiltshire-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 call-handler training and procedures mean there is no longer a substantial risk of incorrect medical advice.
Verbatim wording from the response “The routine one to one monitoring of individual calls is not achievable between a call handler and supervisor. Structures exist within the teams for a supervisor to provide assistance and the assessment of calls forms part of the ongoing training for quality and standards assurance. As call handlers’ training now clearly excludes the provision of medical advice and instead sets out a simple method for involving the ambulance service, there is no longer any substantial risk of call handlers giving incorrect medical advice. The instructions/training mentioned above are in place both for existing and new call handlers.” Source location 2019-0173-Response-by-Wiltshire-Police
Open published response
10 Jul 2018 Eugeniusz Niedziolko · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 8 Arrest culture excluding consideration of drunk-and-incapable arrests View source Inadequate algorithm for assessing deterioration risk in intoxicated people View source Insufficient training and knowledge for assessing alcohol intoxication View source Failure to verify receipt and understanding of critical policies and procedures View source Lack of radio read-back checks for critical information View source Absence of third-party care and deterioration provisions in the 2017 agreement View source Failure to recognise acute alcohol intoxication as a mental disorder or impairment View source Insufficient national police training on mental-disorder implications of acute alcohol intoxication View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Eugeniusz Niedziolko · 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
Eugeniusz Niedziolko, who was heavily intoxicated and vulnerable, was left alone in an unheated public lavatory after police and ambulance staff decided he did not require hospital care. He was found unresponsive several hours later and died from acute alcohol toxicity and hypothermia. The report identifies concerns about failures to follow protocols, assess and communicate critical information, provide appropriate training, and consider available options for keeping him safe and monitored.
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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Arrest culture excluding consideration of drunk-and-incapable arrests
Wider context from the report “f) ARREST CULTURE - I am concerned having heard evidence in particular from ████████ the former who had been told that you simply do not arrest somebody for being drunk and incapable, the latter having given evidence that there was a culture that you do not arrest for drunk and incapable . If you look at the 2017 multi-party agreement one of the fall-back positions if hospital assistance is not regarded as being necessary is the consideration of arresting that individual for being drunk and incapable. Eugeniusz had no home and was vulnerable as well; the latter confirmed by both ████████ and ████████ so the necessity requirement for arrest would have been satisfied. Eugeniusz was clearly drunk (approaching 5½ times the drink drive limit for blood alcohol) and having become incontinent of urine would also have been regarded as being incapable as I see it. In evidence, the officers regarded Eugeniusz as capable at the time they left him – that alone concerns me in terms of a blinkered view as the bladder would have needed time to refill as the body processes the alcohol and the evidence from the experts pointed to a further period of incontinence prior to death. Eugeniusz was so incapable of looking after himself he was unable to relieve himself appropriately even in a public lavatory. If such a culture exists then that is a concern as it removed here an option that was disregarded by the officers concerned and which if exercised may have resulted in Eugeniusz attending hospital or spending the night safe in custody as opposed to having been left alone in a public lavatory block. I would like you to review the guidance given to frontline officers and to consider emphasising that drunk and incapable is still an arrestable offence if the circumstances and necessity warrant such action being taken to protect life. Arresting an individual does not mean that the person will necessarily be charged.
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Inadequate algorithm for assessing deterioration risk in intoxicated people
Wider context from the report “g) 2017 AGREEMENT – I raised with Consultant Paramedic ████████, and he is aware of my concern, that given the evidence of ████████ Consultant in Accident & Emergency who gave evidence that even if the observations had been carried out which to the greatest sense and purpose includes the checks in algorithm on page 10 of 12 of the 2017 Agreement, I am not convinced that if another Eugeniusz was to crop up that this risk of significant deterioration and death would have been picked up and avoided using this algorithm. Sometimes you have to spell it out and there was no questioning in this case as to when the person last consumed alcohol and over what period and what quantity they had consumed relative to this decision-making process. I queried whether especially with somebody who is not being cooperative as to whether the use of a breathalyser (if they were to consent) would aid in the intelligence gathering. There is also no mention of physical presentation. In Eugeniusz’s case, he had become incontinent of urine in respect of which I asked all relevant witnesses as to how many people they knew who were deliberately incontinent of urine. The answer, not unsurprisingly, was no-one. That factor from the common-sense point of view either is suggestive of physical issue whereby Eugeniusz was incontinent or that it was related to the degree of his intoxication in that he could no longer control and had no awareness of bodily function in that respect. The algorithm needs to be reviewed and considered in the light of this case specifically so that it would pick up another “Eugeniusz”.
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and knowledge for assessing alcohol intoxication
Wider context from the report “b) TRAINING AND GENERAL LIFE SKILLS - It was quite clear during the evidence that both police officers had a very limited knowledge in relation to the effects alcohol has on the body . Neither officer asked, nor even attempted to ask, what I would term were obvious questions at the time, namely how much had the individual had to drink and when was the last drink was consumed and over what period the alcohol was consumed. Considering the Courts regard Police Officers as experts in relation to drunkenness (officers tend to provide evidence in relation to drink related offences) neither offered to provide any idea as regards the link between alcoholism and mental health issues; that sex, age and build being all variables can affect how the body processes alcohol; the fact that alcoholics can be quite difficult to judge having regard to tolerance levels (how much they have consumed becoming essential information so as to factor that relevant information to enable a decision to be reached, not just as to what the risk to that individual was at that stage but also in the foreseeable immediate future (in terms of the next few hours or so). The evidence from the Consultant A & E Specialist, ████████ was that there was a poor correlation between visual presentation and the amount of alcohol that might actually be in that individual’s system. I am concerned here that a blinkered approach adopted by officers attending somebody who is intoxicated can easily lead to the wrong decision being taken and one which is based on assumptions. I have been made aware of changes to training programmes but I am concerned that the training does not provide sufficient awareness and that there may be still a significant number of officers who simply do not have the life experience and general knowledge to factor that experience into professional judgement making. It would not surprise me if your officers in Swindon, more likely than not, have a better awareness of these issues and perhaps they could look to improve the training and share their experiences to officers elsewhere in the County.
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to verify receipt and understanding of critical policies and procedures
Wider context from the report “d) COMMUNICATION OF POLICY AND PROCEDURE
I am aware that following this incident the 2009 Agreement between the Hospitals, Ambulance Trust and Wiltshire Police as regards the assessment of people who appear to be drunk and need of medical assessment was circulated. A newer agreement was also subsequently entered into in June 2017. I am surprised and concerned that even now front-line officers, who gave evidence, were unaware of either of these 2 agreements. It would appear that important communications are being sent out but that there is no effective system in place to check that the important information is received and more importantly is understood . This also applies to e-learning which is capable of abuse if the same questions are asked at the end of modules. Interestingly, I heard from Consultant Paramedic, ████████ that in relation to their e-learning systems random questions are asked at the end of e-learning modules in an attempt to overcome the risk of abuse. I fully appreciate that front line officers are under huge amounts of pressure with increasing workloads and less resources but my fear is that there will be a repeat of this incident and other issues arising that may lead to a death occurring through the lack of effective communication of policies and procedures which, at the end of the day, are designed to guide front line personnel and ultimately protect them. With busy workloads, an expectation that these documents will be read is unrealistic and arguably idealistic.
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of radio read-back checks for critical information
Wider context from the report “a) RADIO PROTOCOL
When listening to the radio communications there appeared to be a non-existent radio protocol of any form . My concern relative to this particular point is the absence of a protocol which for example requires the recipient of important information such as PNC markers to reflect or even repeat the information that has been given so that it can be established both ends that the information has been correctly and effectively communicated. The situation that appears to have arisen in this case is that the controller says that all 3 markers were communicated but the transcript supports the 2 officers on the ground recollections that they only received notification of 1. I am concerned that the absence of any check could lead to critical information not being communicated which could lead in certain circumstances to errors occurring that could result in a worst case scenario to a death occurring. This issue of relaying critical information was highlighted by the jury in their Narrative Conclusion.
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Absence of third-party care and deterioration provisions in the 2017 agreement
Wider context from the report “e) 2009 & 2017 MULTI PART AGREEMENT (copies enclosed) - As regards the Agreement in 2009, I noted with interest insofar as the Ambulance protocol was concerned that a risk of deterioration should be assessed and that the patient should be left in the care of a 3rd party , with advice on seeking medical assistance later if required. I am concerned and have aired as to why this is absent from the 2017 Agreement and also I am concerned as to why consideration is not given for a similar provision being incorporated into the police protocol in the 2017 Agreement . Such a measure appears to be eminently sensible as a matter of common sense.
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise acute alcohol intoxication as a mental disorder or impairment
Wider context from the report “c) AWARENESS OF MENTAL HEALTH ISSUES
I have already highlighted a concern with the 2 officers in question who were unaware of the link between mental health and alcoholism that runs in both directions. What was more concerning was that both officers were unaware that acute alcohol intoxication amounts to a mental disorder for the purposes of the Mental Health Act 1983 and a mental impairment for the Mental Capacity Act 2005 . This point is being addressed below to the Chief Executive of the College of Policing and also the Council of Chief Police Officers Mental Health Lead as I suspect that the 2 officers involved in this case, as indeed every other Police Officer who gave evidence, was unaware of this until recently. This needs to change as a matter of urgency as in this case the use of Section 136 Mental Health Act 1983 was never considered as an option because neither officer thought that Eugeniusz was suffering from a mental disorder . ████████ a consultant psychiatrist also expressed a view to the court that he doubted that Eugeniusz actually had mental capacity when appearing to agree to being left in the lavatory block.
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Insufficient national police training on mental-disorder implications of acute alcohol intoxication
Wider context from the report “i) I hope in reaching this stage of the report that you will have read the points made above and you will be aware of my concern that until recently it would appear that the College of Policing and police officers within Wiltshire were unaware that acute alcohol intoxication is regarded as being a mental disorder for the purposes of the Mental Health Act 1983 and a Mental impairment for the purposes of the Mental Capacity Act 2005 (although senior Wiltshire Officers have or should have been aware of this concern since June 2017). The code of practice in relation to the Mental Health Act 1983 highlights this and as I understand ever since 1993 acute alcohol intoxication has been recognised by the World Health Organisation in ICD-10 relating to mental and behavioural disorders with acute alcohol intoxication being classified at F10 as being such a mental disorder. Front line officers need to be aware of such matters so that when dealing with situations that confront them that they have a full awareness and understanding of the range of options and powers that they may have available to them. I fully accept and understand the point that I made in Court that Section 136 of the Mental Health Act 1983 should be sparingly used but that does not mean that it should not be used because the officers concerned do not recognise that the person in front of them has a mental disorder so that they can then go on to consider whether or not the person is in need of immediate care and control and ultimately a mental health assessment. In this case they did not consider Section 136 simply because they did not think that Eugeniusz was suffering from a mental disorder at the time . I would ask you to review the training that is provided nationally to all Police Forces in this respect.
” Open source report
21 Jan 2014 William Howard DOWLING and Victoria Elaine ROSE · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Lack of arrangements enabling doctors to report relevant information during firearms licence terms View source Failure to enable General Practitioners to share public-safety information with relevant authorities View source Lack of independent and transparent firearms licensing decisions for current or former police employees View source
Responses linked to these concerns
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AI-generated summary
William Howard DOWLING and Victoria Elaine ROSE · 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 2 March 2013, William Howard Dowling shot Victoria Elaine Rose twice in the head before shooting himself in the head. The report raised concerns about information sharing between general practitioners and firearms licensing authorities, the wider public-safety implications of confidentiality, and the independence and transparency of firearms licensing decisions involving current or former police employees.
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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements enabling doctors to report relevant information during firearms licence terms
Wider context from the report “(1) During the course of the hearing I heard evidence from ███████ Wiltshire Police Firearms Licensing Manager, who indicated to me that at the present moment in time aside from a letter (copy attached marked A – since July 2011) which is sent to General Practitioners when firearms licence applications are successful or where they are renewed, giving a doctor the opportunity to relay relevant information in relation to their patient within 14 days, there is currently no memorandum of understanding or legislation that allows doctors the ability during the duration of the term of a firearms license, which stands at 5 years, to report matters which may have a bearing on that patient’s suitability to hold a firearms license and possess firearms . Doctors of course are bound at the present moment in time by patient confidentiality. I am concerned that this restriction may impede the firearms authority from making crucial decisions as regards individuals possessing firearms and continuing to hold a firearms licence in circumstances which, at present, may not come before the attention of the Firearms Authority unless the matter has ordinarily come before the police’s attention as a consequence of other aspects of their duties.
In evidence from ███████ she made me aware that Wiltshire Police through the cooperation of NHS Wiltshire Clinical Commissioning Group and two Doctor’s Surgeries were piloting a scheme (directly prompted Victoria’s two sons as a result of his tragedy) effective from September 2013, to allow an increase in the sharing of information in particular having a bearing on the suitability of an individual to hold a firearms licence. She indicated that as a result of this pilot scheme an individual’s firearms were taken away at short notice as a result of the information received from the General Practitioner. This pilot scheme seems to me to be an utterly sensible idea although at present it is a pilot scheme and is not a national concept . This ought to be urgently 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Failure to enable General Practitioners to share public-safety information with relevant authorities
Wider context from the report “(2) I am also concerned that any review arising out of this letter should not be singularly restricted as regards sharing information solely related to the suitability of somebody to hold a firearms licence. Information sharing with a view to public safety should be a reason for General Practitioners to make relevant authority(s) aware and I have in mind here the example of a driver whose eyesight is failing and where advice given from a GP to inform the DVLA, however that driver chooses not to do so as it will mean their licence may be revoked. If it is a matter of public safety then I am concerned at present moment in time that confidentiality appears to outweigh the concept of public safety .
” 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 Wiltshire Police; that does not assign responsibility.
PFD Monitor interpretation Lack of independent and transparent firearms licensing decisions for current or former police employees
Wider context from the report “(3) I am also concerned as regards decisions being made relating to firearms licensing in respect of current employees within that licensing organisation’s (ie the Police) employment or even former employees . Licensing and the determination of such matters should be seen to be transparent and independent . In evidence although relating to matters some 16 years previously there were issues raised by family concerning complaints by Mr Dowling’s ex wife at the time they were getting divorced that appeared to have been “brushed under the carpet” by the police in respect of which Bill was a serving officer. In any event those concerns were not dealt with satisfactorily from the complainant’s perspective. I am concerned that to have a firearms licensing authority dealing with applications from existing police employees or even former employees of that police force is open to possible abuse . Bill Dowling was an exceptionally well known and respected former police employee and my concern is that such matters relative to firearms are so serious that consideration ought to be given to introducing an independent layer so as to ensure independence and transparency .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations