8 May 2024 Donna Smith · Prevention of Future Deaths report Worcestershire
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Concerns raised 2 Failure to provide formal written guidance allocating responsibilities for urgent ambulance calls View source Lack of formalised written governance of the relationship between CCTV operators and police View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 1
Action
Implement a CCTV incident-response process requiring operators to call 999, route serious incidents to appropriate emergency services, obtain reference numbers, and record police contact details.
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AI-generated summary
Donna Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Donna Smith was found unresponsive in Worcester city centre on 4 March 2023 and later died in hospital from acute alcohol intoxication. The report raises concerns about the lack of formal written guidance governing communication and responsibilities between the CCTV operator and West Mercia Police, which led to neither making an immediate ambulance call. It also notes that a related Memorandum of Understanding had not been formalised, creating a risk to others.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wychavon District Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formal written guidance allocating responsibilities for urgent ambulance calls
Wider context from the report “(1) I heard evidence at the inquest that there was at the time of these events, and there remains now, a complete lack of formalised written policies, procedures or guidance governing the relationship between those operating CCTV cameras in Worcestershire ( as Wychavon District Council do in respect of Worcester city centre CCTV cameras ) and West Mercia Police;
(2) At the inquest I found as a matter of fact that the failure by either the CCTV operator or the police communications officer to call the ambulance service immediately after their call over Airwaves , and their lack of understanding over whose responsibility it was to make such a call , arose substantially because of this lack of formal written guidance ;
(3) Furthermore, I heard evidence that despite Ms. Smith’s death having occurred over 12 months ago, a draft Memorandum of Understanding between West Mercia Police and those operating CCTV cameras in Worcestershire had not yet been completed or formalised, but rather was still “being drawn up”.
For all of the above reasons, I am concerned that unless action is taken to formalise the relationship between those operating CCTV cameras in Worcestershire and West Mercia Police, and to provide proper guidance setting out their respective responsibilities in situations such as this , there is a risk that other deaths may occur in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wychavon District Council; that does not assign responsibility.
PFD Monitor interpretation Lack of formalised written governance of the relationship between CCTV operators and police
Wider context from the report “(1) I heard evidence at the inquest that there was at the time of these events, and there remains now, a complete lack of formalised written policies, procedures or guidance governing the relationship between those operating CCTV cameras in Worcestershire ( as Wychavon District Council do in respect of Worcester city centre CCTV cameras ) and West Mercia Police ;
(2) At the inquest I found as a matter of fact that the failure by either the CCTV operator or the police communications officer to call the ambulance service immediately after their call over Airwaves, and their lack of understanding over whose responsibility it was to make such a call, arose substantially because of this lack of formal written guidance;
(3) Furthermore, I heard evidence that despite Ms. Smith’s death having occurred over 12 months ago, a draft Memorandum of Understanding between West Mercia Police and those operating CCTV cameras in Worcestershire had not yet been completed or formalised, but rather was still “being drawn up” .
For all of the above reasons, I am concerned that unless action is taken to formalise the relationship between those operating CCTV cameras in Worcestershire and West Mercia Police , and to provide proper guidance setting out their respective responsibilities in situations such as this, there is a risk that other deaths may occur in the future.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a CCTV incident-response process requiring operators to call 999, route serious incidents to appropriate emergency services, obtain reference numbers, and record police contact details.
Verbatim wording from the response “Therefore, I have considered the letter sent by Alex Murray on behalf of West Mercia on 2 July and would put forward the following as the process to be followed by Wychavon District Council CCTV operators. This process has the aim to close the gap in communication between the agencies and reduce the likelihood of a similar situation happening again. In addition, it provides a means for a formal record to be set up by using the 999 communications channel following the removal of Airwave Radio from CCTV rooms in line with Police policy.” Source location 2024-0264 - Response from Wychavon District Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police decide whether to attend once contacted, with the Most Appropriate Agency Policy then activated.
Verbatim wording from the response “When contact is made with the Police a Contact Record will automatically be created. At this point the police will make a decision around police attendance and the Most Appropriate Agency Policy will be activated. The CCTV operative is to record the details of the Contact Record for future reference on the existing incident record logs.” Source location 2024-0264 - Response from Wychavon District Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further action is expected from CCTV control room operatives after making the call and recording the police contact record.
Verbatim wording from the response “When contact is made with the Police a Contact Record will automatically be created. At this point the police will make a decision around police attendance and the Most Appropriate Agency Policy will be activated. The CCTV operative is to record the details of the Contact Record for future reference on the existing incident record logs.” Source location 2024-0264 - Response from Wychavon District Council
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22 Aug 2023 Lawson Bond · Prevention of Future Deaths report Worcestershire
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Concerns raised 2 Continued sale of puppies and dogs by unscrupulous unlicensed breeders within the Wychavon area View source Lack of proactive monitoring for unlicensed puppy breeders View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 2
Action
Review the monitoring outcomes at the end of the initial 12-month period to inform whether the activity should continue.
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Action
Expand Wychavon intelligence gathering into continuous 12-month monitoring across more selling sites, including searches for large and comparable breeders.
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AI-generated summary
Lawson Bond · 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
Lawson Bond was attacked and mauled by an adult Rottweiler at his home on 28 March 2022 and died from his injuries at Birmingham Children’s Hospital on the morning of 30 March 2022. The report raised concerns that Worcestershire Regulatory Services did not take a sufficiently proactive approach to identifying unlicensed dog breeders, creating a continuing risk from puppies and dogs offered for sale by such breeders.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wychavon District Council; that does not assign responsibility.
PFD Monitor interpretation Continued sale of puppies and dogs by unscrupulous unlicensed breeders within the Wychavon area
Wider context from the report “(1) In evidence to the inquest, ████████, Principal Licensing Officer in the Licensing Team at Worcestershire Regulatory Services, agreed that the Licensing Team has a role in trying to identify unlicensed breeders, but stated that in this respect the Team is “intelligence-led”, i.e. that they will only act on information received or complaints made. Whilst the Team has an intelligence officer who will monitor websites, such monitoring will only take place in response to information received or a complaint made. The Team does not take a more pro-active approach generally, for example by searching websites and social media on a regular basis;
(2) The inquest received evidence from staff at the Worcestershire Coroner’s Office, who had undertaken two separate internet searches looking for Rottweiler puppies for sale within the Worcestershire area. These searches were conducted on 9 June 2023 and 28 June 2023, and found recent adverts placed by ████████ on two separate websites ████████, advertising Rottweiler puppies for sale. An identically worded advert was also found in the name of ████████ ████████ accepted in evidence that this advert was placed on her behalf;
(3) It might be thought that a regulatory authority would have less reason to be concerned about a scrupulous dog breeder, who applies and pays for a dog breeding licence, than about a dog breeder who ignores the licensing scheme. It is therefore concerning that Worcestershire Regulatory Services does not, at present, take a more pro-active approach in this regard, for example by monitoring websites for adverts placed by those selling puppies within its area. It would be quite possible to specify searches in such a way as to concentrate on breeds which might give a greater cause for concern in terms of safety.
For all of the above reasons, I am concerned that unless Regulatory Services within Wychavon District Council take action, there will remain a risk that unscrupulous unlicensed breeders will continue to offer puppies and dogs for sale within the Wychavon area , which present a heightened risk of danger to those who buy them and who come into contact with 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 Wychavon District Council; that does not assign responsibility.
PFD Monitor interpretation Lack of proactive monitoring for unlicensed puppy breeders
Wider context from the report “(1) In evidence to the inquest, ████████, Principal Licensing Officer in the Licensing Team at Worcestershire Regulatory Services, agreed that the Licensing Team has a role in trying to identify unlicensed breeders, but stated that in this respect the Team is “intelligence-led”, i.e. that they will only act on information received or complaints made . Whilst the Team has an intelligence officer who will monitor websites, such monitoring will only take place in response to information received or a complaint made . The Team does not take a more pro-active approach generally, for example by searching websites and social media on a regular basis ;
(2) The inquest received evidence from staff at the Worcestershire Coroner’s Office, who had undertaken two separate internet searches looking for Rottweiler puppies for sale within the Worcestershire area. These searches were conducted on 9 June 2023 and 28 June 2023, and found recent adverts placed by ████████ on two separate websites ████████, advertising Rottweiler puppies for sale. An identically worded advert was also found in the name of ████████ ████████ accepted in evidence that this advert was placed on her behalf;
(3) It might be thought that a regulatory authority would have less reason to be concerned about a scrupulous dog breeder, who applies and pays for a dog breeding licence, than about a dog breeder who ignores the licensing scheme. It is therefore concerning that Worcestershire Regulatory Services does not, at present, take a more pro-active approach in this regard, for example by monitoring websites for adverts placed by those selling puppies within its area . It would be quite possible to specify searches in such a way as to concentrate on breeds which might give a greater cause for concern in terms of safety.
For all of the above reasons, I am concerned that unless Regulatory Services within Wychavon District Council take action, there will remain a risk that unscrupulous unlicensed breeders will continue to offer puppies and dogs for sale within the Wychavon area, which present a heightened risk of danger to those who buy them and who come into contact with them.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the monitoring outcomes at the end of the initial 12-month period to inform whether the activity should continue.
Verbatim wording from the response “Going forward from this month, for a minimum period of 12 months, the intelligence gathering project for Wychavon will be a continuous, business-as-usual activity. The work will cover a significantly larger number of key selling sites and we will ensure that the on-going intelligence gathering activity includes searches for the approximately 65 breeders classed as “large” by the Kennel Club and, guided by the expertise of the Dog Warden Team, any similar breeds that might meet these criteria. We will review the outcomes of this work at the end of this initial 12-month period with a view to continuing if successful.” Source location Response from Wychavon District Council
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand Wychavon intelligence gathering into continuous 12-month monitoring across more selling sites, including searches for large and comparable breeders.
Verbatim wording from the response “Going forward from this month, for a minimum period of 12 months, the intelligence gathering project for Wychavon will be a continuous, business-as-usual activity. The work will cover a significantly larger number of key selling sites and we will ensure that the on-going intelligence gathering activity includes searches for the approximately 65 breeders classed as “large” by the Kennel Club and, guided by the expertise of the Dog Warden Team, any similar breeds that might meet these criteria. We will review the outcomes of this work at the end of this initial 12-month period with a view to continuing if successful.” Source location Response from Wychavon District Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specialist internet selling sites should maintain controls ensuring advertisers who meet the business threshold are licensed.
Verbatim wording from the response “We would also respectfully suggest that specialist internet selling sites which routinely deal with breeders, particularly breed-specific sites, should have their own controls in place to ensure that those advertising who meet the “business” threshold are licensed. We understand that a number do this, refusing to take adverts from people who they believe ought to be licensed and are not. However, this does not stop individuals potentially creating new accounts or using different names to avoid controls. Although it is not perfect, we would ask you to encourage those taking adverts to maintain a robust position with those they believe are acting in the course of a business.” Source location Response from Wychavon District Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations