PFD report

ANTHONY JAMES FITZPATRICK · Prevention of Future Deaths report

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Issued 7 Dec 2021•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to use objective and consistent criteria for risk assessment
    Part of recurring concern: Unreliable objective criteria for safety risk assessment
  2. Lack of a plan to address the known risk-assessment problem
    Part of recurring concern: Failure to establish effective plans to address identified safety concerns
  3. Failure to ensure that recorded risk grades have a clear shared meaning
    Part of recurring concern: Unreliable recording in police custody records
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to use objective and consistent criteria for risk assessment

Wider context from the report

“(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record. (2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials. (3) Despite being aware of this problem, there was no plan in place to address it. ”

Is this part of a recurring concern?

Yes — Unreliable objective criteria for safety risk assessment.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a plan to address the known risk-assessment problem

Wider context from the report

“(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record. (2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials. (3) Despite being aware of this problem, there was no plan in place to address it. ”

Is this part of a recurring concern?

Yes — Failure to establish effective plans to address identified safety concerns.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure that recorded risk grades have a clear shared meaning

Wider context from the report

“(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record. (2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials. (3) Despite being aware of this problem, there was no plan in place to address it. ”

Is this part of a recurring concern?

Yes — Unreliable recording in police custody records.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026