PFD report

Dane Lee Pearson · Prevention of Future Deaths report

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Issued 15 Aug 2019•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.

View original report
Concerns
7

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
20

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 raised7

  1. Failure to assess known vulnerability when issuing CAWNs
    Part of recurring concern: Failure to recognise vulnerability in safeguarding decisions
  2. Failure to clarify available steps when serving CAWNs
  3. Failure to notify people under investigation of decisions
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. Action

    Require pre-service vulnerability risk assessments, documenting the rationale and potential impact on the suspect in Child Abduction Warning Notice records.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.
  2. Action

    Establish audits checking compliance with Child Abduction Warning Notice 48-hour service limits and six-month reviews.

    Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 6 June 2019.
  3. Action

    Disseminate frontline briefings reminding officers to manage release-under-investigation cases, close records, and inform suspects of outcomes.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Until IT systems change, investigating officers are responsible for closing records and informing suspects when investigations conclude without further action.

    Stated by Greater Manchester PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 assess known vulnerability when issuing CAWNs

Wider context from the report

“2. In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account. A risk assessment had not been carried out. In this case, officers attended at his home address and served the CAWN on him .He refused to sign it on the basis; he had no knowledge of it or the circumstances behind it. It was left with him with no clarification about what if any steps he could take in relation to it. The inquest heard evidence that he was deeply worried about it and the impact of it on his life. ”

Is this part of a recurring concern?

Yes — Failure to recognise vulnerability in safeguarding decisions.

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 clarify available steps when serving CAWNs

Wider context from the report

“2. In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account. A risk assessment had not been carried out. In this case, officers attended at his home address and served the CAWN on him .He refused to sign it on the basis; he had no knowledge of it or the circumstances behind it. It was left with him with no clarification about what if any steps he could take in relation to it. The inquest heard evidence that he was deeply worried about it and the impact of it on his life. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 notify people under investigation of decisions

Wider context from the report

“4. The inquest was told that he was placed under investigation for a suspected attempt burglary and possession of an offensive weapon. A decision was taken by the OIC and his sergeant that it should be NFAD. The decision was not communicated to Mr Pearson. The officer had not followed the process for notification of decisions to those under investigation. As a result, at the time of his death he believed he may be charged with a criminal offence. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 documentation explaining the rationale for CAWN issuance

Wider context from the report

“1. In this case, the CAWN had been issued on limited evidence particularly regarding identification. In addition, it had been issued many months after the allegation and after the authorisation. The inquest was told that the process had not been followed relating to timelines. There was no documentation in existence explaining the rationale for the issuing of the CAWN. ”

Is this part of a recurring concern?

Yes — Failure to reliably document the rationale for consequential decisions.

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 update OPUS with vulnerability markers

Wider context from the report

“3. The inquest heard that OPUS the Police system did not appear to have been correctly updated with markers to flag his vulnerability. ”

Is this part of a recurring concern?

Yes — Unreliable placement and maintenance of police risk and vulnerability markers.

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

Issuing CAWNs on limited evidence regarding identification

Wider context from the report

“1. In this case, the CAWN had been issued on limited evidence particularly regarding identification. In addition, it had been issued many months after the allegation and after the authorisation. The inquest was told that the process had not been followed relating to timelines. There was no documentation in existence explaining the rationale for the issuing of the CAWN. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Delays in issuing CAWNs and failure to follow issuance timelines

Wider context from the report

“1. In this case, the CAWN had been issued on limited evidence particularly regarding identification. In addition, it had been issued many months after the allegation and after the authorisation. The inquest was told that the process had not been followed relating to timelines. There was no documentation in existence explaining the rationale for the issuing of the CAWN. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Require pre-service vulnerability risk assessments, documenting the rationale and potential impact on the suspect in Child Abduction Warning Notice records.

Verbatim wording from the response

“2) Carry out a risk assessment prior to the service of a CAWN to ensure that consideration is given to a suspect’s history, particularly relating to any intelligence about vulnerability or threats, and include the outcome of the risk assessment in the CAWN service forms.”

Source location

2019-0056-Responses
Page 6 · response
Published 6 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish audits checking compliance with Child Abduction Warning Notice 48-hour service limits and six-month reviews.

Verbatim wording from the response

“5) Establish an ongoing audit process for checking the 48-hour time limit and six-month reviews are adhered to.”

Source location

2019-0056-Responses
Page 6 · response
Published 6 June 2019

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

Disseminate frontline briefings reminding officers to manage release-under-investigation cases, close records, and inform suspects of outcomes.

Verbatim wording from the response

“- The central criminal justice team provides detailed information to local districts to assist them in the management and governance of RUIs. - Governance expectations and best practise has been disseminated to all districts and branches, this has resulted in changes locally e.g. joining up crime management and RUI activity. - The bail and RUI policy has been revised to provide clarity on the roles and responsibilities of officers and local leaders in the management of RUI. - Targeted work, both local and centrally, to close outstanding RUI records. - Briefings have been disseminated to front line officers to remind them of their responsibility for RUI management, the closure of ICIS records and informing the suspect. - Local bail managers have introduced trackers to manage RUIs in the same way as pre-charge bail is managed.”

Source location

2019-0056-Responses
Page 10 · response
Published 6 June 2019

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 an integrated operating system supporting warning-marker creation, updates, reviews, removal, provenance, accountability, mandatory review notifications, and cautionary prompts.

Verbatim wording from the response

“As a Force, we are currently in the process of implementing a new, integrated operating system which will replace many of our existing systems. ████████ has worked closely alongside the iOPS team to ensure that all requirements for safely managing intelligence are met. GMP have provided the following as essential functions in relation to markers;”

Source location

2019-0056-Responses
Page 8 · response
Published 6 June 2019

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

Release updated Child Abduction Warning Notice guidance requiring vulnerability risk assessment, links to suicide-prevention guidance, and clear explanation of events to recipients.

Verbatim wording from the response

“The College is about to release updated APP on issuing CAWNs and this will reflect the need to carry out a risk assessment. There is existing guidance on suicide prevention in our Mental Health APP. The new CAWNs APP will link to that document so that those dealing with these issues are easily able to access the best advice. It will also make clear that a description of the events leading up to the issue of the CAWN must be carefully explained to the recipient.”

Source location

2019-0056-Responses
Page 1 · response
Published 6 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update Investigations Authorised Professional Practice to require keeping victims and suspects informed about case progress, including investigation conclusions.

Verbatim wording from the response

“The guidance contained in College Investigations APP will be updated to reflect the requirement to keep both victims and suspects updated on progress of cases, including informing a suspect when an investigation about them has been concluded.”

Source location

2019-0056-Responses
Page 2 · response
Published 6 June 2019

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

Strengthen PACE Code C to require proactive identification and recording of vulnerability factors and sharing those records with personnel communicating with the individual.

Verbatim wording from the response

“The treatment of those arrested and under investigation for alleged criminal offences is governed by Part 4 of the Police and Criminal Evidence Act 1984 (PACE) and by PACE Code of Practice C. While, at the time of Mr Pearson’s contact with the police in 2017, there was existing guidance in place relating to the handling of investigations and the treatment of potentially vulnerable individuals, this has subsequently been strengthened.”

Source location

2019-0056-Responses
Page 3 · response
Published 6 June 2019

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

Write and introduce a force Child Abduction Warning Notice policy and procedure defining officer responsibilities.

Verbatim wording from the response

“Greater Manchester Police (GMP) have instructed all staff across the force to ensure that the correct process regarding identification and timeliness is adhered to. The College of Policing national policy has been reviewed alongside GMP’s policy and a new 2019 policy and procedure document written which details the roles and responsibility of each officer involved in the issuing of a CAWN notice. The CAWN notices will be managed within each district in the Intelligence Hub for consistency. This document and the new process within districts will ensure that staff continue to comply with their responsibilities regarding the CAWN process as below,”

Source location

2019-0056-Responses
Page 6 · response
Published 6 June 2019

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

Until IT systems change, investigating officers are responsible for closing records and informing suspects when investigations conclude without further action.

Verbatim wording from the response

“As it stands, without changes in our IT systems (the systems will not be upgraded due to the pending the iOPS implementation), it is the responsibility of the OIC to close the ICIS record and inform the suspect when a decision to finalise the crime and take no further action has been reached.”

Source location

2019-0056-Responses
Page 10 · response
Published 6 June 2019

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 warning-marker policy cannot yet be completed pending assessment of the new system and anticipated inquiry requirements.

Verbatim wording from the response

“████████ of the Force Intelligence Bureau (FIB) is tasked with writing GMP’s first Force policy and guidance document on the use of WM. This will be completed”

Source location

2019-0056-Responses
Page 7 · response
Published 6 June 2019

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

GMP’s existing IT systems will not be upgraded before iOPS implementation, preventing automated notification changes meanwhile.

Verbatim wording from the response

“As it stands, without changes in our IT systems (the systems will not be upgraded due to the pending the iOPS implementation), it is the responsibility of the OIC to close the ICIS record and inform the suspect when a decision to finalise the crime and take no further action has been reached.”

Source location

2019-0056-Responses
Page 10 · response
Published 6 June 2019

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

Operational and procedural concerns about police practice are for the police to address.

Verbatim wording from the response

“The matters of concern that you raised are primarily operational and procedural matters for the police who, I understand, will be responding to you separately.”

Source location

2019-0056-Responses
Page 3 · response
Published 6 June 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.12

  1. 1

    Close outstanding release-under-investigation records through targeted local and central work.

    Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2019.
  2. 2

    Update force intelligence systems with Child Abduction Warning Notice information and conduct monthly reviews of service compliance.

    Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 6 June 2019.
  3. 3

    Manage Child Abduction Warning Notices within district Intelligence Hubs to improve consistency.

    Stated by Greater Manchester PoliceStatus unclearThe respondent did not make the status of this action clear when they made their response on 6 June 2019.
  4. 4

    Use Child Abduction Warning Notice service forms recording inspector approval, comments, and relevant procedural information.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.
  5. 5

    Conduct regular central dip-sampling of release-under-investigation records to monitor compliance and identify cases.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.
  6. 6

    Disseminate release-under-investigation governance expectations and best practice to districts and branches.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.
  7. 7

    Introduce local bail-manager trackers for managing release-under-investigation cases.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.
  8. 8

    Discuss release-under-investigation cases regularly at local crime-governance meetings.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.
  9. 9

    Add policy guidance for failed attempts to serve a Child Abduction Warning Notice.

    Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 6 June 2019.
  10. 10

    Implement a warning message in the system requiring users to review information behind warning markers before acting on them.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.
  11. 11

    Develop the force policy and guidance governing the use of mental-health warning markers.

    Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2019.
  12. 12

    Revise bail and release-under-investigation policy to clarify officer and local-leader responsibilities.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.

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

Close outstanding release-under-investigation records through targeted local and central work.

Verbatim wording from the response

“Prior to July 2018 GMP open RUI records within GMP had been increasing each day such that more were being opened than closed. Since July 2018 a number of activities have been carried out with the aim of reversing this trend and putting in place measures to effectively manage RUI in the future. This activity has had the effect of steadying the increasing number of outstanding RUI.”

Source location

2019-0056-Responses
Page 9 · response
Published 6 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update force intelligence systems with Child Abduction Warning Notice information and conduct monthly reviews of service compliance.

Verbatim wording from the response

“3) Update the Force Intelligence Systems with relevant information about the CAWN and schedule monthly reviews to monitor that notices have been served appropriately.”

Source location

2019-0056-Responses
Page 6 · response
Published 6 June 2019

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

Manage Child Abduction Warning Notices within district Intelligence Hubs to improve consistency.

Verbatim wording from the response

“Greater Manchester Police (GMP) have instructed all staff across the force to ensure that the correct process regarding identification and timeliness is adhered to. The College of Policing national policy has been reviewed alongside GMP’s policy and a new 2019 policy and procedure document written which details the roles and responsibility of each officer involved in the issuing of a CAWN notice. The CAWN notices will be managed within each district in the Intelligence Hub for consistency. This document and the new process within districts will ensure that staff continue to comply with their responsibilities regarding the CAWN process as below,”

Source location

2019-0056-Responses
Page 6 · response
Published 6 June 2019

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 Child Abduction Warning Notice service forms recording inspector approval, comments, and relevant procedural information.

Verbatim wording from the response

“1) The current service forms include the Inspector’s signature and comments to ensure that officers follow the correct procedure and that there is space to record everything applicable.”

Source location

2019-0056-Responses
Page 6 · response
Published 6 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct regular central dip-sampling of release-under-investigation records to monitor compliance and identify cases.

Verbatim wording from the response

“- RUIs are discussed regularly at local crime governance meetings. - Central CJ team are dip sampling records regularly to monitor compliance and highlight cases.”

Source location

2019-0056-Responses
Page 10 · response
Published 6 June 2019

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

Disseminate release-under-investigation governance expectations and best practice to districts and branches.

Verbatim wording from the response

“- The central criminal justice team provides detailed information to local districts to assist them in the management and governance of RUIs. - Governance expectations and best practise has been disseminated to all districts and branches, this has resulted in changes locally e.g. joining up crime management and RUI activity. - The bail and RUI policy has been revised to provide clarity on the roles and responsibilities of officers and local leaders in the management of RUI. - Targeted work, both local and centrally, to close outstanding RUI records. - Briefings have been disseminated to front line officers to remind them of their responsibility for RUI management, the closure of ICIS records and informing the suspect. - Local bail managers have introduced trackers to manage RUIs in the same way as pre-charge bail is managed.”

Source location

2019-0056-Responses
Page 10 · response
Published 6 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce local bail-manager trackers for managing release-under-investigation cases.

Verbatim wording from the response

“- The central criminal justice team provides detailed information to local districts to assist them in the management and governance of RUIs. - Governance expectations and best practise has been disseminated to all districts and branches, this has resulted in changes locally e.g. joining up crime management and RUI activity. - The bail and RUI policy has been revised to provide clarity on the roles and responsibilities of officers and local leaders in the management of RUI. - Targeted work, both local and centrally, to close outstanding RUI records. - Briefings have been disseminated to front line officers to remind them of their responsibility for RUI management, the closure of ICIS records and informing the suspect. - Local bail managers have introduced trackers to manage RUIs in the same way as pre-charge bail is managed.”

Source location

2019-0056-Responses
Page 10 · response
Published 6 June 2019

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 release-under-investigation cases regularly at local crime-governance meetings.

Verbatim wording from the response

“- RUIs are discussed regularly at local crime governance meetings. - Central CJ team are dip sampling records regularly to monitor compliance and highlight cases.”

Source location

2019-0056-Responses
Page 10 · response
Published 6 June 2019

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 policy guidance for failed attempts to serve a Child Abduction Warning Notice.

Verbatim wording from the response

“4) Update the policy with guidance on what to do when attempts to serve a CAWN fail.”

Source location

2019-0056-Responses
Page 6 · response
Published 6 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement a warning message in the system requiring users to review information behind warning markers before acting on them.

Verbatim wording from the response

“5) There will be a detailed warning message to be displayed within the system. This warns officers accessing information that they must not act on a WM without reviewing the information that sits behind it;”

Source location

2019-0056-Responses
Page 8 · response
Published 6 June 2019

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop the force policy and guidance governing the use of mental-health warning markers.

Verbatim wording from the response

“████████ of the Force Intelligence Bureau (FIB) is tasked with writing GMP’s first Force policy and guidance document on the use of WM. This will be completed”

Source location

2019-0056-Responses
Page 7 · response
Published 6 June 2019

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 bail and release-under-investigation policy to clarify officer and local-leader responsibilities.

Verbatim wording from the response

“- The central criminal justice team provides detailed information to local districts to assist them in the management and governance of RUIs. - Governance expectations and best practise has been disseminated to all districts and branches, this has resulted in changes locally e.g. joining up crime management and RUI activity. - The bail and RUI policy has been revised to provide clarity on the roles and responsibilities of officers and local leaders in the management of RUI. - Targeted work, both local and centrally, to close outstanding RUI records. - Briefings have been disseminated to front line officers to remind them of their responsibility for RUI management, the closure of ICIS records and informing the suspect. - Local bail managers have introduced trackers to manage RUIs in the same way as pre-charge bail is managed.”

Source location

2019-0056-Responses
Page 10 · response
Published 6 June 2019

Open published response
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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