PFD report

Keiron Christopher Bould · Prevention of Future Deaths report

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Issued 13 Jun 2018•Birmingham and Solihull

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
2

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
2

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 raised2

  1. Failure to verbally confirm transfers of cases between police forces
    Part of recurring concern: Unreliable transfer of cases between police forces
  2. Failure to verbally confirm which force has primacy for an incident
    Part of recurring concern: Unreliable transfer of cases between police forces
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.2

  1. Action

    Re-circulate College of Policing guidance on missing-person ownership to control-room managers, supervisors and staff.

    Stated by Warwickshire PoliceStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
  2. Action

    Implement a mandatory follow-up telephone call to confirm receipt when transferring missing-person reports to another force before closing the log.

    Stated by Warwickshire PoliceStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Telephone contact did occur to confirm which police force should deal with the case, despite the concern seeking verbal confirmation.

    Stated by Warwickshire PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 verbally confirm transfers of cases between police forces

Wider context from the report

“2. When Warwickshire police decided to transfer the case to West Midlands police an email was sent at 01.53 to a generic email address. There was a 4 hour delay in this email being picked up and actioned. There should be a system in place to ensure verbal confirmation about a transfer so the receiving force is aware of the referral. ”

Is this part of a recurring concern?

Yes — Unreliable transfer of cases between police forces.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to verbally confirm which force has primacy for an incident

Wider context from the report

“1. When each force received a missing person report soon after 12 midnight on 18/09/17, there was no communication about who would take primacy of the inquiry. There should be a system in place to ensure verbal communication confirms who is dealing with any incident. ”

Is this part of a recurring concern?

Yes — Unreliable transfer of cases between police forces.

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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

Re-circulate College of Policing guidance on missing-person ownership to control-room managers, supervisors and staff.

Verbatim wording from the response

“In addition, we are aware of the response you have received from Chief Constable Thornton on behalf of the NPCC and would clarify that the College of Policing Approved Professional Practice (APP) direction around ownership of missing people has been re-circulated to our Control Room Management, supervisors and staff to remind them of what should be done to provide clarity on ownership of missing persons enquiries, and the importance of that ownership.”

Source location

2018-0178-Response-by-Warwickshire-Police
Page 3 · response
Published 8 July 2018

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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 mandatory follow-up telephone call to confirm receipt when transferring missing-person reports to another force before closing the log.

Verbatim wording from the response

“Having learnt that West Midlands system is different to the Warwickshire system (where call handlers have a separate screen to monitor emails as well as a system showing the calls and incidents logs) changes were made to our policies and procedures as detailed in the witness statement of Chief Inspector Kent from Warwickshire Police and West Mercia Police, including the need for telephone contact with the other force in respect of transfer of primacy. These changes were implemented in February 2018.”

Source location

2018-0178-Response-by-Warwickshire-Police
Page 2 · response
Published 8 July 2018

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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

Telephone contact did occur to confirm which police force should deal with the case, despite the concern seeking verbal confirmation.

Verbatim wording from the response

“It can be seen therefore, that at 00:59 Warwickshire Police did make telephone contact with West Midlands in respect of confirming who should best deal with this case. There was confusion as to which Police area Mr Bould lived within, and therefore Warwickshire confirmed that we would make further enquiries, including travelling to the West Midlands police area to do so.”

Source location

2018-0178-Response-by-Warwickshire-Police
Page 2 · response
Published 8 July 2018

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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

The communication issues did not appear to affect the outcome because the overdose likely occurred before Mr Bould was reported missing.

Verbatim wording from the response

“I note the matters you raise as concerns, and would say at the outset that we acknowledge that there were issues with the communication between Warwickshire Police and West Midlands Police at the initial stages of the police involvement in this tragic case. However we also note that, based on your findings that the evidence indicates it is likely that Mr Bould took the morphine overdose at around midnight – shortly before the time he was reported missing to both forces – the matters giving rise to concern in this case would not appear to have affected the outcome in relation to Mr Bould.”

Source location

2018-0178-Response-by-Warwickshire-Police
Page 1 · response
Published 8 July 2018

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