PFD report

Suzanne Cammell · Prevention of Future Deaths report

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Issued 28 Jul 2014•Oxfordshire

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
1

Named on the report

Responses found
1

Of 1 recipient

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 make high-risk information available to responding officers
    Part of recurring concern: Failure of police operational communications to reliably share safety-critical informationPart of recurring concern: Failure to make previous self-harm and suicide-risk information available for safety assessments
  2. Failure to pass high-risk information between police forces and control rooms
    Part of recurring concern: Unreliable multi-agency communication proceduresPart of recurring concern: Unreliable sharing of safety-critical information 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.1

  1. Action

    Complete a thorough review of the information-sharing concern, consulting senior colleagues across relevant departments.

    Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 28 July 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Gloucestershire Police was responsible for assessing whether the shared information required a different intervention.

    Stated by Thames Valley 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 make high-risk information available to responding officers

Wider context from the report

“(1) There was also an incident on 23 September 2013 in Gloucestershire when Ms Cammell had been sectioned under Section 136 of the MHA because she had been seen placing her head under the wheels of a recycling lorry where she lived. She was seen by neighbours and/or the driver in time. This information about the incident on 23 September 2013 was held on the Police National Database which, presumably, Gloucestershire control and ████████ would have had access to. The concern therefore is in relation to communication between TVP and Gloucestershire Constabulary and, in turn, communication between Gloucestershire Control and its Officers. At Inquest, I did not have available to me details of the specific information passed by TVP control to Gloucestershire control in the early hours which subsequently led to ████████ and his colleague carrying out the welfare check at approximately 03.30. The evidence of ████████ at Inquest was that he did not know that she had been found lying underneath the wheels of the lorry earlier in the morning. He gave evidence that, if he had known this, he would have put in hand arrangements for a MHA assessment. ████████ also gave evidence that he did not know about the previous similar incident on 23 September despite the fact that it was on the PND and, furthermore, on Gloucestershire’s “Unified” Intelligence database. The issue of concern therefore is the fact that specific information, of a high risk nature, was not or may not have been passed by TVP to Gloucestershire Constabulary or, if it was, it may not have been available to ████████. I appreciate that ████████ carried out a prompt welfare check and that Ms Cammell’s presentation was such that ████████ did not consider her to be at risk but it appears he did not have available crucial information. ”

Is this part of a recurring concern?

Yes — Failure of police operational communications to reliably share safety-critical information; Failure to make previous self-harm and suicide-risk information available for safety assessments.

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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 pass high-risk information between police forces and control rooms

Wider context from the report

“(1) There was also an incident on 23 September 2013 in Gloucestershire when Ms Cammell had been sectioned under Section 136 of the MHA because she had been seen placing her head under the wheels of a recycling lorry where she lived. She was seen by neighbours and/or the driver in time. This information about the incident on 23 September 2013 was held on the Police National Database which, presumably, Gloucestershire control and ████████ would have had access to. The concern therefore is in relation to communication between TVP and Gloucestershire Constabulary and, in turn, communication between Gloucestershire Control and its Officers. At Inquest, I did not have available to me details of the specific information passed by TVP control to Gloucestershire control in the early hours which subsequently led to ████████ and his colleague carrying out the welfare check at approximately 03.30. The evidence of ████████ at Inquest was that he did not know that she had been found lying underneath the wheels of the lorry earlier in the morning. He gave evidence that, if he had known this, he would have put in hand arrangements for a MHA assessment. ████████ also gave evidence that he did not know about the previous similar incident on 23 September despite the fact that it was on the PND and, furthermore, on Gloucestershire’s “Unified” Intelligence database. The issue of concern therefore is the fact that specific information, of a high risk nature, was not or may not have been passed by TVP to Gloucestershire Constabulary or, if it was, it may not have been available to ████████. I appreciate that ████████ carried out a prompt welfare check and that Ms Cammell’s presentation was such that ████████ did not consider her to be at risk but it appears he did not have available crucial information. ”

Is this part of a recurring concern?

Yes — Unreliable multi-agency communication procedures; Unreliable sharing of safety-critical information 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

Complete a thorough review of the information-sharing concern, consulting senior colleagues across relevant departments.

Verbatim wording from the response

“████████ of our Professional Standards Department has carried out a thorough review of this matter, in the course of which he has consulted with senior colleagues from the Control Room & Enquiries Department, the Force Intelligence Bureau and the Partnership Team (which covers mental health).”

Source location

2014-0579-Response-by-Thames-Valley-Police
Page 1 · response
Published 28 July 2014

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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

Gloucestershire Police was responsible for assessing whether the shared information required a different intervention.

Verbatim wording from the response

“In summary, it would seem that TVP informed Gloucestershire Police of the concerns as reported by ████████ insofar as he had found Ms Cammell in a confused state and that she had been trying to get underneath a lorry. Admittedly, the information shared did not go into quite the detail reported by ████████, who said that he actually woke Ms Cammell while she was under a lorry and not simply that she was trying to get under one. I am not sure whether this would have made a material difference to ████████ risk assessment when he visited Ms Cammell at home. This would seem to be a matter for Gloucestershire but I hope I have at least been able to clarify the information that was shared.”

Source location

2014-0579-Response-by-Thames-Valley-Police
Page 4 · response
Published 28 July 2014

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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

Thames Valley Police disputes that it failed to inform Gloucestershire Police of the relevant welfare concerns.

Verbatim wording from the response

“In summary, it would seem that TVP informed Gloucestershire Police of the concerns as reported by ████████ insofar as he had found Ms Cammell in a confused state and that she had been trying to get underneath a lorry. Admittedly, the information shared did not go into quite the detail reported by ████████, who said that he actually woke Ms Cammell while she was under a lorry and not simply that she was trying to get under one. I am not sure whether this would have made a material difference to ████████ risk assessment when he visited Ms Cammell at home. This would seem to be a matter for Gloucestershire but I hope I have at least been able to clarify the information that was shared.”

Source location

2014-0579-Response-by-Thames-Valley-Police
Page 4 · response
Published 28 July 2014

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

Gloucestershire Police addressed the concern about using the Police National Database in its own response.

Verbatim wording from the response

“I understand that you posed to Gloucestershire a question in respect of the use of the Police National Database and that they have covered this in their response. Furthermore, I gather that at the Inquest you expressed concern in relation to a lack of information sharing between the Professional Standards Department and the officer who prepared the report for you. ████████ has put in place measures to address this. He has taken the liberty of making an appointment with you on 4 November 2014 to brief you on these measures and, of course, deal with any further questions you might have in respect of the case of Ms Cammell.”

Source location

2014-0579-Response-by-Thames-Valley-Police
Page 4 · response
Published 28 July 2014

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.1

  1. 1

    Put measures in place to address information-sharing between Professional Standards and officers preparing reports.

    Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 28 July 2014.

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

Put measures in place to address information-sharing between Professional Standards and officers preparing reports.

Verbatim wording from the response

“I understand that you posed to Gloucestershire a question in respect of the use of the Police National Database and that they have covered this in their response. Furthermore, I gather that at the Inquest you expressed concern in relation to a lack of information sharing between the Professional Standards Department and the officer who prepared the report for you. ████████ has put in place measures to address this. He has taken the liberty of making an appointment with you on 4 November 2014 to brief you on these measures and, of course, deal with any further questions you might have in respect of the case of Ms Cammell.”

Source location

2014-0579-Response-by-Thames-Valley-Police
Page 4 · response
Published 28 July 2014

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