PFD report

Lewis Dean JOHNSON · Prevention of Future Deaths report

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Issued 23 May 2025•Inner North London

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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

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Concerns raised1

  1. Failure to include measurement of the distance between pursuing and subject vehicles in forensic collision investigation terms of reference
    Part of recurring concern: Unreliable forensic collision investigations in fatal incidentsPart of recurring concern: Unreliable specialist and forensic support for death investigations
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

    Update internal guidance to require investigators to consider distance calculations in collision-investigator terms of reference and consult the Coroner about the investigative approach.

    Stated by Independent Office for Police ConductStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025.

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

  1. Position

    Collision investigation, including measuring vehicle distances, is assigned to specialist Forensic Collision Investigators rather than undertaken by the IOPC.

    Stated by Independent Office for Police ConductRedirects 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 include measurement of the distance between pursuing and subject vehicles in forensic collision investigation terms of reference

Wider context from the report

“At inquest I heard that the terms of reference set out for the forensic collision investigator by the IOPC (then IPCC) at the outset of the investigation, did not include an instruction to attempt to measure the distance between the pursuing vehicle and the subject vehicle at points when the two appeared to be closer together. Obviously this omission did not have an impact upon Lewis Johnson’s death, but it did have an impact upon the inquest. It meant that the jury had no clear objective evidence about the distance between his motor cycle and the police car behind. Given that learning and at times policy are informed by such findings, it appears that this would be helpful to include in future investigations when death follows a police pursuit. ”

Is this part of a recurring concern?

Yes — Unreliable forensic collision investigations in fatal incidents; Unreliable specialist and forensic support for death investigations.

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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

Update internal guidance to require investigators to consider distance calculations in collision-investigator terms of reference and consult the Coroner about the investigative approach.

Verbatim wording from the response

“We are in the process of updating the internal written guidance we provide to IOPC lead investigators to ensure consideration is given to securing a full Forensic Collision Investigation Report and that there is consultation with the Coroner about our approach. Following your Preventing Future Deaths Report, our guidance will now also require investigators to consider if a distance calculation should form part of the terms of reference for the Forensic Collision Investigator. This guidance will be available to IOPC lead investigators within the next fortnight.”

Source location

Response from Independent Office for Police Conduct
Page 2 · response
Published 29 May 2025

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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

Collision investigation, including measuring vehicle distances, is assigned to specialist Forensic Collision Investigators rather than undertaken by the IOPC.

Verbatim wording from the response

“We work to ensure we gather all relevant and available evidence and seek expert advice where it is necessary and proportionate to the circumstances of the case. Collectively, this helps to inform the investigation and our ability to reach evidence-based decisions. With specific reference to matters involving road traffic incidents, the IOPC does not possess the technical skills or expertise to undertake collision investigation work. As such, we work with policing partners who have a duty to provide independent assistance by way of objective and unbiased opinion in relation to matters within their expertise. The reports produced by Forensic Collision Investigators are provided to the IOPC and the salient points are then included in the IOPC investigation report.”

Source location

Response from Independent Office for Police Conduct
Page 1 · response
Published 29 May 2025

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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

Distance measurement may not be possible or proportionate in every road traffic collision investigation because the process can be complicated and time-consuming.

Verbatim wording from the response

“The Forensic Collision Investigator would be the expert responsible for measuring distance between two vehicles. However, it is our understanding that this process is not always possible or straightforward and can, on occasion, be particularly complicated and take a significant amount of time. In light of this it may not be possible, or proportionate, in every road traffic collision investigation to pursue this line of enquiry.”

Source location

Response from Independent Office for Police Conduct
Page 2 · response
Published 29 May 2025

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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.3

  1. 1

    Have internal technical leads liaise with investigators early in road-traffic-fatality investigations to ensure appropriate investigative considerations are made.

    Stated by Independent Office for Police ConductStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025.
  2. 2

    Set minimum standards for streamlined collision investigation reports where appropriate, ensuring all relevant information is secured.

    Stated by Independent Office for Police ConductStated plannedThe respondent said that this action was planned when they made their response on 29 May 2025.
  3. 3

    Maintain protocols enabling investigators to instruct NPCC-panel subject matter experts on policy, procedure and training compliance.

    Stated by Independent Office for Police ConductStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.

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

Have internal technical leads liaise with investigators early in road-traffic-fatality investigations to ensure appropriate investigative considerations are made.

Verbatim wording from the response

“In the meantime, our internal technical leads will liaise with investigators in the early stages of any investigations involving a road traffic fatality to ensure the correct considerations are made. In instances where we feel it is appropriate to secure a streamlined collision investigation report, we will set out the minimum standards we expect for that report, to ensure all relevant information is secured.”

Source location

Response from Independent Office for Police Conduct
Page 2 · response
Published 29 May 2025

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

Set minimum standards for streamlined collision investigation reports where appropriate, ensuring all relevant information is secured.

Verbatim wording from the response

“In the meantime, our internal technical leads will liaise with investigators in the early stages of any investigations involving a road traffic fatality to ensure the correct considerations are made. In instances where we feel it is appropriate to secure a streamlined collision investigation report, we will set out the minimum standards we expect for that report, to ensure all relevant information is secured.”

Source location

Response from Independent Office for Police Conduct
Page 2 · response
Published 29 May 2025

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

Maintain protocols enabling investigators to instruct NPCC-panel subject matter experts on policy, procedure and training compliance.

Verbatim wording from the response

“The IOPC now has protocols in place with the NPCC and College of Policing for the IOPC to instruct subject matter experts from a panel organised by the NPCC who can provide an expert opinion on compliance with policy, procedure and training.”

Source location

Response from Independent Office for Police Conduct
Page 2 · response
Published 29 May 2025

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