PFD report

Luisa Mendes · Prevention of Future Deaths report

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Issued 30 Jun 2016•Warwickshire

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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 raised4

  1. Lack of specific training in handovers between controllers coming on and off shift
  2. Failure to categorise incidents involving allegations of violence as violent
    Part of recurring concern: Failure to reliably identify and investigate violent crimes
  3. Lack of formalised handover procedures between controllers coming on and off shift
    Part of recurring concern: Unreliable shift handover processes
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.4

  1. Action

    Develop a STORM alert that automatically reactivates out-of-time priority incidents and notifies relevant staff to mitigate unauthorised deferrals.

    Stated by Warwickshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2016.
  2. Action

    Strengthen controller handover training and incorporate handover requirements into the controller task book.

    Stated by Warwickshire PoliceStated completedThe respondent said that this action was complete when they made their response on 30 June 2016.
  3. Action

    Build a new command-and-control platform incorporating inquest-related changes, including correct authority levels for deferring incidents.

    Stated by Warwickshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2016.

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

  1. Position

    The varied nature of OCC calls prevents handover procedures from being made over-prescriptive.

    Stated by Warwickshire PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Lack of specific training in handovers between controllers coming on and off shift

Wider context from the report

“(2) The handover procedures between controllers coming on and off shift in the Operations and Communications Centre. The basis for the concern is that there are no formalised procedures and no specific training in relation to handovers between controllers coming on and off shift. ”

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 categorise incidents involving allegations of violence as violent

Wider context from the report

“(1) The approach of controllers and call handlers to the categorisation of incidents which include allegations of violence. The basis for the concern is that the incident should have been categorised as “violent” but it was not. ”

Is this part of a recurring concern?

Yes — Failure to reliably identify and investigate violent crimes.

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 formalised handover procedures between controllers coming on and off shift

Wider context from the report

“(2) The handover procedures between controllers coming on and off shift in the Operations and Communications Centre. The basis for the concern is that there are no formalised procedures and no specific training in relation to handovers between controllers coming on and off shift. ”

Is this part of a recurring concern?

Yes — Unreliable shift handover processes.

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

Absence of a STORM computer system feature alerting management to unauthorised deferrals

Wider context from the report

“(3) The set up of the STORM computer system as it relates to deferrals. The basis for the concern is the absence of any feature on the STORM computer system which will alert management to the effect that an unauthorised deferral has been effected by a controller. ”

Is this part of a recurring concern?

Yes — Unreliable operation of the STORM emergency incident-management system.

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

Develop a STORM alert that automatically reactivates out-of-time priority incidents and notifies relevant staff to mitigate unauthorised deferrals.

Verbatim wording from the response

“There remains a difficulty with substantive technical adaptations to the STORM system as it is used by a large number of police forces and other emergency service providers. After discussions with the company who own the system, Sopra-Steria, we have identified a change to the system that we are seeking to introduce in the next few weeks that will provide some mitigation to the issue of unauthorised deferrals. This change is still under development and it is intended that it will provide an alert on all priority incidents out of time. It is recognised that this does not prevent irregular deferrals being made, however within the current restraints of the system, is considered the best change we can deliver.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 3 · response
Published 30 June 2016

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 controller handover training and incorporate handover requirements into the controller task book.

Verbatim wording from the response

“Compelling evidence was identified during the preparation and ultimate delivery of the evidence to the inquest that showed the handover procedure between controllers in the OCC required improvement. However, the complex and varied nature of the calls received within the OCC means that the handover process must be dynamic and cannot be subject of an over-prescriptive process. It has been recognised that there was a need to reinforce the critical importance of passing vital information between controllers. In order to achieve this, changes have been made to the initial training programme for controllers and additional requirements incorporated into the controller ‘task book’, which is a list of skills that controllers need to demonstrate before progression in their role.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 3 · response
Published 30 June 2016

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

Build a new command-and-control platform incorporating inquest-related changes, including correct authority levels for deferring incidents.

Verbatim wording from the response

“Finally, Warwickshire Police and West Mercia Police are in the advanced stages of the procurement of a new Command and Control system. We are building the new platform with the suppliers, to our specifications, which will include the changes required as a result of the learning through the inquest. This will include the correct authority level around deferring incidents.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 4 · response
Published 30 June 2016

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

Check deferred priority incidents for supervisor consent for a defined period and reinforce the prohibition on unauthorised deferrals.

Verbatim wording from the response

“The change will be in addition to the reinforcement of the policy in relation to deferrals and the commitment that for a given period, all deferred priority incidents should be subject to checks to ensure that they were deferred with the consent of a supervisor. This will also serve to reinforce the training that no priority incident should be deferred without the consent of a supervisor. It addresses the deferral issue because, if the incident in question has been deferred, either rightly or wrongly, the system will automatically re-activate it and then send the relevant alerts.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 4 · response
Published 30 June 2016

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

The varied nature of OCC calls prevents handover procedures from being made over-prescriptive.

Verbatim wording from the response

“2. The handover procedures between controllers coming on and off shift in the Operations and Communications Centre (OCC). The basis of the concern is that there are no formalised procedures and no specific training in relation to handovers between controllers coming on and off shift.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 3 · response
Published 30 June 2016

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

Substantive STORM adaptations are constrained by the shared system, so only the best feasible mitigation can be delivered.

Verbatim wording from the response

“3. The set up of the STORM computer system as it relates to deferrals. The basis for the concern is the absence of any feature on the STORM computer system which will alert management to the effect that an unauthorised deferral has been effected by a controller.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 3 · response
Published 30 June 2016

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

Incident categorisation need not determine response; controllers should focus instead on threat, harm, risk and vulnerability.

Verbatim wording from the response

“1. The approach of controllers and call handlers to the categorisation of incidents which include allegations of violence. The basis for the concern is that the incident should have been categorised as ‘violent’ but it was not.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 2 · response
Published 30 June 2016

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.5

  1. 1

    Provide supervisors and managers with additional training to support staff dealing with challenging vulnerability-related issues.

    Stated by Warwickshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2016.
  2. 2

    Deliver vulnerability-recognition and response workshops to relevant Warwickshire Police staff.

    Stated by Warwickshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2016.
  3. 3

    Provide OCC training on protecting vulnerable people from domestic abuse, mental health issues and child sexual exploitation.

    Stated by Warwickshire PoliceStated completedThe respondent said that this action was complete when they made their response on 30 June 2016.
  4. 4

    Train OCC staff to identify threat, harm, risk and vulnerability using NDM and THRIVE, with ongoing refresher training.

    Stated by Warwickshire PoliceStated completedThe respondent said that this action was complete when they made their response on 30 June 2016.
  5. 5

    Research the feasibility of introducing an electronic reminder of handover requirements when controllers log on.

    Stated by Warwickshire PoliceStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2016.

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

Provide supervisors and managers with additional training to support staff dealing with challenging vulnerability-related issues.

Verbatim wording from the response

“More recently, we have commenced innovative one day workshops to encourage and develop our staff to recognise and respond to vulnerability. These workshops will include all relevant staff within Warwickshire Police and are at the core of the ambition I have of protecting the most vulnerable in our society. To support these workshops, all supervisors and managers are being provided with additional inputs in how we can support our staff in dealing with the challenging issues that this ambition will create. The workshops are pioneering within policing and their impact will be subject of academic assessment by Worcester University. The workshops commenced in July and will have been delivered to all relevant Warwickshire officers and staff by December 2016.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 2 · response
Published 30 June 2016

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

Deliver vulnerability-recognition and response workshops to relevant Warwickshire Police staff.

Verbatim wording from the response

“More recently, we have commenced innovative one day workshops to encourage and develop our staff to recognise and respond to vulnerability. These workshops will include all relevant staff within Warwickshire Police and are at the core of the ambition I have of protecting the most vulnerable in our society. To support these workshops, all supervisors and managers are being provided with additional inputs in how we can support our staff in dealing with the challenging issues that this ambition will create. The workshops are pioneering within policing and their impact will be subject of academic assessment by Worcester University. The workshops commenced in July and will have been delivered to all relevant Warwickshire officers and staff by December 2016.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 2 · response
Published 30 June 2016

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

Provide OCC training on protecting vulnerable people from domestic abuse, mental health issues and child sexual exploitation.

Verbatim wording from the response

“Additionally to add context, increase professional knowledge and to aid decision making, staff have been provided with specific inputs around protecting vulnerable people from harm. Officers and staff with specialist knowledge have provided bespoke training around high harm issues such as Domestic Abuse, Mental Health and Child Sexual Exploitation at OCC training days. These sessions are supported where applicable by on-line learning and knowledge checks provided by the College of Policing.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 2 · response
Published 30 June 2016

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

Train OCC staff to identify threat, harm, risk and vulnerability using NDM and THRIVE, with ongoing refresher training.

Verbatim wording from the response

“To ensure this happens all staff have been trained regarding the identification of threat, harm, risk and vulnerability using the National Decision Making model (NDM) as part of their induction process. As an additional aide to appropriate information capture and decision making, this is being complemented by the introduction of the THRIVE model, (Threat, Harm, Risk, Investigation, Vulnerability, Engagement). This provides a framework for staff to consider the issues evident in each individual case and provide the most appropriate response, assessing the needs of the caller. This training on NDM and THRIVE was refreshed to all Operations and Communications Centre (OCC) staff between January and March 2016. All training will be kept under review with appropriate refresher training given on an ongoing basis.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 2 · response
Published 30 June 2016

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

Research the feasibility of introducing an electronic reminder of handover requirements when controllers log on.

Verbatim wording from the response

“Additionally, we are exploring the option of an electronic reminder for controllers that will pop-up and remind them of the requirements of handovers when they log on to the system and commence their handover; this is dependent on whether the current system allows for such a development. This is being researched and we await a response as to its feasibility.”

Source location

2016-0243-Response-by-Warwickshire-Police
Page 3 · response
Published 30 June 2016

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