PFD report

Neil Woodley · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 23 Jul 2024•South 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.

View original report
Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
3

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised1

  1. Failures in communication during welfare-check responses
    Part of recurring concern: Failure of police operational communications to reliably share safety-critical informationPart of recurring concern: Unreliable multi-agency communication procedures
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

    Deliver learning to MPS staff and officers on district location sharing and compliance with relevant standard operating procedures.

    Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 7 August 2024.

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

  1. Position

    Existing procedures for transferring calls to other police forces were followed appropriately and ensured timely information transfer.

    Stated by Surrey PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Failures in communication during welfare-check responses

Wider context from the report

“Mr Woodley’s brother and sister-in-law gave evidence at the hearing that a colleague of Mr Woodley called the police on the morning of 4 January concerned that he had not arrived at work. Their evidence was that an ambulance arrived to carry out a welfare check the following day (5 January) at around 1pm. They were told that the reason for the delay was confusion between Surrey Police and the Metropolitan Police. On the evidence before me, including that of Mr Woodley and his wife, I am satisfied that an earlier attendance would not have affected the outcome. However, I am concerned that failures in communication could result in avoidable fatalities in future cases. ”

Is this part of a recurring concern?

Yes — Failure of police operational communications to reliably share safety-critical information; Unreliable multi-agency communication procedures.

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

Deliver learning to MPS staff and officers on district location sharing and compliance with relevant standard operating procedures.

Verbatim wording from the response

“As an organisation, learning will be delivered to MPS staff and officers, highlighting the importance of district location sharing and compliance with standard operating procedures designed to protect front line policing and prevent correlation errors such as this incident.”

Source location

Response from Metropolitan Police
Page 3 · response
Published 7 August 2024

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

Existing procedures for transferring calls to other police forces were followed appropriately and ensured timely information transfer.

Verbatim wording from the response

“Having carefully considered the records relating to both calls, it is evident that they were handled correctly and were promptly passed to the MPS to manage. The policies and procedures that Surrey Police have in place to ensure the smooth transfer of calls to other police forces were followed appropriately. All relevant information was passed to the MPS in a timely manner and the informants were made aware of the transfer to the MPS to allow them to take appropriate action.”

Source location

Response from Surrey Police
Page 2 · response
Published 7 August 2024

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 records do not show a communication failure between Surrey Police and the Metropolitan Police Service; both calls were handled correctly.

Verbatim wording from the response

“Having carefully considered the records relating to both calls, it is evident that they were handled correctly and were promptly passed to the MPS to manage. The policies and procedures that Surrey Police have in place to ensure the smooth transfer of calls to other police forces were followed appropriately. All relevant information was passed to the MPS in a timely manner and the informants were made aware of the transfer to the MPS to allow them to take appropriate action.”

Source location

Response from Surrey Police
Page 2 · response
Published 7 August 2024

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

No communication failure between Surrey Police and the Metropolitan Police occurred because no record of a relevant 4 January call exists.

Verbatim wording from the response

“The MPS have no records of Mr Woodley’s work colleague or SPS contacting the MPS regarding an incident concerning Mr Woodley on 4th January 2024.”

Source location

Response from Metropolitan Police
Page 2 · response
Published 7 August 2024

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.2

  1. 1

    Investigate why the Prevention of Future Deaths communication was not escalated under Surrey Police procedures.

    Stated by Surrey PoliceStated in progressThe respondent said that this action was in progress when they made their response on 7 August 2024.
  2. 2

    Identify and complete appropriate actions to ensure future Prevention of Future Deaths communications are promptly escalated.

    Stated by Surrey PoliceStated plannedThe respondent said that this action was planned when they made their response on 7 August 2024.

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

Investigate why the Prevention of Future Deaths communication was not escalated under Surrey Police procedures.

Verbatim wording from the response

“I would firstly like to extend my sincere apologies for the delay in providing this response. I understand that an email was sent by the Coroner’s Officer to three different email addresses attaching the PFD Report. It would appear that two of these email addresses are not valid email addresses used by Surrey Police. One of the email addresses, for the Contact Centre, does appear to be correct and an internal investigation is underway to establish why it was not escalated in accordance with our usual policies and procedures. I will ensure that appropriate actions are identified and completed to ensure that any communications of this nature are promptly escalated in the future.”

Source location

Response from Surrey Police
Page 1 · response
Published 7 August 2024

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

Identify and complete appropriate actions to ensure future Prevention of Future Deaths communications are promptly escalated.

Verbatim wording from the response

“I would firstly like to extend my sincere apologies for the delay in providing this response. I understand that an email was sent by the Coroner’s Officer to three different email addresses attaching the PFD Report. It would appear that two of these email addresses are not valid email addresses used by Surrey Police. One of the email addresses, for the Contact Centre, does appear to be correct and an internal investigation is underway to establish why it was not escalated in accordance with our usual policies and procedures. I will ensure that appropriate actions are identified and completed to ensure that any communications of this nature are promptly escalated in the future.”

Source location

Response from Surrey Police
Page 1 · response
Published 7 August 2024

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
2/2

Data last updated 7 September 2026