PFD report

David John Thompson · Prevention of Future Deaths report

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Issued 10 Feb 2026•Devon, Plymouth and Torbay

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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.

Report evidence summary

Concerns raised2

  1. Failure to use understandable terminology when questioning members of the public reporting missing persons
    Part of recurring concern: Unreliable missing-person response
  2. Lack of police staff understanding of the meaning of ‘suicidal ideation’ when responding to missing-person reports
    Part of recurring concern: Unreliable missing-person response
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

    Continue delivering Control Room refresher training on suicidality, fluctuating risk, plain language and broader exploratory questioning.

    Stated by Devon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
  2. Action

    Clarify in operational guidance that “suicidal ideation” means thoughts or feelings about suicide.

    Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
  3. Action

    Introduce operational guides for frontline officers and staff addressing Article 2 risks and suicidality.

    Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Rigid definitions and scripted questions are not adopted because they may create false reassurance and information loss; plain language and open questioning are preferred.

    Stated by Devon & Cornwall 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 use understandable terminology when questioning members of the public reporting missing persons

Wider context from the report

“(1) The inquest heard that when Mr. Thompson’s partner reported him missing to the police, she was repeatedly asked (by both the 999 call handler and the attending police officers) whether he had demonstrated any ‘suicidal ideation’. It was clear that she did not fully understand what that meant, and as a result information which would have been relevant to the consideration of the level of risk presented by Mr. Thompson going missing was not recorded by the police. (2) Furthermore, I heard evidence that the term ‘suicidal ideation’ was still being widely used by the constabulary when asking questions of members of the public who were reporting missing persons, and I am concerned that a member of the public may not understand what is being asked of them and may not therefore respond appropriately. ”

Is this part of a recurring concern?

Yes — Unreliable missing-person response.

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 police staff understanding of the meaning of ‘suicidal ideation’ when responding to missing-person reports

Wider context from the report

“(3) During the course of the inquest I heard evidence from 5 police officers and 2 members of the police staff. When asked what their understanding of the term ‘suicidal ideation’ was, their answers were vague and inconsistent. There therefore appears to be a lack of understanding by those employed by the police as to what the term means, creating a danger that the risk posed by a missing person is not fully appreciated by staff responding to a missing person report. ”

Is this part of a recurring concern?

Yes — Unreliable missing-person response.

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

Continue delivering Control Room refresher training on suicidality, fluctuating risk, plain language and broader exploratory questioning.

Verbatim wording from the response

“As a Force, we will continue to deliver refresher training to Control Room Staff to further strengthen their understanding of suicidality, associated risks, and the dynamic and fluctuating nature of such incidents.”

Source location

2026-0080 - Response from Devon and Cornwall Police
Page 1 · response
Published 13 February 2026

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

Clarify in operational guidance that “suicidal ideation” means thoughts or feelings about suicide.

Verbatim wording from the response

“Guidance issued in 2024 clarified that the term ‘suicidal ideation’ refers to thoughts of suicide (with reference to publications within the Lancet, and commentary provided in open-source by the Samaritans within which ‘ideation’ relates primarily to ‘thinking about suicide or could be making a plan to take their own life. This can range from a passing thought to a detailed plan’). This clarification has been further reinforced and incorporated into training and operational guidance that is being issued and delivered throughout 2026 – with specific emphasis on the wide variety of incidents and risks that the term encompasses.”

Source location

2026-0080 - Response from Devon and Cornwall Police
Page 2 · response
Published 13 February 2026

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

Introduce operational guides for frontline officers and staff addressing Article 2 risks and suicidality.

Verbatim wording from the response

“3. Reinforcement of the above approach to frontline officers and staff through the introduction of operational guidance (Op Guides) relating to incidents involving Article 2 risks and suicidality.”

Source location

2026-0080 - Response from Devon and Cornwall Police
Page 2 · response
Published 13 February 2026

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

Issue and deliver reinforced training and operational guidance on the broad spectrum of risk associated with suicidality throughout 2026.

Verbatim wording from the response

“Guidance issued in 2024 clarified that the term ‘suicidal ideation’ refers to thoughts of suicide (with reference to publications within the Lancet, and commentary provided in open-source by the Samaritans within which ‘ideation’ relates primarily to ‘thinking about suicide or could be making a plan to take their own life. This can range from a passing thought to a detailed plan’). This clarification has been further reinforced and incorporated into training and operational guidance that is being issued and delivered throughout 2026 – with specific emphasis on the wide variety of incidents and risks that the term encompasses.”

Source location

2026-0080 - Response from Devon and Cornwall Police
Page 2 · response
Published 13 February 2026

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

Rigid definitions and scripted questions are not adopted because they may create false reassurance and information loss; plain language and open questioning are preferred.

Verbatim wording from the response

“Whilst ‘suicidal ideation’ may be considered a clinical term in some contexts, the Force recognises that in emergency situations and when communicating with members of the public, it is often more appropriate to use plain language that is not prescribed or confined to a single definition. Accordingly, operational practice encourages the use of straightforward terminology such as ‘thoughts or feelings about suicide’ when discussing potential suicide risk.”

Source location

2026-0080 - Response from Devon and Cornwall Police
Page 2 · response
Published 13 February 2026

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

    Explore use of the Ovenstone criteria to help assess suicide risk.

    Stated by Devon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.

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

Explore use of the Ovenstone criteria to help assess suicide risk.

Verbatim wording from the response

“We have also undertaken some work with other Forces and have become aware of a ‘Ovenstone criteria’ (A criteria formed in 1973 by Dr. Irene Ovenstone) Whilst predominantly an investigative method to assist in determining whether a death was likely to be suicide, it is also useful for determining suicidal risk and provides some evidence of suspected pre-suicidal criteria and we are actively exploring this use.”

Source location

2026-0080 - Response from Devon and Cornwall Police
Page 3 · response
Published 13 February 2026

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

Official responses located
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Data last updated 7 September 2026