PFD report

Grant Nicholas LOWRY · Prevention of Future Deaths report

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Issued 30 Mar 2026•Teesside and Hartlepool

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
8

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
21

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 raised8

  1. Failure to communicate accurate heat-source information to the family
    Part of recurring concern: Unreliable management of observed heat signatures during police searches
  2. Failure to accurately record search locations and outcomes
    Part of recurring concern: Unreliable recording of safety-critical police incident locations
  3. Delays in requesting Polsa Mutual Aid
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.6

  1. Action

    Amend the Silver Commander rota to provide shift-based supervisory leadership during evening and heightened-demand periods for high-risk missing-person incidents.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  2. Action

    Promote the PolSA role and provide search-resource awareness through PolSA training and Mountain Rescue input for Licensed Search Officers.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  3. Action

    Provide one-to-one reflective learning on officers’ operational equipment responsibilities and escalation of equipment problems to supervisors.

    Stated by Cleveland PoliceStated plannedThe respondent said that this action was planned when they made their response on 7 April 2026.

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

  1. Position

    Immediate deployment of fully constituted specialist teams or capabilities cannot always be achieved during the earliest response stages.

    Stated by Cleveland 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

Failure to communicate accurate heat-source information to the family

Wider context from the report

“There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include: 1. The location of the first NPAS heat source was not recorded accurately. 2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area. 3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded. 4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search. 5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas. 6. The family were told that no heat sources had been identified by NPAS. 7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces. 8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat. ”

Is this part of a recurring concern?

Yes — Unreliable management of observed heat signatures during police searches.

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 accurately record search locations and outcomes

Wider context from the report

“There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include: 1. The location of the first NPAS heat source was not recorded accurately. 2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area. 3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded. 4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search. 5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas. 6. The family were told that no heat sources had been identified by NPAS. 7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces. 8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat. ”

Is this part of a recurring concern?

Yes — Unreliable recording of safety-critical police incident locations.

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

Delays in requesting Polsa Mutual Aid

Wider context from the report

“There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include: 1. The location of the first NPAS heat source was not recorded accurately. 2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area. 3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded. 4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search. 5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas. 6. The family were told that no heat sources had been identified by NPAS. 7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces. 8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat. ”

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

Unavailability of a full set of operational PPE for night searches

Wider context from the report

“There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include: 1. The location of the first NPAS heat source was not recorded accurately. 2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area. 3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded. 4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search. 5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas. 6. The family were told that no heat sources had been identified by NPAS. 7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces. 8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat. ”

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

Lack of liaison between officers during searches

Wider context from the report

“There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include: 1. The location of the first NPAS heat source was not recorded accurately. 2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area. 3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded. 4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search. 5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas. 6. The family were told that no heat sources had been identified by NPAS. 7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces. 8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat. ”

Is this part of a recurring concern?

Yes — Unreliable management of observed heat signatures during police searches.

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 heed identified heat-source details

Wider context from the report

“There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include: 1. The location of the first NPAS heat source was not recorded accurately. 2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area. 3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded. 4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search. 5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas. 6. The family were told that no heat sources had been identified by NPAS. 7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces. 8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat. ”

Is this part of a recurring concern?

Yes — Unreliable management of observed heat signatures during police searches.

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

Delays in requesting specialist search resources

Wider context from the report

“There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include: 1. The location of the first NPAS heat source was not recorded accurately. 2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area. 3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded. 4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search. 5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas. 6. The family were told that no heat sources had been identified by NPAS. 7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces. 8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat. ”

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 maintain charged batteries for search equipment and work mobile phones

Wider context from the report

“There were issues with communication and record keeping which impacted on the quality and effectiveness of the searches undertaken. Some prevented re-tasking of further and full searches of the heat sources, to include: 1. The location of the first NPAS heat source was not recorded accurately. 2. The outcome of the search into the first NPAS heat source was not recorded accurately by the Officers involved or the call handler, whether in an Officer's day book, or on the STORM log, OEL or CAD. This prevented re-tasking of a search at that area. 3. The details of the second NPAS heat source were not heeded, whether by the Officers at Summerhill Park, the call handler or listening Supervision. This meant the heat source was not searched or recorded. 4. There was no liaison between Hartlepool and Stockton officers during the search at Summerhill Park on the evening of 01.06.22. This contributed to an unorganised and uncoordinated search. 5. There was inaccurate recording of which fields around ████████ had been searched, which was relied upon by Supervision and prevented later searches of those areas. 6. The family were told that no heat sources had been identified by NPAS. 7. There were delays in requesting Polsa Mutual Aid from neighbouring police forces. 8. There were delays in requesting the involvement of Mountain Rescue( with their dogs) and the police dog unit. In addition, the officer who was guided by NPAS to the first heat source did not have a full set of operational PPE for a search at night time in a dense area. The batteries on his torch and work mobile phone were flat. ”

Is this part of a recurring concern?

Yes — Unreliable provision and readiness of torches for safety-critical site and search work.

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

Amend the Silver Commander rota to provide shift-based supervisory leadership during evening and heightened-demand periods for high-risk missing-person incidents.

Verbatim wording from the response

“Additional supervision has also been increased with explicit scrutiny of high-risk missing persons investigations by senior officers (Silver Commanders):”

Source location

Response from Cleveland Police
Page 3 · response
Published 7 April 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

Promote the PolSA role and provide search-resource awareness through PolSA training and Mountain Rescue input for Licensed Search Officers.

Verbatim wording from the response

“Promotion of the PolSA role was undertaken in 2022 and 2023 to raise awareness among operational frontline Inspectors and Sergeants. PolSAs often provide advice remotely particularly in the early stages of an incident. Although specialist resources can be co-ordinated and scaled as an incident develops, the organisation is not always in a position, particularly during the earliest stages of a response, to immediately deploy fully constituted specialist teams or specialist capabilities.”

Source location

Response from Cleveland Police
Page 4 · response
Published 7 April 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

Provide one-to-one reflective learning on officers’ operational equipment responsibilities and escalation of equipment problems to supervisors.

Verbatim wording from the response

“This will be referred to the force’s Dress and Equipment Group and the Heath & Safety Group to review the matter and learning from the inquest. Both the Dress and Equipment Group and the Health and Safety Group will review officer equipment requirements and personal protective equipment. Both Groups will consider whether the current provision and equipment requirements meet the requirements of conducting searches. In addition, direct one-to-one reflective learning will be included regarding individual officers’ responsibilities in respect of operational equipment and escalating issues with equipment to their supervisor.”

Source location

Response from Cleveland Police
Page 5 · response
Published 7 April 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

Increase and redistribute minimum Licensed Search Officer staffing levels following review through the Specialist Capabilities Strategic Threat and Risk Assessment.

Verbatim wording from the response

“Actions taken to address this concern is as follows: The force has significantly improved the operating procedures and governance around its Specialist Capabilities areas, including police dogs, to ensure sufficient resilience is maintained. In addition, the geographical distribution of Licensed Search Officers (LSOs) has been reviewed as part of the Specialist Capabilities Strategic Threat and Risk Assessment (STRA). Consequently, minimum staffing levels will be increased and more evenly aligned across the force area.”

Source location

Response from Cleveland Police
Page 4 · response
Published 7 April 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

Review officer equipment and personal protective equipment requirements for searches through the Dress and Equipment Group and Health and Safety Group.

Verbatim wording from the response

“This will be referred to the force’s Dress and Equipment Group and the Heath & Safety Group to review the matter and learning from the inquest. Both the Dress and Equipment Group and the Health and Safety Group will review officer equipment requirements and personal protective equipment. Both Groups will consider whether the current provision and equipment requirements meet the requirements of conducting searches. In addition, direct one-to-one reflective learning will be included regarding individual officers’ responsibilities in respect of operational equipment and escalating issues with equipment to their supervisor.”

Source location

Response from Cleveland Police
Page 5 · response
Published 7 April 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

Share search-related organisational learning and recording requirements with staff, the Search portfolio lead, and specialist training governance.

Verbatim wording from the response

“Actions taken to address these concerns are as follows: The feedback and organisational learning set out in the statement provided by Greater Manchester Police (GMP) has been shared with staff via the force’s Specialist Training Tactical Governance Group. This group is responsible for ensuring that specialist training is identified and delivered through the force’s mandatory or annual training schedule, and that appropriate training is delivered to support operational requirements. The learning from GMP’s feedback has also been provided to the force lead for the Search portfolio, and includes prioritisation of the requirement to record:”

Source location

Response from Cleveland Police
Page 2 · response
Published 7 April 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

Immediate deployment of fully constituted specialist teams or capabilities cannot always be achieved during the earliest response stages.

Verbatim wording from the response

“Promotion of the PolSA role was undertaken in 2022 and 2023 to raise awareness among operational frontline Inspectors and Sergeants. PolSAs often provide advice remotely particularly in the early stages of an incident. Although specialist resources can be co-ordinated and scaled as an incident develops, the organisation is not always in a position, particularly during the earliest stages of a response, to immediately deploy fully constituted specialist teams or specialist capabilities.”

Source location

Response from Cleveland Police
Page 4 · response
Published 7 April 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.15

  1. 1

    Deliver the First Line Leadership Development Programme to operational Sergeants and equivalent staff, including operational decision-making records and rationale.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  2. 2

    Introduce a PolSA rota lead and monthly governance reporting to strengthen 24/7 rota resilience and oversight.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  3. 3

    Deliver specific missing-persons training to control-room teams and introduce regular staff training and briefing sessions alongside scheduled CPD days.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  4. 4

    Deliver future CPD for front-line supervisors and new Sergeants and Inspectors, incorporating learning from the incident.

    Stated by Cleveland PoliceStated plannedThe respondent said that this action was planned when they made their response on 7 April 2026.
  5. 5

    Introduce the Drone as First Responder programme to provide rapid remote drone deployment and early search-area and hazard identification.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  6. 6

    Review the missing-persons question set against College of Policing Authorised Professional Practice.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  7. 7

    Provide a Response Inspector across each Local Policing Area to manage initial responses to critical incidents and coordinate resources, partners, and risk management.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  8. 8

    Implement a Niche dashboard enabling 24/7 real-time monitoring of live missing-person cases by Duty Inspectors and Silver commanders.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  9. 9

    Deliver annual CPD for Silver Commanders incorporating incident learning and strengthening operational decision-making.

    Stated by Cleveland PoliceStated plannedThe respondent said that this action was planned when they made their response on 7 April 2026.
  10. 10

    Review the incident to identify staff development needs and provide one-to-one reflective learning to staff requiring further training or development.

    Stated by Cleveland PoliceStated plannedThe respondent said that this action was planned when they made their response on 7 April 2026.
  11. 11

    Provide twice-daily Pacesetter meetings with missing persons as a standing agenda item for senior oversight.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  12. 12

    Establish a dedicated Missing Persons Investigation Team to review live and long-term missing-person reports seven days a week during office hours.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  13. 13

    Expand search capability through accredited drone pilots, an operational drone fleet, and routine deployment for high-risk missing-person investigations.

    Stated by Cleveland PoliceStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  14. 14

    Implement electronic prompts requiring clinicians to confirm risk-assessment review or document why it was not possible before saving clinical entries.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
  15. 15

    Escalate Inquest learning through a formal Quality Standards Group discussion and request its cascade to clinical teams.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing continuous risk-assessment requirements already require clinicians to review, document and update risks during clinical reviews.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 the First Line Leadership Development Programme to operational Sergeants and equivalent staff, including operational decision-making records and rationale.

Verbatim wording from the response

“In November 2024, the force introduced a First Line Leadership Development Programme for all operational Sergeants and staff equivalents. This input consisted of a week-long course and included development on how to manage incidents as an ‘Operational Bronze’ commander, outlining their supervisory responsibilities in accordance with College of Policing Authorised Professional Practice (APP). Recording of decision-making and supporting rationale was included as part of this input. A large cohort of operational bronzes have now been trained.”

Source location

Response from Cleveland Police
Page 2 · response
Published 7 April 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 a PolSA rota lead and monthly governance reporting to strengthen 24/7 rota resilience and oversight.

Verbatim wording from the response

“A rota lead for PolSAs has been introduced. The lead reports into monthly rota governance chaired by a Superintendent. The chair reports strategic rota assurance into an Assistant Chief Constable at the Specialist Capabilities Board. Having this increased scrutiny over all rotas, including each rota area having a dedicated lead officer, provides the force with confidence that the rotas are sufficiently resilient and can respond 24/7 when required. Since this governance has been introduced the PolSA rota has been managed more effectively, with no reported adverse occurrences linked to resilience.”

Source location

Response from Cleveland Police
Page 4 · response
Published 7 April 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

Deliver specific missing-persons training to control-room teams and introduce regular staff training and briefing sessions alongside scheduled CPD days.

Verbatim wording from the response

“• Specific Missing Persons training was rolled out late in October/early November 2024. This training was delivered to all control room teams, including call handlers, dispatchers and operational supervisors (Sergeants and Inspectors). There has been improved staff development by introducing regular staff training and briefing sessions. These sessions are in addition to scheduled CPD training days.”

Source location

Response from Cleveland Police
Page 3 · response
Published 7 April 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

Deliver future CPD for front-line supervisors and new Sergeants and Inspectors, incorporating learning from the incident.

Verbatim wording from the response

“Future continuous professional development (CPD) sessions for front line supervisors will include learning identified from this incident. New Sergeants and Inspectors training will be delivered by the end of 2026. A wider review of the incident is scheduled to take place in June 2026 to identify any staff development needs. Direct one-to-one reflective learning will be done with those staff identified as requiring additional training or development as a result of this inquiry.”

Source location

Response from Cleveland Police
Page 2 · response
Published 7 April 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 the Drone as First Responder programme to provide rapid remote drone deployment and early search-area and hazard identification.

Verbatim wording from the response

“Whilst NPAS remains a viable tactical option for supporting missing person searches, the force has significantly enhanced its drone capability since 2023. Cleveland Police now has 58 accredited drone pilots and an operational fleet of 15 drones, providing a resilient and flexible asset. This capability is available at all times and is routinely employed in support of High Risk ‘Missing From Home’ investigations. The drones are equipped with advanced tracking functions and high-grade night imaging technology, enabling effective searching across challenging environments and in conditions where visibility is otherwise limited. In addition to conventional deployment, the force has introduced a fleet of drones through the Drone as First Responder (DFR) programme.”

Source location

Response from Cleveland Police
Page 4 · response
Published 7 April 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

Review the missing-persons question set against College of Policing Authorised Professional Practice.

Verbatim wording from the response

“• In March 2025 the Force Control Room undertook a review of the Missing Persons question set, assessing it against the Authorised Professional Practice for Missing Persons.”

Source location

Response from Cleveland Police
Page 3 · response
Published 7 April 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

Provide a Response Inspector across each Local Policing Area to manage initial responses to critical incidents and coordinate resources, partners, and risk management.

Verbatim wording from the response

“• In January 2023 the force amended its structure to a Basic Command Unit (BCU) model. The BCU model is led by a Chief Superintendent, and consolidates resources, personnel, and emergency response across multiple neighbourhoods or boroughs to manage demand, improve flexibility, and deliver consistent policing. This change aligned the force to the same operating model as the Local Authorities, and established four Local Policing Areas (LPA) of Hartlepool, Stockton, Middlesbrough and Redcar & Cleveland each led by a District Commander (Superintendent). One of the main benefits of adopting this model was increasing the provision of a Response Inspector across all four districts, instead of one Inspector for South (Redcar and Middlesbrough), and one Inspector for North (Hartlepool and Stockton).”

Source location

Response from Cleveland Police
Page 2 · response
Published 7 April 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

Implement a Niche dashboard enabling 24/7 real-time monitoring of live missing-person cases by Duty Inspectors and Silver commanders.

Verbatim wording from the response

“• In 2024, enhancements were made to the force digital records management system (referred to as Niche) which now enables real-time monitoring of all live ‘Missing From Home’ cases via a dedicated”

Source location

Response from Cleveland Police
Page 2 · response
Published 7 April 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

Deliver annual CPD for Silver Commanders incorporating incident learning and strengthening operational decision-making.

Verbatim wording from the response

“• To further strengthen capability and ensure consistency of approach, later in 2026 the cadre of Silver Commanders will receive annual CPD designed to enhance their knowledge, operational effectiveness and decision-making proficiency. The learning identified from this incident will be included as part of this.”

Source location

Response from Cleveland Police
Page 3 · response
Published 7 April 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

Review the incident to identify staff development needs and provide one-to-one reflective learning to staff requiring further training or development.

Verbatim wording from the response

“Future continuous professional development (CPD) sessions for front line supervisors will include learning identified from this incident. New Sergeants and Inspectors training will be delivered by the end of 2026. A wider review of the incident is scheduled to take place in June 2026 to identify any staff development needs. Direct one-to-one reflective learning will be done with those staff identified as requiring additional training or development as a result of this inquiry.”

Source location

Response from Cleveland Police
Page 2 · response
Published 7 April 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

Provide twice-daily Pacesetter meetings with missing persons as a standing agenda item for senior oversight.

Verbatim wording from the response

“• Further oversight is provided by Pacesetter meetings which take place twice a day, one in the morning (chaired by Gold (Chief Superintendent or Chief Officer)) and one in the evening (chaired by the Silver Commander or Force Incident Manager from the Force Control Room) where missing persons are a standing agenda item.”

Source location

Response from Cleveland Police
Page 3 · response
Published 7 April 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

Establish a dedicated Missing Persons Investigation Team to review live and long-term missing-person reports seven days a week during office hours.

Verbatim wording from the response

“• In October 2024, the Force introduced a dedicated Missing Persons Investigation Team consisting of a Sergeant and 6 officers to review live and long-term missing from home reports during office hours 7 days a week. This supplements the work of Response Inspectors 24/7 in this area.”

Source location

Response from Cleveland Police
Page 3 · response
Published 7 April 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

Expand search capability through accredited drone pilots, an operational drone fleet, and routine deployment for high-risk missing-person investigations.

Verbatim wording from the response

“Whilst the force has ensured that it undertakes all National Police Air Service (NPAS) allocated flying hours and maintains appropriate level of use of NPAS search capabilities, it has furthered its aviation capability for searches.”

Source location

Response from Cleveland Police
Page 4 · response
Published 7 April 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

Implement electronic prompts requiring clinicians to confirm risk-assessment review or document why it was not possible before saving clinical entries.

Verbatim wording from the response

“I can confirm that, following GL's death, changes have been made to the electronic care recording system currently in place. The system now incorporates an automatic prompt requiring clinicians to confirm whether a risk assessment has been reviewed when completing a clinical entry; where it has not, a documented rationale must be provided.”

Source location

Response from TWEV NHS Foundation Trust
Page 2 · response
Published 7 April 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

Escalate Inquest learning through a formal Quality Standards Group discussion and request its cascade to clinical teams.

Verbatim wording from the response

“Following the Inquest this matter has been escalated through the Quality Standards Group, which is chaired by the Associate Directors of Nursing and attended by Team Managers, Matrons, and Clinical Specialists. A formal discussion was held at the Quality Standards meeting on 8th April 2026 to address this information, with a request that the findings be cascaded to clinical teams accordingly.”

Source location

Response from TWEV NHS Foundation Trust
Page 2 · response
Published 7 April 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

Existing continuous risk-assessment requirements already require clinicians to review, document and update risks during clinical reviews.

Verbatim wording from the response

“To provide further assurance regarding risk assessment processes following clinical reviews, it is important to note that risk assessment is a continuous process in which clinicians are required to assess an individual's risks and any changes thereto on an ongoing basis. Should any changes in risk be identified during a review, these must be clearly documented within the electronic care records and within the patient's risk assessment.”

Source location

Response from TWEV NHS Foundation Trust
Page 1 · response
Published 7 April 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

Data last updated 7 September 2026