PFD report

Mark Craig BANKS · Prevention of Future Deaths report

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Issued 14 Apr 2017•Exeter and Great Devon District

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
4

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.

Concerns raised4

  1. Failure to contact ambulance service after caller request
  2. Insufficient efforts to search and check upon a person's wellbeing when asked to attend the scene
    Part of recurring concern: Failure to conduct required welfare checks on people in distressPart of recurring concern: Unreliable welfare-check processes for people whose health is of concern
  3. Failure to grade calls correctly where there is a clear danger to life
    Part of recurring concern: Unsafe emergency call handling
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.2

  1. Action

    Review and update policy D051 to align grading and deployment decisions with national incident-recording and call-handling standards, incorporating the THRIVE risk-assessment tool.

    Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 25 November 2017.
  2. Action

    Compile a working practice for auditing incident logs, including audit sampling, quality assurance and reporting to the Force Crime and Incident Registrar.

    Stated by Devon & Cornwall PoliceStated in progressThe respondent said that this action was in progress when they made their response on 25 November 2017.

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

  1. Position

    Existing grading and deployment policies, audits and working practices are considered sufficient to ensure compliance with national incident-recording and call-handling standards.

    Stated by Devon & Cornwall 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

Failure to contact ambulance service after caller request

Wider context from the report

“(1) Failure to contact ambulance service after caller request in addition a failure to record the request on the incident log. ”

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

Insufficient efforts to search and check upon a person's wellbeing when asked to attend the scene

Wider context from the report

“(3) RE: ████████ at Page 176 of the Independent Police Complaints Commission report – insufficient efforts to search and check upon Mr Banks’ wellbeing when asked to attend the scene. ”

Is this part of a recurring concern?

Yes — Failure to conduct required welfare checks on people in distress; Unreliable welfare-check processes for people whose health is of concern.

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 grade calls correctly where there is a clear danger to life

Wider context from the report

“(2) Failure to grade the call correctly when there was a clear danger to Mr Bank’s life. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

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 record ambulance requests on the incident log

Wider context from the report

“(1) Failure to contact ambulance service after caller request in addition a failure to record the request on the incident log. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Review and update policy D051 to align grading and deployment decisions with national incident-recording and call-handling standards, incorporating the THRIVE risk-assessment tool.

Verbatim wording from the response

“In addition, since the death of Mr Banks, the police’s grading and deployment policy (policy D051) and operational practices regarding call grading and incident creation have been reviewed to ensure that they are compliant with the NSIR and National Call Handling Standards (NCHS). D051 was subsequently updated to reflect that good decision-making in terms of grading and deployment required consideration of and compliance with national guidance on log classification; namely, the NSIR and NCHS.”

Source location

2017-0271-Response-by-Devon-Cornwall-Police
Page 2 · response
Published 25 November 2017

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

Compile a working practice for auditing incident logs, including audit sampling, quality assurance and reporting to the Force Crime and Incident Registrar.

Verbatim wording from the response

“Furthermore, as a part of our ongoing work in this area, the Registrar has directed that a working practice should be compiled to allow for the audit of incident logs to ensure compliance with the NSIR.”

Source location

2017-0271-Response-by-Devon-Cornwall-Police
Page 3 · response
Published 25 November 2017

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 grading and deployment policies, audits and working practices are considered sufficient to ensure compliance with national incident-recording and call-handling standards.

Verbatim wording from the response

“I am now satisfied that every reasonable effort has been made to ensure that the police’s policies and practices in this respect will be compliant with the required national standards. Furthermore, in order to keep abreast of developments in this area and as a part of a general effort to refine and improve our working practices in this regard, D051 has been reviewed and updated on five occasions following the death of Mr Banks.”

Source location

2017-0271-Response-by-Devon-Cornwall-Police
Page 3 · response
Published 25 November 2017

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.3

  1. 1

    Provide specifically trained Enhanced Crisis Communicators to manage initial contact with people indicating self-harm or potential suicide until a police negotiator is available.

    Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 25 November 2017.
  2. 2

    Make the updated D051 policy publicly available through the police website and provide it with the response.

    Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 25 November 2017.
  3. 3

    Amend the location-assistance process and standard operating procedure to prompt call handlers to gather information supporting location of callers unable to provide a definitive address.

    Stated by Devon & Cornwall PoliceStated completedThe respondent said that this action was complete when they made their response on 25 November 2017.

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

  1. 1

    The amended process and standard operating procedure for locating callers without fixed addresses are considered sufficient to address the concern.

    Stated by Devon & Cornwall PoliceExisting 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

Provide specifically trained Enhanced Crisis Communicators to manage initial contact with people indicating self-harm or potential suicide until a police negotiator is available.

Verbatim wording from the response

“In addition, our Contact Management and Communications Unit (who are ultimately responsible for handling incoming calls from members of the public) now have specific staff members trained as Enhanced Crisis Communicators (ECCs). The purpose of this”

Source location

2017-0271-Response-by-Devon-Cornwall-Police
Page 2 · response
Published 25 November 2017

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

Make the updated D051 policy publicly available through the police website and provide it with the response.

Verbatim wording from the response

“Our policy D051 is made publicly-available via our website, but I have enclosed a copy of the most recent version for your ease of reference. You can find further detail about ‘THRIVE’ and the ECCs at paragraph 3.2.”

Source location

2017-0271-Response-by-Devon-Cornwall-Police
Page 3 · response
Published 25 November 2017

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

Amend the location-assistance process and standard operating procedure to prompt call handlers to gather information supporting location of callers unable to provide a definitive address.

Verbatim wording from the response

“Since the death of Mr Banks, the police have amended the process for assisting people who have called us and are (for whatever reason) unable to provide their definitive location. In these instances, the call handler now creates an incident log and refers to a standard operating procedure which prompts them to ask the caller to confirm the following points (where possible):”

Source location

2017-0271-Response-by-Devon-Cornwall-Police
Page 3 · response
Published 25 November 2017

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 amended process and standard operating procedure for locating callers without fixed addresses are considered sufficient to address the concern.

Verbatim wording from the response

“Since the death of Mr Banks, the police have amended the process for assisting people who have called us and are (for whatever reason) unable to provide their definitive location. In these instances, the call handler now creates an incident log and refers to a standard operating procedure which prompts them to ask the caller to confirm the following points (where possible):”

Source location

2017-0271-Response-by-Devon-Cornwall-Police
Page 3 · response
Published 25 November 2017

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