National Police Chiefs Council

PFD Addressee
Reports: 54 Earliest: Apr 2015 Latest: 30 Mar 2026

100% 2-year response rate (above 83% average). 32% of classified responses show concrete action taken.

PFD Reports
54 results
Thomas Mayhew
Response Pending
2026-0225 East Sussex
Concerns I heard expert evidence from a Consultant Intensive Care Physician, who explained that there is a limited window of time (approximately ten minutes) during which emergency life-saving treatment can...
Oliver Roberts
All Responded
2026-0184 30 Mar 2026 Dorset
Emergency services related deaths Mental Health related deaths
Concerns summary (AI summary) There is a lack of practical guidance for police officers on applying their powers to obtain communications data under the Investigatory Powers Act 2016, especially regarding urgent Grade 2 requests.
Noted (AI summary) • The College of Policing provides eLearning training for investigators on the national ‘College Learn’ platform. • These learning packages “Introduction to Communications Data,” sit within the Digital Media Investigators (DMI) modules. • This training is available for all police officers and staff across England and Wales.
Benjamin Websdale
All Responded
2026-0094 17 Feb 2026 West Sussex, Brighton and Hove
Suicide
Concerns summary (AI summary) There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. Also, not all police forces have implemented trauma education campaigns.
Action Taken (AI summary) • The NPCC has been collating near real time suspected suicide surveillance data since January 2022, facilitated through the NPCC Suicide Prevention Steering Group and formulated from data returns provided by police forces in England, Scotland, and Wales. • Data returns are voluntary and used for Police Officer and Police Staff deaths by suspected suicide over recent years. • The NPCC is working with the College of Policing to develop a national curriculum for trauma awareness training for police officers.
Ann Laskowsky
All Responded
2025-0502 7 Oct 2025 West Yorkshire Western
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to a failure to recognise severe medical needs.
Action Planned (AI summary) The College of Policing will formally raise the case of Ms. Laskowsky at the next meeting of the NPCC First Aid Forum on 4 December 2025, to ensure that national learning is disseminated and embedded. They will produce national learning summaries and practice notes, update Authorised Professional Practice (APP) and training materials, and engage with force training leads and clinical governance advisors. West Yorkshire Police has posted an intranet briefing reminding staff about the YAS Partner Triage Line, included details in operational briefings, updated training and guidance material, and tasked the Right Care Right Person team with monitoring its usage. First Aid trainers will also remind officers of the YAS Partner Triage Line during annual training. The NPCC has recommended that West Yorkshire Police implement clinical governance arrangements consistent with NPCC guidance and has offered support in implementing this. They confirm that assessment of breathing and responsiveness levels are mandated in Learning Outcome 1.3. of Police First Aid Learning Programme.
Marta Vento
All Responded
2025-0137 11 Mar 2025 Dorset
Mental Health related deaths Other related deaths
Concerns summary (AI summary) No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. Additionally, national guidance is lacking for ensuring continuity of care for released prisoners with mental health needs.
Action Planned (AI summary) NHS England required ICBs to review community mental health services by September 2024. NHS England understands that NHS Dorset would actively support the expansion of this work to support sharing of mental health care plans. The DCR Partnership is looking to have the capability to share information with others using the NRL from March 2026 onwards. The College of Policing acknowledges concerns about the lack of a bespoke risk assessment tool for violence in MOSOVO units. They will consult with the NPCC Lead for MOSOVO and relevant subject matter experts to improve guidance and direction and will liaise with Dorset Constabulary to ensure they are fully sighted on current guidance. The NPCC will request the College of Policing to review APP and training material to highlight violence risk assessment more strongly within risk management plans; they have also reiterated a request for a full review of the ARMS process. NHS Dorset supported a learning event led by NHSE regarding mental health needs, and will work with SWAST to enable access to the Dorset Care Record. They have also opened a risk on the system risk register to scrutinise the accessibility of information across system partners. HM Prison and Probation Service acknowledges concerns about sharing risk information from prison with sentencing courts and highlights the establishment of immediate release pathfinders in three prisons to develop multi-agency approaches. They will task the Safety Group in HMPPS to consider this specific area when reviewing the Prison Safety Policy Framework later in 2025-26.
Robert Evans
All Responded
2025-0120 4 Mar 2025 Liverpool and Wirral
Police related deaths
Concerns summary (AI summary) A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing drugs during a street search if not arrested, creating a critical gap in care compared to those in custody.
Noted (AI summary) The NPCC Stop & Search portfolio will review the Regulation 28 document and work to ensure officers are equipped to resolve incidents such as these; they will work with other portfolios and stakeholders to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them. The College of Policing asserts that its Authorised Professional Practice (APP) on Detention and Custody adequately addresses concerns about medical attention for individuals suspected of swallowing drugs, pointing to existing guidance on immediate medical response, arrest procedures, risk assessment, and information sharing.
Anugrah Abraham
All Responded
2025-0024 14 Jan 2025 Manchester North
Police related deaths Suicide
Concerns summary (AI summary) Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers disclosing suicidal thoughts, and student officer training causes stress without adequate progress tracking.
Action Planned (AI summary) West Yorkshire Police has reflected on the events, and has already taken or is planning to take the following actions: The OH answerphone message should include advice for the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, Discussions between the clinical team regarding risk should be documented, Frequency of suicidal ideation should be recorded, Protective factors should be recorded, the OH page should include the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, contact Force Legal Services to provide inquest feedback, the service level agreement target is to be abandoned as unrealistic, Introduction of 90mins appointments, and Escalation to Force Medical Advisor for student officers referred due to their mental health. The College of Policing will review APP on suicide prevention to incorporate Anugrah Abraham's case and will also create a central repository of information on suicide prevention. They will also ensure the sharing of information about concerns with performance and any associated processes that are commenced will be referenced.
Matthew Brierley
All Responded
2025-0008 8 Jan 2025 Cumbria
Police related deaths Suicide
Concerns summary (AI summary) Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support fail to address their elevated risk.
Noted (AI summary) The College of Policing outlines existing guidance and practitioner advice for officers and staff regarding suspects of child sexual exploitation and risk assessment processes following release from custody, noting Mr. Brierley declined support offered. The Home Office acknowledges the report and expresses condolences, notes the relevant guidance provided by the College of Policing, and states that a review concluded appropriate support was provided to Mr. Brierley by Border Force. The Ministry of Justice believes the report should have been directed to the Home Secretary, as it relates to police investigative procedures, bail conditions, and Border Force (Home Office) matters. The NPCC is undertaking research to identify commonalities in post-custody suicides to establish a post-release risk assessment process and mandatory referral to support agencies, and has shared the PFD report with all UK custody leads with recommendations for investigative strategies.
Angela Mittal
All Responded
2024-0446 13 Aug 2024 Berkshire
Other related deaths
Concerns summary (AI summary) Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk assessment tool has not been adopted due to financial and compatibility issues.
Action Planned (AI summary) Thames Valley Police will replace current questions in the DOM 5 with questions from the DARA, include reference to the College of Policing definition of serious harm, and train every front line officer in its use. The NPCC highlights the national launch of the Domestic Abuse Risk Assessment (DARA) tool in November 2022 and ongoing work with forces and IT providers to drive implementation, in addition to various supporting products available to deliver against the curriculum.
Emma, Ellette and George Pattison
All Responded
2024-0438 8 Aug 2024 Surrey
Other related deaths Suicide
Concerns summary (AI summary) The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. Licensing authorities also lack methods to fully uncover coercive controlling behaviour.
Action Planned (AI summary) DHSC describes the rollout of a system by May 2023 to alert GPs when a patient with a shotgun certificate experiences a relevant medical condition, enabling them to flag it to the police. National FEO training will encourage positive engagement with the applicant and their family to ascertain their “domestic health and wellbeing”, and revised guidance may require interviews and engagement with families; the police are also looking to introduce the right to draw adverse inference if an applicant is evasive about family/previous partners. Surrey Police has revised its practice so FEOs now ask about the use of other medical services during visits to elicit information from applicants, and notes a national initiative to rewrite questions to be more explicit. The Home Office plans to issue a refreshed version of the Statutory Guidance early in 2025, which will include additional guidance for the police to help ensure that perpetrators of domestic abuse, coercive or controlling behaviour do not have access to firearms. The GPC will update its guidance to GPs to highlight the potential information gap in firearms licensing if external prescribers don't share relevant information or patients withhold it.
George Dillon
All Responded
2024-0488 16 Jul 2024 Hampshire, Portsmouth and Southampton
Road (Highways Safety) related deaths
Concerns summary (AI summary) Police lacked adequate understanding, training, and procedures for responding to automated car crash alerts from electronic devices, leading to delayed response and potential risk to life.
Action Planned (AI summary) Hampshire and Isle of Wight Constabulary has updated guidance to operators regarding automated crash detection calls, requiring deployment of officers unless contact is quickly re-established and police are confirmed to be unnecessary. The National Police Chiefs Council (NPCC) will direct a task and finish group on 13th September 2024 to create an agreed national position in relation to automated calls. The 999/112 Liaison Committee will also update its Memorandum of Understanding (MOU) in relation to SOS-Alerts using UK GSM Networks.
Miles Hurley
All Responded
2024-0364 9 Jul 2024 West Sussex, Brighton & Hove
Mental Health related deaths
Concerns summary (AI summary) Ineffective communication and documentation between police and the Liaison Diversion Service, coupled with a lack of guidelines for mental health assessments of intoxicated individuals, compromised appropriate care in custody.
Noted (AI summary) NHS England acknowledges the concerns raised, noting the national Liaison and Diversion service specification requires timely information sharing with police. They also describe national NHS England work on reviewing PFD reports to identify emerging trends. Midlands Partnership NHS Trust, which now provides Liaison and Diversion services in Sussex, has introduced a Custody Pathway Standard Operating Procedure. They are also considering extending their service hours and introducing an on-call service and are working with Sussex Police and Mitie to agree on the content of a revised MOU. Sussex Police references existing College of Policing guidance on handover procedures, risk assessments, intoxication, and mental vulnerabilities. They state they will not create a separate MOU due to concerns it could conflict with or become outdated compared to national guidance. The NPCC is considering a nationally recognised pre-arrival risk assessment to communicate risks and concerns to custody. They also plan to raise concerns regarding a lack of 24-hour LDS service and NHS Trust information sharing with NHSE. Mitie acknowledges the coroner's concerns regarding communication and documentation but states that they are not involved in mental health assessments in police custody and that the concerns should be addressed by the Police, NHS England and its local mental health and liaison and diversion services teams. However, Mitie has liaised with Sussex Police and the L&D Trust to understand their role in any formal process that they may wish to put in place.
Tcherno Bari
All Responded
2024-0296 3 Jun 2024 Birmingham and Solihull
Suicide
Concerns summary (AI summary) Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor information sharing, lack of staff awareness regarding procedures, and ineffective challenge processes between mental health services and police.
Noted (AI summary) This is an appendix to the BSMHFT response, specifically the Trust's Missing Patient Policy. It outlines the actions to be taken when a patient is missing or AWOL, relating to Informal inpatients, Detained patients who are AWOL and patients in the community, read in line with National Partnership Agreement: Right Care, Right Person (RCRP). NHS England will issue guidance to health systems on reviewing Serious Incident investigations to ensure lessons are learned and changes agreed upon. A national oversight group has been set up to review concerns and issues with RCRP, and this group feeds into a ministerial working group. West Midlands Police (WMP) has provided additional RCRP training to call handlers and officers and produced an exhibit detailing the escalation point of contact for partner agencies to West Midlands Police. WMP has also emphasised the need for officers to gather information from all sources and record the rationale for decisions made, particularly regarding vulnerable people. The National Police Chiefs' Council clarifies the aims of Right Care Right Person (RCRP) and states that it appears the situation concerning Mr. Bari was treated as a missing person case from the outset by West Midlands Police, and therefore RCRP principles would not apply. BSMHFT has updated their Missing Persons Policy in line with Right Care Right Person (RCRP) changes, incorporating feedback from the inquest, and a new Executive Director of Quality and Safety/Chief Nursing Officer will be accountable for the policy. The updated policy includes a revised Appendix C form focusing on the reasoning for critical concern and requires formal notification from the police with their decision and reasoning if they have decided not to deploy immediately. The APCC provides background on its role and the role of PCCs in local policing, noting that it has developed guidance for members on the Right Care, Right Person approach. It states that the NPCC is reviewing the report to identify relevant national learning. The Department of Health and Social Care acknowledges the concerns raised, noting that local policies should align with the Mental Health Act Code of Practice and that local partners should reassess joint processes on risk assessment, communication, and escalation. They emphasise the importance of collaboration between policing and health partners. The College of Policing is undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process. They are also working to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. The Home Office outlines the rationale and purpose of the National Partnership Agreement (NPA) and notes that decisions on implementation of Right Care Right Person (RCRP) are for individual Chief Constables. They state that missing persons cases are outside the scope of RCRP and existing police procedures should continue to operate.
Jonathan Shaw
Partially Responded
2024-0223 25 Apr 2024 Manchester North
Suicide
Concerns summary (AI summary) UK Border Force lacks legal powers and national guidance to effectively seize or manage consignments of substances ordered for self-harm, with no mandatory notification or welfare checks before release.
Action Planned (AI summary) The Home Office is actively exploring legislative and policy options regarding Border Force powers to seize substances used for suicide, and will engage across government to highlight the issue; the Home Secretary has also written to the Health Secretary to ask that they consider this issue as part of the Suicide Prevention Strategy.
Chloe Macdermott
Partially Responded
2023-0534 19 Dec 2023 Inner West London
Suicide
Concerns summary (AI summary) Online forums encourage suicide by providing methods without age restrictions or help signposting, and harmful content is not effectively removed. Lethal products are also easily purchased via international online retailers and delivered to the UK without effective border controls.
Action Planned (AI summary) Amazon has globally restricted the sale of high concentration sodium nitrite to Amazon Business customers since October 2022 and prohibits the sale of poisons as defined under Schedule 1A of the UK Poisons Act 1972. The NPCC Suicide Prevention Steering Group has disseminated briefing materials to all NPCC force and regional suicide prevention leads regarding the emerging trend of Sodium Nitrate and Nitrite use in suicides. They have also supported the National Crime Agency's criminal investigation into the supply of Sodium Nitrite. Ofcom is implementing the Online Safety Act 2023, developing codes of practice to address illegal content and protect children, and will take enforcement action against non-compliant services, including financial penalties and business disruption measures. Google Search prevents predictions for queries relating to methods of suicide and provides prominent signposting to authoritative information and support when users search for suicide-related terms, and delists content that directly facilitates activities that could cause immediate harm. DSIT outlines how the Online Safety Act will force companies to take more accountability for the safety of their users, including those who use VPNs to bypass protections, and details Ofcom's enforcement powers for non-compliant services. DHSC leads a cross-government group to tackle emerging methods of suicide, including sodium nitrite, reducing public access, and working with retailers to ensure labeling compliance for products like curing salt.
Carl Fullalove
Partially Responded
2023-0408 25 Oct 2023 Cheshire
Other related deaths
Concerns summary (AI summary) Inadequate police training on identifying nuanced symptoms of Acute Behavioural Disturbance (ABD) and the risks of prone restraint for drug-intoxicated individuals led to fatal outcomes.
Action Taken (AI summary) The College of Policing updated their First Aid Learning Programme (FALP) in April 2024 to include updated guidance on Acute Behavioural Disturbance (ABD), including de-escalation and communication strategies.
John Condron
Partially Responded
2023-0374 6 Oct 2023 Cheshire
Suicide
Concerns summary (AI summary) There is no agreed national protocol or specified timescale for police to inform suspects of a decision to take no further action, creating a risk of further self-inflicted deaths.
Action Taken (AI summary) Cheshire Constabulary has reviewed its suspect policy and procedure, introduced in August 2023, and now specifies that when a decision is made not to take further action against a suspect, they must be updated at the earliest practicable opportunity or within 48 hours.
Jack Zarrop
All Responded
2023-0362 2 Oct 2023 West London
Suicide
Concerns summary (AI summary) Custodial Nurse Practitioners lack adequate mental health training for complex patients and suicide risk, and agency staff in prisons receive insufficient training on the ACCT process.
Noted (AI summary) NHS England will ensure all staff, including agency and bank staff, have timely access to all joint training, including ACCT, that is necessary for them to undertake their role effectively within the prison environment and regional teams will be asked to give assurance at a meeting planned for June 2024, that the proposed action has been delivered and agency and bank staff have timely access to ACCT training. The NPCC clarifies that Custodial Nurse Practitioners (CNPs) are qualified and trained to work in police custody, with appropriate clinical support and supervision, according to the National Healthcare Specification. They assert the 2003 Home Office circular is outdated and the current healthcare model for police custody is robust. The Home Office states that Home Office Circular 020/2003 is no longer extant and therefore they propose to take no action in response to the report. They note the NPCC response regarding the National Healthcare Specification for police custody and NHS England's response regarding training of prison healthcare staff in the ACCT process.
Andre Moura
All Responded
2023-0348 3 Jul 2023 Manchester South
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed the safety officer role, and relied on subjective assessments instead of objective AVPU checks.
Action Planned (AI summary) The College of Policing has revised its First Aid Learning Programme (FALP) and the new Public and Personal Safety Training (PPST) training implementation went live in 2023, and the revised ABD training package will be published mid-September 2023. The NPCC is revising the Body Worn Video (BWV) guidance to include that BWV should be left running during periods of prisoner transport. This guidance will be published in October.
Anthony Ingram
All Responded
2023-0071Deceased 23 Feb 2023 Suffolk
Suicide
Concerns summary (AI summary) Crucial information about a suicidal missing person, including means of suicide and transport, was not shared between police forces due to a lack of standardized cross-border protocols.
Action Planned (AI summary) The NPCC has initiated a Task and Finishing Group and developed draft advice on cross-border missing person enquiries, which has been circulated for consultation. The National Transfer form is being updated to include a section for requesting enquiries in another force and direct communication between forces.
Hannah Warren
All Responded
2023-0055Deceased 13 Feb 2023 Swansea Neath Port Talbot
Other related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) There is a national lack of formal guidance and training for correlating missing person risk assessments with vehicle stop priorities, leading to dangerous mismatches and inappropriate response levels.
Noted (AI summary) The NPCC and College of Policing state that missing persons APP sets out clear processes and procedures and that current ACT instructions should be followed with an instruction to STOP in similar cases. NPCC will raise the issues apparent in the case through appropriate portfolio areas. The Metropolitan Police Service is developing a training package on ANPR and ACT reports, to be rolled out within 12 months. A new Service Level Agreement will require higher authorisation for ACT reports and nominated contacts for updates. The Home Office acknowledges the concerns and states that the College of Policing sets standards for police investigations, including ACT reports. They have consulted with the College, Metropolitan Police and NPCC and are satisfied that current guidance is in place.
Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd
All Responded
2023-0085Deceased 8 Feb 2023 Plymouth, Torbay and South Devon
Child Death Other related deaths
Concerns summary (AI summary) Concerns were raised regarding the risks associated with the legal availability, lethality, ease of use, and rapid fire capabilities of certain items, and their role in crime.
Disputed (AI summary) Dorset Police will provide additional training to further enhance the quality of FEO investigations through the national Professionalising Investigations Programme at level 1 over the next 18 months. A presentation of the key learning from the incident to a CPD event for all Firearms Licensing Managers will be delivered in May 2023. Avon and Somerset Police completed a review and found no cases where approval should not have been granted. They are reviewing their training requirements and will be implementing additional mandatory training for all staff, including PiP Level 1 training. North Wales Police will review cases over the last 5 years where applications have been refused or licenses revoked, but where subsequent applications or appeals resulted in a grant, aiming to complete this by 2nd October 2023. They highlight existing processes for quality control and previous review work undertaken. Merseyside Police firearms enquiry officers have completed the South Yorkshire Police training package and are enrolled on Mowbray Partners online training. They will also review cases within one month where firearms were seized or surrendered but subsequently returned, and applications refused/licenses revoked but later granted, aiming to complete this by 2nd October 2023. South Wales Police is reviewing approximately 1300 records where certificate holders were subject to a suitability review to determine if certificates were seized, surrendered, revoked or refused and subsequently approved. They are also working with Gwent Police to align processes, conduct peer reviews, and arrange an annual peer assessment of firearms licensing approvals. North Yorkshire Police has established a Gold group to oversee their response and commenced a review of records relating to certificates seized, refused, revoked, or surrendered and then subsequently approved over the last 5 years, aiming for completion by October 2nd. They are developing an Action Plan to manage the response and record decisions. Lancashire Constabulary has commenced a review of all certificates refused, revoked, seized or surrendered and then subsequently approved over the past 5 years, against the March 2023 Home Office Statutory Guidance, expected to be completed by the end of October 2023. They have also introduced process and scrutiny changes, including a dedicated Chief Inspector responsible for Firearms Licensing and training for staff. Greater Manchester Police will review between 70-80 cases at Senior Officer Panel, for the five-year period, where certificates have been seized, refused, revoked or surrendered and then subsequently approved and guns returned. The Firearms Licensing Manager and Detective Sergeant will attend a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. The College of Policing is developing significantly revised and updated Authorised Professional Practice (APP) on firearms licensing. This will underpin the development of a national training course for staff involved in firearms licensing. Surrey Police will review firearms and shotgun licensing prioritizing cases where firearms have been seized or surrendered and then returned; it will review most recent decisions first and applications that have been refused or licences revoked but where subsequent applications/appeals resulted in a grant. An additional resource has been seconded into the department to expedite this review and provide a full report by 2nd October 2023. Gloucestershire Constabulary will conduct a review of firearms licensing decisions, as per the letter from the NPCC lead, with a target completion date of 2 October 2023. Norfolk Constabulary will commission external training for Firearms Licensing Unit staff starting in May 2023. They will also conduct a review of certificates seized, refused, revoked, or surrendered and then subsequently approved, prioritizing cases not already subject to renewal, with a dip-sample approach to other cases. Essex Police is reviewing decisions to return firearms licenses over a five-year period, prioritizing cases where firearms were seized or surrendered and then returned. They have implemented local training for firearms licensing staff, including a lesson plan developed collaboratively with Kent Police, and external auditors will review the team's compliance. Bedfordshire Cambridgeshire and Hertfordshire Police have instructed a review of firearms seized and returned, certificate holders refused or revoked then successfully reapplied, and holders subject to police intelligence reports over the last five years. New role-specific training is being undertaken by all Firearms Explosives Licencing Unit staff, and an external training package has been purchased. Sussex Police's Firearms and Explosives Licencing Unit believes its process for the return of a certificate is suitably stringent and is catered for within a force policy; the team is working with the national NPCC lead and the College of Policing in developing a national curriculum and learning outcomes for Firearms Enquiry Officers, and will be active participants at the two day CPD event hosted by the College of Policing in May 2023. Kent Police will review 134 firearms licensing cases where certificates were returned after seizure/surrender, or granted after refusal/revocation, assessing them against the current Home Office Statutory Guidance. Local firearms licensing training, including refresher courses and mentoring, is provided, with plans to develop a lesson plan with Essex Police by the end of August 2023. West Mercia Police will review firearms licensing decisions related to returns, refusals, revocations, and surrenders over the past five years, aiming to complete the review by the end of October. A designated team, including a firearms instructor and tactical advisor, will conduct the review. Staffordshire Police and West Midlands Police (collaborated service) provided tables that outline certificates seized and returned, revoked, and refused. They have a series of scheduled quality assurance programmes in relation to internal and external audits over decision making. Devon and Cornwall Police invested £3 million into the force's Firearms and Explosives Licensing Unit (FELU). In 2023, training is planned, including integrating firearms licensing into practical scenarios for Personal Safety Training and presenting key learning from the incident at CPD events. The Lord Chief Justice acknowledges the concerns but states that the report does not substantiate the suggestion that judges are not giving appeals the necessary careful and detailed consideration, are applying the incorrect legal test, or are failing to have regard to the statutory guidance. Nottinghamshire Police has identified a dedicated resource to review firearms licensing cases where firearms were seized/surrendered and later returned, or where licenses were refused/revoked and later granted. A sample of cases from a 2021 review will be independently re-reviewed, and all reviews will be completed by 2 October 2023. Durham Constabulary details their history of firearms licensing reform following a 2013 report and states that they are satisfied that their review of decisions to return firearms to licence holders after seizure or surrender was appropriate and subjected to the appropriate level of scrutiny and oversight. Northamptonshire Police will prioritise reviewing cases where firearms have been seized/surrendered and then returned, and cases where applications were refused/licenses revoked but later granted, completing this by 2nd October 2023. They have secured temporary resources and engaged external companies to audit the unit. City of London Police acknowledge the findings and learnings from the Keyham Inquest and will review their SOP to ensure procedures for Application / Annual Renewal / Return meet or exceed common national standards, including robust checks across medical, crime recording and Risk Assessment. Risk assessment training and CPD training for all licensing team will be implemented on an annual cycle. The Metropolitan Police expresses condolences and describes existing processes for reviewing firearms licensing decisions, including reviews conducted in August 2021, and states they are contributing to national discussions on firearms licensing training. They explain the process used to identify cases for review following the Home Secretary's request. Leicestershire Police will review cases from April 2023 for the past 5 years where certificates were seized, refused, revoked or surrendered and then subsequently approved, prioritizing cases where firearms were seized or surrendered. The review will be conducted by individuals independent from the original decision makers and findings will be reported to the strategic lead for Firearms Licensing. Staffordshire Police (and West Midlands Police, as part of a collaborated service) detail existing training for staff, including the National Triage Firearms Classification Course and Police National Decision Model training. They also refer to the review of certificates seized, refused, revoked or surrendered and subsequently approved. The Home Office is allocating £500,000 to the College of Policing to develop accredited training for firearms licensing staff. They will consult on mandating this training and are working to address health information sharing, in consultation with medical bodies. Thames Valley Police will review seized and returned guns over a 5-year period, grants that have been revoked/refused/surrendered, and applications refused/revoked but subsequently granted via appeal. The aim is to complete these stages by 2 October 2023. Devon and Cornwall Police completed a review of 611 license holders identified as meeting the criteria of having certificates seized, refused, revoked or surrendered and then subsequently approved between May 2018 and December 2019. Eleven of these cases identified internal processes that did not meet expected standards, but no ongoing risks were identified. Suffolk Constabulary will review cases relating to certificates issued between April 2019 and August 2020. For other periods, they will dip-sample cases, with a wider review if concerns are identified, and highlight prior review work undertaken in Autumn 2021. Dyfed Powys Police will undertake a further review of decision files where firearms have been seized following any incident and subsequently returned to the holder. They welcome and support the recommendation of the Coroner to formalise a training programme to encompass all Firearms roles and responsibilities. Derbyshire Police has implemented IT system improvements for recording and sharing information, ensuring automatic notifications to the firearms licensing team for incidents involving license holders. They are developing a digital learning package for frontline officers and are exploring an independent scrutiny panel. Warwickshire Police states that they have already responded to the Home Secretary's request in 2021 regarding license applications that were refused or revoked but subsequently granted. The force will direct a review of firearms and shotgun licensing, prioritizing cases where firearms were seized or surrendered but then returned.
Nicholas Dumphreys
All Responded
2023-0021Deceased 19 Jan 2023 Cumbria
Road (Highways Safety) related deaths
Concerns summary (AI summary) Safety-critical vehicle information may not reach all police forces due to informal communication channels. There's also no policy to prevent faulty decommissioned police vehicles from being sold, and a lack of national garage standards risks inadequate maintenance.
Action Planned (AI summary) The NPCC has reorganised its fleet structure and is establishing a new NPCC-led governance and delivery structure to oversee police fleet issues. They will also reissue disposal advice under NPCC branding and are working to develop national vehicle servicing standards and a code of practice.
Christopher Boughton
All Responded
2022-0235 29 Jul 2022 Surrey
Suicide
Concerns summary (AI summary) A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, resulting in search requests being mismanaged and crucial information not being disclosed.
Action Planned (AI summary) The National Police Chiefs' Council (NPCC) highlights existing APP guidance on cross-border cases and states that a Task and Finishing Group has developed draft NPCC advice on ‘Requesting Missing Person Enquiries in Another Force and Transfers of Investigations’ which has been circulated for comment.
Aliny Godinho
Partially Responded
2022-0149 14 Mar 2022 Surrey
Other related deaths Police related deaths
Concerns summary (AI summary) Ongoing risks exist due to delayed training for Domestic Abuse Team staff and supervisors on updated policies. There is also no system for effective supervisory review of initial risk assessments and safeguarding plans.
Action Taken (AI summary) The NPCC and College of Policing emphasize an individual needs approach to domestic abuse victims, with a focus on professional curiosity, cultural competence, and improving risk assessment. Training, guidelines and advice are in place to improve understanding of vulnerability and risk.