Home Office
PFD Addressee
Reports: 113
Earliest: Nov 2013
Latest: 24 Mar 2026
83% 2-year response rate (matches average). 36% of classified responses show concrete action taken.
PFD Reports
113 resultsNatasha Johnston
All Responded
2024-0587
25 Oct 2024
Surrey
Accident at Work and Health and Safety related deaths
Other related deaths
Concerns summary (AI summary)
The absence of regulation on the number and weight of dogs an individual can walk in public creates significant safety risks for both dog walkers and other members of the public.
Action Planned
(AI summary)
DEFRA will engage with local authorities, the police and animal welfare stakeholders to gather evidence on the use of existing powers to implement controls on dog walking at a local level to review the effectiveness of the existing regime and the need for any further national measures. Surrey County Council implemented a 'Dog Walking Code of Conduct' in response to the incident, sends regular newsletters promoting good practices, and uses 'ambassadors' to champion responsible dog walking.
Sean Heath
All Responded
2024-0524
2 Oct 2024
Manchester South
Mental Health related deaths
Suicide
Concerns summary (AI summary)
Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.
Noted
(AI summary)
NHS England acknowledges the coroner's concerns regarding connectivity between mental health services abroad and in the UK, but notes that information sharing cannot be mandated for overseas healthcare providers. They highlight the work of the Regulation 28 Working Group in sharing learnings from PFD reports. The Home Office outlines the Right Care, Right Person (RCRP) approach, which GMP is rolling out, to ensure the right agencies respond to people in need of support, but defers to the College of Policing and GMP for specific issues. NWAS has provided feedback and reflection to the Mental Health Practitioner involved in the incident. They continue to deploy mental health Trust practitioners in NWAS control rooms and directly employ mental health practitioners for triaging calls. The DHSC acknowledges concerns about training for police officers, notification of carers for Mental Health Act admissions, connectivity between international and UK mental health services, GP practice list removals, and communication between mental health agencies, deferring to other bodies on some points and explaining existing policy on others. GMMH has emphasized the notification of carers following admission under the Mental Health Act through daily staff huddles and implemented a process to ensure written information is provided to carers within 72 hours of admission. GMMH will also carry out an audit to ensure staff are following guidance on safe transfers between teams by the end of March 2025. The College of Policing highlights the national 'Right Care Right Person' (RCRP) framework, supported by Authorised Professional Practice (APP) and a toolkit, along with a bespoke e-learning training package. They are in contact with Greater Manchester Police, who are implementing RCRP. The CQC acknowledges the concerns but states that they fall outside of its regulatory remit, particularly regarding GP practices and information sharing between agencies. It outlines its inspection methodology but takes no direct action. Trafford Council has reinforced expectations within Adult Social Care that staff must verify if the Police are responding to a call, reviewed and strengthened safeguarding processes, and invested in mental health management and practitioner capacity. Single agency recommendations from the Safeguarding Adults Review have been actioned. Response contains only blank pages.
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.
Zara Aleena
All Responded
2024-0409
26 Jul 2024
East London
Other related deaths
Concerns summary (AI summary)
Severe understaffing within the probation service led to poor quality risk assessments, inadequate staff training, and ineffective risk management. Additionally, the existing risk assessment tool and alert systems proved to be unwieldy and ineffective.
Action Planned
(AI summary)
London Borough of Redbridge details existing CCTV operator training which includes modules on behavioural body language training designed to detect suspicious behaviours. They also describe how they ensure risks for lone females are considered when planning events. The Metropolitan Police Service acknowledges the reviews lacked rigor. To address this, they will implement recommendations from an independent review, introduce body-worn video, review the integrated offender management system and implement Proactive Management Plans and have developed a new process map for clarity around recalls to prison. The Home Office acknowledges the concerns and will consider how to encourage business owners and staff to report predatory behavior. They mention plans to target perpetrators and address the causes of abuse and violence. HMPPS and MoJ acknowledge staffing issues and communication failures, but highlight the Prioritisation Framework implemented in January 2022. They also mention the Integrated Offender Management (IOM) guidance update (V4.1) from August 30, 2024, which explicitly requires POMs to be invited to all multiagency case conferences to improve communication.
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)
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. 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. 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.
Katie Madden
All Responded
2024-0295
30 May 2024
Suffolk
Suicide
Concerns summary (AI summary)
Child services lacked systems to treat vulnerable parents (e.g., Claire's Law recipients) as higher risk in child care investigations, failing to assess the mental health impact of child removal processes or provide independent support. Funding for specialist therapy was also problematic.
Noted
(AI summary)
NSFT has asked all clinicians that receive referrals into services to identify those where treatments have been recommended by non-NSFT clinicians in order to offer an assessment prior to signposting elsewhere. CYP staff will be reminded that a referral ought to be made, staff will be reminded that a referral ought to be made, nonetheless. This aspect of identified learning shall become a dedicated focus within our annual PLO training for CYP colleagues working across our operational services to raise awareness of presenting significant MH issues, Legal Services, when accepting a new case from CYP, shall be required to discuss with social workers any relevant vulnerabilities relating to the parent(s) and a referral has been sent to the Community Safety Partnership for consideration for a domestic homicide review of this case. Norfolk and Waveney ICB states that they have reviewed their Mental Health Individual Funding Request records and have not been able to identify any Individual Funding Request being made to them on behalf of Ms Madden, for Schema-based Cognitive Behavioral Therapy. Suffolk Constabulary notes the concerns raised but states that they conduct their own risk assessments when delivering Claire’s Law disclosures, which would include the wellbeing of the recipient of that disclosure and the delivery was conducted in accordance with policy and appropriate aftercare. The ICB will work with partners to ensure that learning and action is taken forward from this case, and the Trust has asked all its clinicians that receive referrals into mental health services to identify those where treatments have been recommended by clinicians from outside the Trust in order to offer an assessment prior to any decision being made on the most appropriate way forward. The Home Office acknowledges receipt of the report and restates commitment but describes no specific actions taken or planned.
Elizabeth McCann
All Responded
2024-0288
29 May 2024
Manchester South
Other related deaths
Concerns summary (AI summary)
High probation caseloads, inadequate supervision for new staff, and limited information sharing protocols between agencies, coupled with severe, long-standing understaffing in police Sexual Offender Management Units, compromised effective offender management.
Noted
(AI summary)
The College has a new Standard Operating Procedure for all referrals received from external agencies. The Trust is developing an organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework and is commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents; the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes. The Trust's safeguarding leads have supported College leads in developing a more robust safeguarding policy for enrolees, provided additional learning sessions to college staff and volunteers, and have a rolling programme of support in place; Additionally, the Executive Director of Quality, Nursing and Health Professionals has introduced new governance processes including a Central Safety Summit with an approved scope and purpose agreed at Board level with reporting into the Trust’s Quality Committee for continuous oversight at a Non-Executive Director level. The Home Office is working with police forces to ensure improvements in effectiveness and efficiency of the system to manage sex offenders and prevent them from committing further harm, and is working with the National Police Chiefs’ Council’s Violence and Public Protection and Violence Against Women and Girls portfolios. The VKPP engages with forces and key partners to identify promising practice and share knowledge to shape future responses to serious crime that exploits vulnerability. HMPPS is developing a new Continuing Professional Development risk learning product to be piloted towards the end of this year before being launched from February 2025, and has identified SEEDS2 as a strategic learning priority for 2024-2025 with Probation Officers required to complete the learning by September 2025 as part of their Continuing Professional Development requirement. No actions or plans described.
James Furlong, Joseph Ritchie-Bennett and David Wails
All Responded
2024-0276
20 May 2024
Central Criminal Court
Other related deaths
Concerns summary (AI summary)
No specific concerns were detailed in the provided text, only a general statement about "The Failures that Contributed to the Deaths".
Noted
(AI summary)
NHS England acknowledges concerns about secondary healthcare in prisons, particularly staffing shortages, but focuses its response on NHS England's remit. They have engaged regional colleagues and will consider responses from other Trusts, while also highlighting national work on PFD reports. Berkshire Healthcare has continued developing the One Team model, implemented monthly audits of Community Mental Health Team caseloads, and conducted various training programs (suicide awareness, trauma-informed care). They have also improved VCSE engagement and reinforced MAPPA escalation processes. Oxford Health NHS Foundation Trust will consider introducing guidance for psychological therapy staff about recording when an individual declines treatment in prison, to include guidance that declined offers of treatment are always considered in caseload management supervision. Thames Valley Police details actions taken by both the force and Counter Terrorism Policing South-East, including improvements to intelligence dissemination, Prevent training, MAPPA procedures, and Operation Plato. A multi-agency exercise was conducted to test the effectiveness of the Operation Plato plan. Midlands Partnership NHS Foundation Trust has refreshed the psychology pathway and updated referral criteria, and is standardising practice in regard to psychological care pathways. They have also developed a pilot of the Mental Health & Wellbeing Practitioner role and provide ongoing training for staff. The Ministry of Justice outlines changes to probation and prison procedures, including enhanced risk assessment tools, improved information sharing through MAPPA, and updated training for staff. These changes aim to better manage individuals who pose a terrorism risk. The Home Office describes ongoing improvements to the Prevent programme including reviews, case assurance, and annual statistics. They are implementing improved information sharing practices and conducting assurance reviews of training and processes related to discontinuing impending prosecutions.
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.
Jane Walker
All Responded
2024-0137
13 Mar 2024
North West Wales
Alcohol, drug and medication related deaths
Other related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Paramedics are unable to administer rapid-acting analgesics like mucosal fentanyl lozenge due to controlled drug legislation, potentially delaying critical pain relief and extrication.
Noted
(AI summary)
The NHS England Task & Finish Group on Analgesia is considering recommendations from the Manchester Arena Inquiry regarding paramedics administering mucosal fentanyl lozenges. The group has been provided with a copy of the coroner's letter for reference, and any recommendations will be considered by a future government.
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. 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. 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. 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.
Steven Bowker
Partially Responded
2023-0504
2 Dec 2023
Manchester South
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The prolonged prescription and use of opiate medication pose significant dangers to patients.
Noted
(AI summary)
The Department acknowledges the concerns regarding prolonged opiate prescriptions, explains the role of clinicians and the MHRA, and highlights existing guidance and monitoring processes, including updates to product information and labeling.
Barbara Rymell
Partially Responded
2023-0482
27 Nov 2023
Somerset
Care Home Health related deaths
Concerns summary (AI summary)
Care staff with insufficient English proficiency pose a risk to vulnerable patients by hindering effective communication with emergency services, potentially delaying urgent medical attention.
Noted
(AI summary)
The Home Office expresses condolences and explains the English language requirements for various immigration routes. They will tighten requirements for care workers coming to the UK on the Health and Care visa and will keep immigration requirements under review as part of this work, but does not believe raising the level of the English language requirements for Skilled Workers would be appropriate.
Gracie Spinks
All Responded
2023-0479
27 Nov 2023
Derby and Derbyshire
Other related deaths
Concerns summary (AI summary)
Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of comprehensive and ongoing risk assessments.
Action Planned
(AI summary)
The Home Office is exploring with stakeholders where Government intervention could improve the criminal justice response to stalking and support for victims, including within the Victims and Prisoners Bill; officials will review statutory guidance on coercive and controlling behaviour and work with the NPCC to gather examples of best practice in policing stalking cases. Derbyshire Constabulary has updated training and guidance, reinforced requirements for record keeping, and reviewed policies regarding found weapons, including issuing specific policy relating to found weapons in October 2023.
Manoel Santos
Partially Responded
2023-0361
3 Oct 2023
Inner South London
State Custody related deaths
Suicide
Concerns summary (AI summary)
Delays in notifying foreign national offenders of immigration detention and inadequate access to legal advice are compounded by poor inter-agency communication and a lack of specialist prison staff for immigration matters.
Action Taken
(AI summary)
The Home Office has implemented new commissioning and handling processes and established a Strategic Improvement Operations team within FNORC to log, review, and track recommendations from internal and external investigations, ensuring risks are managed consistently. They also use a specific form called ‘Request for Risk Information’ to request an OASys assessment. These are now centrally administered by the FNO coordination hub to ensure that there is a central referral point for the Home Office. The request is then sent directly to the relevant practitioner to action, or the team if the matter is not yet allocated. An escalation process that highlights responses that have not been received within 20 days has also been introduced. Practice Plus Group has implemented weekly and fortnightly meetings between healthcare management and prison governors to improve communication between agencies. They have also clarified the established process regarding concerns for a prisoner's safety, where officers should inform a member of the healthcare team if they are presence. HMPPS has re-issued a notice to staff at HMP Belmarsh clarifying procedures for unlocking cell doors during the night state, emphasizing preservation of life takes precedence. Additionally, learning from probation-involved inquests will be disseminated across the probation service, and included as part of the Offender Management in Custody (OMiC) model of working.
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.
David Celino
All Responded
2023-0303
21 Aug 2023
West Yorkshire (Eastern)
Alcohol, drug and medication related deaths
Child Death
Concerns summary (AI summary)
Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff training for identifying drug reactions contribute to preventable deaths.
Noted
(AI summary)
Leeds City Council, via its Licensing Committee, detailed enhancements made by Festival Republic for the 2023 Leeds Festival, including improved security and stewarding, SIA-accreditation checks on security staff, enhanced staff manuals, daily briefings, and new AIR Hubs. Arrest data analysis suggests Festival Republic's drug security strategy was effective, with increased arrests and drug-related arrests in 2023. Festival Republic implemented improvements for Leeds Festival 2023, including enhanced security at gates, search operations, presence of dogs, visible messaging, and covert operations. They addressed medical facilities concerns by improving the Forward Operating Base, triage processes, ambulance resourcing, and welfare support. They also plan to consider further improvements for the 2024 festival. Festival Republic provides updated arrest statistics from West Yorkshire Police regarding drug offenses at an event. West Yorkshire Police increased measures to combat drug supply at the 2023 Leeds Festival, including a dedicated intelligence researcher, liaison with other festivals, robust searches at ingress points, increased use of drug dogs, covert operations, and a WYP officer stationed in the Festival Republic Control Room, resulting in more arrests. They will also ensure a dedicated detective inspector attends the hospital with the ill person in future. The Home Office highlights government efforts to tackle illegal drugs through police action, reducing demand, and improving treatment. It notes that organisations wishing to deliver back-of-house drug checking facilities at festivals can apply for a license.
Paul Keating
All Responded
2023-0279
25 Jul 2023
West Yorkshire (Eastern)
Other related deaths
Concerns summary (AI summary)
The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one resident's flat remaining unconnected, which likely contributed to his fire-related death.
Noted
(AI summary)
Leeds City Council acknowledges the coroner's concerns regarding a lack of legal powers to access properties for safety works without tenant consent. The council states that granting additional legal powers to landlords is a matter for central government. The Home Office acknowledges the coroner's concerns about fire risks in social housing but explains the existing regulatory framework, including the Regulatory Reform (Fire Safety) Order 2005 and the Housing Health and Safety Rating System. It highlights the role of Fire and Rescue Authorities and the Home Office's Fire Kills campaign.
Heather Findlay
All Responded
2023-0193
12 Jun 2023
Inner North London
Suicide
Concerns summary (AI summary)
Staff are unprepared for patients absconding, with policies lacking clear guidance on following or police engagement, leading to confusion and potential non-attendance by police for distressed patients.
Noted
(AI summary)
NHS England acknowledges the concerns, states that it is not the appropriate organisation to respond to many of them, but will consider the Trust's response and has been sighted on the Trust’s Patient Safety Serious Incident Review Report. It also draws attention to NHS England’s national Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme. The MPS has the Affinity Protocol in place since 2021 and will undertake work as part of the implementation of the Right Care, Right Person to ensure policies of all parties align and there is a clear understanding of definitions and terminology used. The Home Office describes the Right Care Right Person (RCRP) approach to assist police decision making. It states that the investigation of a missing person report is an operational decision for individual police forces and refers to the MPS Affinity Protocol. The Trust has updated its Missing and AWOL policy, reviewed procedures for patients leaving acute wards, and changed observation guidance. They will review their Risk Assessment policy and the Grab Pack's alignment with local policies, including seeking external expert opinion, with a 3-6 month timescale.
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)
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.
Gavin Pedleham
All Responded
2023-0005Deceased
30 Dec 2022
Surrey
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
There is a lack of regulation governing the safe storage and access of controlled drugs like Oramorph in community settings, unlike highly regulated institutional environments.
Noted
(AI summary)
The Home Office, after consulting with the Department for Health and Social Care, believes that appropriate measures are already in place to reduce the risk of accidents involving liquid morphine and has no plans to introduce additional controls. NICE believes its existing guideline [NG46] on controlled drugs: safe use and management is sufficient, including recommendations for healthcare professionals to advise patients on safe storage and appropriate use. The MHRA will work with marketing authorisation holders to update product information for Oramorph, highlighting the need for secure storage and supervision after dilution.
Jack Knapman
All Responded
2022-0405
16 Dec 2022
Northamptonshire
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Despite DNP's toxicity and planned reclassification as a poison, there's no clear government department or organisation designated to monitor and prevent its sale for human consumption, risking further deaths.
Action Taken
(AI summary)
The Home Office has laid legislation to regulate DNP as a poison under the Poisons Act 1972, restricting sales to registered pharmacists with a valid EPP license from October 2023.
Raneem Oudeh and Khaola Saleem
All Responded
2022-0352
3 Nov 2022
Birmingham and Solihull
Emergency services related deaths
Police related deaths
Concerns summary (AI summary)
Severe understaffing in the domestic abuse unit meant cases were not investigated, leaving high-risk victims vulnerable to ongoing violence and threats due to a lack of effective police action.
Noted
(AI summary)
West Midlands Police restructured the Public Protection Department in 2019, increasing staff allocated to DA investigation and replacing Domestic Abuse Teams with Adult Investigation and Adult Complex Investigation Teams; they have also established a scrutiny panel with the CPS to review decisions where no further action is taken. West Midlands Police restructured the Public Protection Department in 2019, increasing staff allocated to DA investigation and replacing Domestic Abuse Teams with Adult Investigation and Adult Complex Investigation Teams; they have also established a scrutiny panel with the CPS to review decisions where no further action is taken. The Home Office highlights the Domestic Abuse Act 2021 and the Tackling Domestic Abuse Plan, committing to assist in funding the rollout of Domestic Abuse Matters training and funding the College of Policing to develop a new module aimed at investigators of domestic abuse; they also mention the Police Uplift Programme and additional funding for West Midlands Police. The College of Policing has created a 'DA Matters' training package for police responders focusing on coercive control, delivered by DA charities, and has rolled out the Domestic Abuse Risk Assessment tool (DARA) to every force in England and Wales. West Midlands Police is publishing a revised Domestic Abuse policy with an initial response action checklist and will launch it with a tailored communication and briefing package; they have also created an improvement plan to increase the number of Domestic Violence Protection Notices and Orders. The Police and Crime Commissioner acknowledges the coroner's report and highlights ongoing efforts by West Midlands Police to address domestic abuse, while also noting resource constraints and the impact of cuts to public services.
Reginald Cauthery
All Responded
2022-0326
4 Oct 2022
Inner North London
Community health care and emergency services related deaths
Other related deaths
Product related deaths
Concerns summary (AI summary)
A vulnerable person's telecare service was not reviewed despite increased fire risk, and smoke alarms were not connected to telecare, delaying emergency fire brigade notification.
Noted
(AI summary)
The TEC Services Association (TSA) will issue guidance to certified monitoring organizations by the end of November 2022. They also plan to develop a Fire Call Handling Pathway Decision Support Tool with the support of NFCC and LFB, but anticipate it will not be available until 2024. The CQC acknowledges the concerns but states they relate to services outside their scope of regulation (fire service and telecare service) and therefore they have no powers to prevent future deaths in relation to these services. The Department of Health and Social Care has reminded local authorities to consider technology-enabled care in maintaining independence and linking preventative devices like smoke detectors. It also published an updated Adult Social Care Digital Skills Framework to support the development of digital skills across the adult social care workforce. The organisation recommends monitored smoke detectors and rapid heat detectors for elderly and vulnerable service users, referencing recommendations made with London Fire Brigade in 2003. The Home Office will share information from the case with the National Fire Chiefs Council (NFCC) and encourage them to disseminate findings and highlight the importance of linking telecare systems to smoke alarms during fire safety checks. The London Borough of Hackney will address its procedures and guidance within its 'Mosaic' system to reduce risks to vulnerable individuals, especially regarding fire safety for those with risk factors like being bed-bound and a smoker; a table detailing planned actions and timelines is attached.