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
67 resultsKatie 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.
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.
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.
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)
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. 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 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)
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.
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 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. 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.
Jessica Laverack
All Responded
2022-0344
27 Jun 2022
East Riding and Hull
Alcohol, drug and medication related deaths
Suicide
Concerns summary (AI summary)
The report identifies a need for recognition of the link between domestic abuse and suicide, lack of systems to care for vulnerable individuals not meeting 'high risk' criteria, and a lack of information sharing between agencies.
Noted
(AI summary)
The Ministry of Justice is working with the Home Office to prioritise commitments in the Tackling Domestic Abuse Plan, including investing over £230 million in tackling domestic abuse. They have also worked to improve probation staff awareness of MARAC and published a draft Victims Bill. The Home Office acknowledges the report and states that officials will provide a full response by the stated deadline. The Home Office highlights the Domestic Abuse Act 2021, its statutory guidance published in July 2022, and the cross-Government Tackling Domestic Abuse Plan published in March. The plan includes funding, model policies, training and awareness packages. The Department of Health and Social Care is working with the Home Office on the Tackling Domestic Abuse Plan and will include measures to tackle domestic abuse in the national suicide prevention strategy. Integrated care boards are required to set out how they will address the needs of victims of abuse and NHS England is developing guidance to assist them.
Ketheeswaren Kunarathnam
All Responded
2022-0030
26 Jan 2022
West London
Mental Health related deaths
Other related deaths
State Custody related deaths
Concerns summary (AI summary)
Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.
Action Taken
(AI summary)
The Home Office outlines actions taken to address concerns, including mandatory training for officials engaged in detention, focusing on best practice and vulnerability, and Self Harm Awareness Sessions run by HMPPS for front-line immigration officers in prisons. They also highlight improvements to the Adults at Risk in Immigration Detention policy and the introduction of Detention Case Progress Panels.
Mustafa Abdelkarim
All Responded
2021-0393
19 Nov 2021
Gwent
Other related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Immigration Officers receive an introduction to pursuit policy but lack specific training in pursuit procedures and decision-making during stressful pursuit situations.
Action Planned
(AI summary)
Immigration Enforcement will revise training to provide greater focus on dynamic decision making, with mandatory training for officers delivered from April 2022. Pursuit policy will be incorporated into the operational assurance framework.
Fishmongers’ Hall Inquests
All Responded
2021-0362
3 Nov 2021
London City
Other related deaths
Police related deaths
State Custody related deaths
Concerns summary (AI summary)
This document is a questionnaire for the jury, intended to determine the means and circumstances by which Jack Merritt and Saskia Jones died, focusing on identifying any errors, omissions, or circumstances that may have caused or contributed to their deaths.
Noted
(AI summary)
The Learning Together Network CIC states it cannot take steps on the recommendations as it did not employ staff or run partnerships, and will be dissolved in January 2022. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders. The Office for Students will write to all registered higher education providers in England, making them aware of the report and asking them to consider changes to their approach to risk assessment of events, programmes, and information sharing. The College of Policing acknowledges the concerns raised and states its commitment to supporting other bodies in achieving improvements in terrorist offender management. They provide broader offender management training products and guidance and will work with partners to ensure they are updated. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders and now feed this into the MAPPA panel. The government is legislating a new power of personal search through the Police, Crime, Sentencing and Courts Bill, allowing police to stop and search terrorist offenders on license under certain circumstances. The Secretary of State will engage with the higher education sector to encourage action to implement the recommendations and officials have spoken to the Office for Students to encourage them to take action. Officials have also engaged with HMPPS to design a new framework to define roles and responsibilities of prisons and higher education providers. The University of Cambridge has created a new policy and guidance for staff and students working with people who have offended, and the Institute of Criminology has developed a Risk Assessment Form for all activities. The University has also stopped delivering the Learning Together programme. MoJ accepted recommendations relating to the Fishmongers' Hall attack. A new framework is being designed for Learning Together activity in prisons. Statutory guidance on MAPPA meetings will be strengthened, and the Police, Crime, Sentencing and Courts Bill includes a power for police to search terrorist offenders on licence.
Hamish Howitt
All Responded
2021-0320
23 Sep 2021
West Sussex
Police related deaths
Concerns summary (AI summary)
Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading to a missed traumatic brain injury. Training needs to mandate hospital referral for such individuals.
Action Planned
(AI summary)
The Home Office has consulted with the College of Policing and NPCC, and the College will address the coroner's concerns about police first aid training through its formal governance routes. Avon and Somerset Constabulary circulated a memorandum to all officers with guidance on head injury risk, sent guidance to first aid trainers, and added guidance to first aid training modules. They also incorporated training on head injury response into Taser, Public Safety, and Public Order training, all completed in October 2021. The College of Policing and NPCC will raise concerns about alcohol's impact and head injury assessment in first aid training at the next First Aid Forum meeting in December to assess feasibility of addressing them within the FALP licence scope. The College is also reviewing high-level learning outcomes within the FALP to emphasize life-saving elements, considering acute alcohol intoxication, intentional overdoses, and extending head injury learning to Module 2.
Emiel Malinski
All Responded
2021-0198
10 Jun 2021
Manchester South
Other related deaths
Product related deaths
Suicide
Concerns summary (AI summary)
Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, ammunition control, and first aid provisions.
Action Planned
(AI summary)
The Home Office is reviewing the firearms licensing exemption for miniature rifle ranges, prompted by the incident. They conducted a public consultation on tightening controls and will consider the responses before deciding on further measures.
Chelsie Greatorex
All Responded
2021-0018
11 Nov 2020
East London
Alcohol, drug and medication related deaths
Police related deaths
Concerns summary (AI summary)
The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.
Action Planned
(AI summary)
The Home Office is conducting a review of the criminal justice response to rape, consulting on a new Victims’ Law, and investing in rape support centers and Independent Sexual Violence Advisers (ISVAs). The MPS is developing a Suicide Prevention Policy Document and Toolkit, including information on suicide prevention, support services, risk indicators, contacts and best practice, with a draft expected by the end of December 2020; they are also improving training and guidance for officers and staff, including an investigative standards document and meeting with other forces to share good practice.
London Bridge & Borough Market Terror Attack
All Responded
2019-0332
1 Nov 2019
London Inner (South)
Other related deaths
Concerns summary (AI summary)
The coroner identified matters of concern which are being reported to the addressees, after taking into account submissions from the bereaved.
Noted
(AI summary)
The City of London Police (CoLP) are working with partner agencies to test interoperability of communications and enhance training scenarios, including a 7 day live trial in February 2020 to station staff in the MPS control room, with a review in Autumn 2020, and are engaging with the MPS in ICCS and CAD upgrade projects, planning an interim solution until upgrades are complete. The BVRLA has worked with the DfT and law enforcement to prevent the use of rental vehicles in terrorist attacks, providing training, guidance and engagement opportunities to members, and has included additional criteria within member audits from Jan 2020 to monitor awareness, training and compliance against the Rental Vehicle Security Scheme. The LAS is planning a live trial for seven days in February 2020, with LAS and LFB staff based in the MPS control room, and will analyze the outcome and consider a recommendation for approval by Autumn 2020; it is also working with its emergency service partners and increased visibility of the HART and TRU teams. The Home Office acknowledges the coroner's concerns and provides context, stating that the issues raised are technical and will be considered by the police in collaboration with the Emergency Services Network programme. It also mentions ongoing work led by the National Police Chiefs' Council. The MPS is trialing a "London Emergency Services Contact Centre" with representatives from the LFB and LAS deployed within the Specialist Operations Room, with a table top exercise followed by a real-life 7-day trial planned for early 2020.
Kay Martin
All Responded
2019-0262
27 Aug 2019
Sunderland
Other related deaths
Concerns summary (AI summary)
A perpetrator of domestic abuse was not subject to any police bail conditions or restrictions for over a month, leaving the victim unprotected and at severe risk.
Action Taken
(AI summary)
The Home Office has coordinated the implementation of several actions, including the NPCC publishing operational guidance on domestic abuse and high harm cases. HMICFRS are also inspecting all forces on their use of pre-charge bail. The government also introduced the Domestic Abuse Bill.
Karen Burns
All Responded
2019-0273
12 Aug 2019
Birmingham and Solihull
Emergency services related deaths
Suicide
Concerns summary (AI summary)
Police resources are critically insufficient, leading to incorrect call grading and leaving numerous P2 and P3 calls unanswered due to high demand for priority incidents.
Action Planned
(AI summary)
West Midlands Police has reviewed its call handling procedures, including providing additional training, instituting a "Log Closure Doctrine", reducing the number of logs held by each dispatcher, changing the dispatch model and shift patterns. They are also developing a new Command and Control platform to support call handlers. The Home Office will ask officials to contact West Midlands Police to identify if any remedial or additional measures need to be put in place to ensure calls are handled appropriately. The Home Office states that public safety remains the government's number one priority and cites increased police funding and plans to increase officer numbers. West Midlands Police accepted that the 101 call was incorrectly graded and has discussed this with the staff member in question, and has promised additional training for all control room staff. They have also instituted a "Log Closure Doctrine", reduced the number of logs held by each dispatcher, changed the dispatch model and shift patterns, and are developing a new Command and Control platform.