College of Policing

PFD Addressee
Reports: 48 Earliest: Jan 2014 Latest: 30 Mar 2026

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

PFD Reports
31 results
Oliver Roberts
All Responded
2026-0184 30 Mar 2026 Dorset
Emergency services related deaths Mental Health related deaths
Concerns summary (AI summary) There is a lack of practical guidance for police officers on applying their powers to obtain communications data under the Investigatory Powers Act 2016, especially regarding urgent Grade 2 requests.
Noted (AI summary) • The College of Policing provides eLearning training for investigators on the national ‘College Learn’ platform. • These learning packages “Introduction to Communications Data,” sit within the Digital Media Investigators (DMI) modules. • This training is available for all police officers and staff across England and Wales.
Katie Overd
All Responded
2025-0517 15 Oct 2025 Manchester North
Accident at Work and Health and Safety related deaths Community health care and emergency services related deaths
Concerns summary (AI summary) A lack of proactive public communication about the "Right Care Right Person" policy risks the public delaying seeking emergency assistance, misunderstanding response times.
Noted (AI summary) The RCRP Strategic Partnership Board acknowledges the concerns and explains that Right Care: Right Person (RC:RP) is an internal process for directing calls to the most appropriate service. They state that they will discuss call transfer and external communications with partner agencies. The Deputy Mayor will further consider with relevant agencies the options that will best meet the needs of the public, recognising that NWAS would not have powers of entry and would have to call GMFRS in the described scenario. They wish to take the time to consider the various options that will best meet the needs of the public. The College of Policing explains that Right Care Right Person (RCRP) focuses on internal triage processes between agencies, not on directing the public to specific services when calling for emergency assistance. They state they will continue to monitor emerging themes and risks with partner agencies.
Ann Laskowsky
All Responded
2025-0502 7 Oct 2025 West Yorkshire Western
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Inadequate first aid training for police officers in assessing patient conditions and poor awareness of a dedicated medical advice line led to a failure to recognise severe medical needs.
Action Planned (AI summary) The College of Policing will formally raise the case of Ms. Laskowsky at the next meeting of the NPCC First Aid Forum on 4 December 2025, to ensure that national learning is disseminated and embedded. They will produce national learning summaries and practice notes, update Authorised Professional Practice (APP) and training materials, and engage with force training leads and clinical governance advisors. West Yorkshire Police has posted an intranet briefing reminding staff about the YAS Partner Triage Line, included details in operational briefings, updated training and guidance material, and tasked the Right Care Right Person team with monitoring its usage. First Aid trainers will also remind officers of the YAS Partner Triage Line during annual training. The NPCC has recommended that West Yorkshire Police implement clinical governance arrangements consistent with NPCC guidance and has offered support in implementing this. They confirm that assessment of breathing and responsiveness levels are mandated in Learning Outcome 1.3. of Police First Aid Learning Programme.
Kaine Fletcher
All Responded
2025-0383 25 Jul 2025 Nottinghamshire
Emergency services related deaths Mental Health related deaths Police related deaths
Concerns summary (AI summary) Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite rejection by psychiatric bodies.
Action Planned (AI summary) The Trust is providing training for all acute facing mental health staff on ABD in August and October 2025 and signs and symptoms, clinical assessment and escalation processes are now included within the Trust Fundamentals of Care training for mental health staff. The Trust has updated Internal Working Instructions and established a strategy group and works across the system to strategically plan access and treatment for people with dual diagnosis needs. The NPCC clinical panel is reviewing existing guidance developed by the Faculty of Legal and Forensic Medicine regarding Acute Behavioural Disturbance. The College of Policing provides the Mental Health Approved Professional Practice (APP) to assist forces in developing their policies and responses to incidents relating to people with mental ill health. The Department and NHS England are finalising the Co-occurring Mental Health and Substance Use Delivery framework to improve delivery of integrated, person-centred care across drug and alcohol treatment and mental health services.
Elaine Tarbuck
All Responded
2025-0342 7 Jul 2025 Manchester West
Police related deaths
Concerns summary (AI summary) The "Right Care, Right Person" policy led to misclassification of a "concern for welfare" call, causing significant delays in emergency services forcing entry and resulting in inappropriate first responder attendance.
Action Planned (AI summary) GMP are implementing measures to mitigate risks around the evaluation and assessment of concern for welfare calls, including mandatory briefings, enhanced training, revision of risk assessment tools, and a review of the escalation process, overseen by the FCCO Senior Leadership Team. NWAS and GMP have implemented collaborative measures including targeted training, review of incident logs, visits by GMP supervisors to the NWAS control room, and ongoing meetings between leadership teams, to address the issue of calls being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare. The College of Policing will highlight the issue of forced entry at the next meeting of the National RCRP Tactical Delivery Board to ensure national learning is shared; the College continues to monitor the impact of RCRP and is committed to refining the guidance based on operational feedback and case reviews.
Muhammad Qasim
All Responded
2025-0446 25 Jun 2025 Birmingham and Solihull
Alcohol, drug and medication related deaths Police related deaths
Concerns summary (AI summary) Conflicting interpretations of "spontaneous pursuit" guidance and inadequate police training pose risks. Furthermore, the IOPC's investigation priorities led to the absence of a crucial forensic collision report.
Action Planned (AI summary) The IOPC will update internal guidance to investigators about securing full Forensic Collision Investigation Reports, including early contact with the Coroner, and will update internal written guidance within six weeks. The College of Policing will amend the Police Pursuit APP to replace 'spontaneous pursuit' with clearer guidance aligned with the National Decision Model, aiming to publish revised guidance by December 2025.
Amy Levy
All Responded
2025-0289 10 Jun 2025 Avon
Emergency services related deaths Mental Health related deaths Police related deaths
Concerns summary (AI summary) Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying location and aid for a critically ill individual.
Action Planned (AI summary) The College of Policing will support national sharing of best practice on voicemail protocols, update the national Contact Management Curriculum to address voicemail guidance in emergencies, and ensure forces align training programs by March 2026. Surrey Police has updated its procedure to include guidance on leaving voicemails, is incorporating this guidance into training for new recruits and detectives, and will evaluate the effectiveness of the training. Avon and Somerset Constabulary will introduce a dedicated force policy and procedure for 'suicidal' cases, update the Concern for Welfare policy to mandate leaving voicemails or text messages, and provide training to all communications staff on the updated policies.
Marta Vento
All Responded
2025-0137 11 Mar 2025 Dorset
Mental Health related deaths Other related deaths
Concerns summary (AI summary) No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. Additionally, national guidance is lacking for ensuring continuity of care for released prisoners with mental health needs.
Action Planned (AI summary) NHS England required ICBs to review community mental health services by September 2024. NHS England understands that NHS Dorset would actively support the expansion of this work to support sharing of mental health care plans. The DCR Partnership is looking to have the capability to share information with others using the NRL from March 2026 onwards. The College of Policing acknowledges concerns about the lack of a bespoke risk assessment tool for violence in MOSOVO units. They will consult with the NPCC Lead for MOSOVO and relevant subject matter experts to improve guidance and direction and will liaise with Dorset Constabulary to ensure they are fully sighted on current guidance. The NPCC will request the College of Policing to review APP and training material to highlight violence risk assessment more strongly within risk management plans; they have also reiterated a request for a full review of the ARMS process. NHS Dorset supported a learning event led by NHSE regarding mental health needs, and will work with SWAST to enable access to the Dorset Care Record. They have also opened a risk on the system risk register to scrutinise the accessibility of information across system partners. HM Prison and Probation Service acknowledges concerns about sharing risk information from prison with sentencing courts and highlights the establishment of immediate release pathfinders in three prisons to develop multi-agency approaches. They will task the Safety Group in HMPPS to consider this specific area when reviewing the Prison Safety Policy Framework later in 2025-26.
Robert Evans
All Responded
2025-0120 4 Mar 2025 Liverpool and Wirral
Police related deaths
Concerns summary (AI summary) A lack of guidance and power prevents police officers from ensuring medical attention for individuals suspected of swallowing drugs during a street search if not arrested, creating a critical gap in care compared to those in custody.
Noted (AI summary) The NPCC Stop & Search portfolio will review the Regulation 28 document and work to ensure officers are equipped to resolve incidents such as these; they will work with other portfolios and stakeholders to provide the necessary training and guidance to ensure officers have a refreshed knowledge of all policing powers available to them. The College of Policing asserts that its Authorised Professional Practice (APP) on Detention and Custody adequately addresses concerns about medical attention for individuals suspected of swallowing drugs, pointing to existing guidance on immediate medical response, arrest procedures, risk assessment, and information sharing.
Anugrah Abraham
All Responded
2025-0024 14 Jan 2025 Manchester North
Police related deaths Suicide
Concerns summary (AI summary) Police occupational health lacks specialist mental health nurses and post-death investigation for learning. Protocols are unclear for officers disclosing suicidal thoughts, and student officer training causes stress without adequate progress tracking.
Action Planned (AI summary) West Yorkshire Police has reflected on the events, and has already taken or is planning to take the following actions: The OH answerphone message should include advice for the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, Discussions between the clinical team regarding risk should be documented, Frequency of suicidal ideation should be recorded, Protective factors should be recorded, the OH page should include the National Police Wellbeing Service ‘Oscar Kilo’ Crisis line number, contact Force Legal Services to provide inquest feedback, the service level agreement target is to be abandoned as unrealistic, Introduction of 90mins appointments, and Escalation to Force Medical Advisor for student officers referred due to their mental health. The College of Policing will review APP on suicide prevention to incorporate Anugrah Abraham's case and will also create a central repository of information on suicide prevention. They will also ensure the sharing of information about concerns with performance and any associated processes that are commenced will be referenced.
Matthew Brierley
All Responded
2025-0008 8 Jan 2025 Cumbria
Police related deaths Suicide
Concerns summary (AI summary) Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support fail to address their elevated risk.
Noted (AI summary) The College of Policing outlines existing guidance and practitioner advice for officers and staff regarding suspects of child sexual exploitation and risk assessment processes following release from custody, noting Mr. Brierley declined support offered. The Home Office acknowledges the report and expresses condolences, notes the relevant guidance provided by the College of Policing, and states that a review concluded appropriate support was provided to Mr. Brierley by Border Force. The Ministry of Justice believes the report should have been directed to the Home Secretary, as it relates to police investigative procedures, bail conditions, and Border Force (Home Office) matters. The NPCC is undertaking research to identify commonalities in post-custody suicides to establish a post-release risk assessment process and mandatory referral to support agencies, and has shared the PFD report with all UK custody leads with recommendations for investigative strategies.
Chad Allford
All Responded
2024-0585 25 Oct 2024 Derby and Derbyshire
Alcohol, drug and medication related deaths Police related deaths
Concerns summary (AI summary) Police officers lacked crucial training and guidance on responding to drug concealment in the mouth, leading to unsafe interventions and failure to warn suspects of life-threatening choking risks.
Action Planned (AI summary) Derbyshire Constabulary has designed and implemented a lesson plan covering concealment of items in a subject’s mouth and mandated that safety training includes a scenario covering this topic. They have also contacted the College of Policing to inform them of the concerns raised. The College of Policing is revising the Personal Safety Manual to include guidance on informing a subject about the risk to their life when swallowing drugs. In the interim, communication will be sent nationally to advise forces of this recommendation.
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.
Kevin Cashin
All Responded
2024-0345 21 Jun 2024 Manchester North
Other related deaths
Concerns summary (AI summary) Police officers lacked understanding of agonal breathing and how to recognize early cardiac arrest, causing a significant delay in intervention. Their first aid training curriculum is insufficient in these critical areas.
Action Taken (AI summary) The College of Policing has updated its First Aid Learning Programme (FALP) to include specific reference to recognising agonal gasps and has developed new Public and Personal Safety Training (PPST) for forces to implement.
Tcherno Bari
All Responded
2024-0296 3 Jun 2024 Birmingham and Solihull
Suicide
Concerns summary (AI summary) Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor information sharing, lack of staff awareness regarding procedures, and ineffective challenge processes between mental health services and police.
Noted (AI summary) This is an appendix to the BSMHFT response, specifically the Trust's Missing Patient Policy. It outlines the actions to be taken when a patient is missing or AWOL, relating to Informal inpatients, Detained patients who are AWOL and patients in the community, read in line with National Partnership Agreement: Right Care, Right Person (RCRP). NHS England will issue guidance to health systems on reviewing Serious Incident investigations to ensure lessons are learned and changes agreed upon. A national oversight group has been set up to review concerns and issues with RCRP, and this group feeds into a ministerial working group. West Midlands Police (WMP) has provided additional RCRP training to call handlers and officers and produced an exhibit detailing the escalation point of contact for partner agencies to West Midlands Police. WMP has also emphasised the need for officers to gather information from all sources and record the rationale for decisions made, particularly regarding vulnerable people. The National Police Chiefs' Council clarifies the aims of Right Care Right Person (RCRP) and states that it appears the situation concerning Mr. Bari was treated as a missing person case from the outset by West Midlands Police, and therefore RCRP principles would not apply. BSMHFT has updated their Missing Persons Policy in line with Right Care Right Person (RCRP) changes, incorporating feedback from the inquest, and a new Executive Director of Quality and Safety/Chief Nursing Officer will be accountable for the policy. The updated policy includes a revised Appendix C form focusing on the reasoning for critical concern and requires formal notification from the police with their decision and reasoning if they have decided not to deploy immediately. The APCC provides background on its role and the role of PCCs in local policing, noting that it has developed guidance for members on the Right Care, Right Person approach. It states that the NPCC is reviewing the report to identify relevant national learning. The Department of Health and Social Care acknowledges the concerns raised, noting that local policies should align with the Mental Health Act Code of Practice and that local partners should reassess joint processes on risk assessment, communication, and escalation. They emphasise the importance of collaboration between policing and health partners. The College of Policing is undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process. They are also working to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. The Home Office outlines the rationale and purpose of the National Partnership Agreement (NPA) and notes that decisions on implementation of Right Care Right Person (RCRP) are for individual Chief Constables. They state that missing persons cases are outside the scope of RCRP and existing police procedures should continue to operate.
Samuel Curless
All Responded
2024-0089 19 Feb 2024 Manchester South
Suicide
Concerns summary (AI summary) Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary first aid refresher training for life-preservation.
Noted (AI summary) The College of Policing updated the First Aid Learning Programme (FALP) in 2020, increasing recommended training time for both refresher and initial training for public-facing officers, now including basic life support and airway techniques. Annual refresher training is a core requirement of the FALP license. Response is a placeholder document.
Lee Bowman
All Responded
2024-0109 8 Nov 2023 South Yorkshire East
Other related deaths
Concerns summary (AI summary) Police made significant assumptions about a missing person, focusing on past addiction rather than prioritizing crucial family information regarding his current mental state and usual daily contact.
Action Planned (AI summary) The College of Policing will update its Missing Persons APP to alert police officers and staff to the need to avoid imprecise terms such as 'chaotic lifestyle' and instead set out clearly what matters and issues have been identified that have a bearing on the assessment of risk.
Nicholas Ledger
All Responded
2023-0314 31 Aug 2023 Inner North London
Suicide
Concerns summary (AI summary) The report refers to evidence from the investigating officer and an investigator from the Metropolitan Police’s Directorate of Professional Standards.
Action Planned (AI summary) The College of Policing outlines that updated statutory guidance, e-learning, and knowledge products have been released regarding pre-charge bail, and specific guidance on safeguarding those subject to RUI has been issued. It also highlights existing guidance on risk assessments for those released from custody, and custody training aimed at reducing the risks of post detention suicides. The Metropolitan Police Service plans to implement a new policy by April 2024 requiring a risk assessment to be completed by the OIC no earlier than fourteen days prior to issuing the PCR for suspects charged with a recordable offence. This assessment will be supervised by line management and form part of the PCR process.
Andre Moura
All Responded
2023-0348 3 Jul 2023 Manchester South
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Police training on Acute Behaviour Disturbance (ABD) was ineffective in real-life recognition, lacked formal testing, failed to embed the safety officer role, and relied on subjective assessments instead of objective AVPU checks.
Action Planned (AI summary) The College of Policing has revised its First Aid Learning Programme (FALP) and the new Public and Personal Safety Training (PPST) training implementation went live in 2023, and the revised ABD training package will be published mid-September 2023. The NPCC is revising the Body Worn Video (BWV) guidance to include that BWV should be left running during periods of prisoner transport. This guidance will be published in October.
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. Dorset Police will provide additional training to further enhance the quality of FEO investigations through the national Professionalising Investigations Programme at level 1 over the next 18 months. A presentation of the key learning from the incident to a CPD event for all Firearms Licensing Managers will be delivered in May 2023. Avon and Somerset Police completed a review and found no cases where approval should not have been granted. They are reviewing their training requirements and will be implementing additional mandatory training for all staff, including PiP Level 1 training. North Wales Police will review cases over the last 5 years where applications have been refused or licenses revoked, but where subsequent applications or appeals resulted in a grant, aiming to complete this by 2nd October 2023. They highlight existing processes for quality control and previous review work undertaken. South Wales Police is reviewing approximately 1300 records where certificate holders were subject to a suitability review to determine if certificates were seized, surrendered, revoked or refused and subsequently approved. They are also working with Gwent Police to align processes, conduct peer reviews, and arrange an annual peer assessment of firearms licensing approvals. North Yorkshire Police has established a Gold group to oversee their response and commenced a review of records relating to certificates seized, refused, revoked, or surrendered and then subsequently approved over the last 5 years, aiming for completion by October 2nd. They are developing an Action Plan to manage the response and record decisions. Lancashire Constabulary has commenced a review of all certificates refused, revoked, seized or surrendered and then subsequently approved over the past 5 years, against the March 2023 Home Office Statutory Guidance, expected to be completed by the end of October 2023. They have also introduced process and scrutiny changes, including a dedicated Chief Inspector responsible for Firearms Licensing and training for staff. Greater Manchester Police will review between 70-80 cases at Senior Officer Panel, for the five-year period, where certificates have been seized, refused, revoked or surrendered and then subsequently approved and guns returned. The Firearms Licensing Manager and Detective Sergeant will attend a two-day continuous professional development (CPD) event delivered by Chief Constable Tedds at the College of Policing on the 18th and 19th May 2023. The College of Policing is developing significantly revised and updated Authorised Professional Practice (APP) on firearms licensing. This will underpin the development of a national training course for staff involved in firearms licensing. Surrey Police will review firearms and shotgun licensing prioritizing cases where firearms have been seized or surrendered and then returned; it will review most recent decisions first and applications that have been refused or licences revoked but where subsequent applications/appeals resulted in a grant. An additional resource has been seconded into the department to expedite this review and provide a full report by 2nd October 2023. 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. 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. 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. 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. 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. 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. City of London Police acknowledge the findings and learnings from the Keyham Inquest and will review their SOP to ensure procedures for Application / Annual Renewal / Return meet or exceed common national standards, including robust checks across medical, crime recording and Risk Assessment. Risk assessment training and CPD training for all licensing team will be implemented on an annual cycle. The 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. 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. 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 Metropolitan Police expresses condolences and describes existing processes for reviewing firearms licensing decisions, including reviews conducted in August 2021, and states they are contributing to national discussions on firearms licensing training. They explain the process used to identify cases for review following the Home Secretary's request. Leicestershire Police will review cases from April 2023 for the past 5 years where certificates were seized, refused, revoked or surrendered and then subsequently approved, prioritizing cases where firearms were seized or surrendered. The review will be conducted by individuals independent from the original decision makers and findings will be reported to the strategic lead for Firearms Licensing. Staffordshire Police (and West Midlands Police, as part of a collaborated service) detail existing training for staff, including the National Triage Firearms Classification Course and Police National Decision Model training. They also refer to the review of certificates seized, refused, revoked or surrendered and subsequently approved. The Home Office is allocating £500,000 to the College of Policing to develop accredited training for firearms licensing staff. They will consult on mandating this training and are working to address health information sharing, in consultation with medical bodies. Thames Valley Police will review seized and returned guns over a 5-year period, grants that have been revoked/refused/surrendered, and applications refused/revoked but subsequently granted via appeal. The aim is to complete these stages by 2 October 2023. Devon and Cornwall Police completed a review of 611 license holders identified as meeting the criteria of having certificates seized, refused, revoked or surrendered and then subsequently approved between May 2018 and December 2019. Eleven of these cases identified internal processes that did not meet expected standards, but no ongoing risks were identified. 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. 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. 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. 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.
Gaia Pope-Sutherland
All Responded
2022-0222 21 Jul 2022 Dorset
Mental Health related deaths
Concerns summary (AI summary) Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and complex mental health conditions pose significant risks.
Noted (AI summary) NHS Dorset will undertake a review of nursing resources in epilepsy care locally, encompassing primary and secondary care for adults and children, and interaction with other specialities. The Regulation 28 Report will be shared and reviewed with NHS partners at the Pan Dorset Mortality Group. BCP Council's AMHP service uses the Mental Health Act 1983 and Code of Practice, monitored through a Quality Assurance Framework, to inform practice. They are actively engaging with Dorset Healthcare Trust to amend the Pan-Dorset Standard Operating Procedure and discussing with AMHPs how to succinctly share information with GPs. The Integrated Care Board (ICB) are carrying out an 8 week review of the entire Epilepsy and Neurology service which started on 11 August 2022. Dorset Council has completed an internal review of its AMHP pathways and recording systems to ensure adherence to the Mental Health Act Code of Practice, focusing on information sharing. The AMHP service managers will ensure review of records before assessment and there is a new mandatory field to notify the allocated social care practitioner of any Mental Health Act assessment. The trust outlines multiple planned actions, including updating policies to address sexual harassment/assaults on inpatient units, reviewing patient observation practices, improving documentation of rationale for observation levels, reviewing guidance on informal patient status, ensuring comprehensive discharge summaries are sent to GPs after Mental Health Act assessments. Dorset Police supports sharing learning about life-threatening illnesses with the College of Policing and has offered to support national training. They have implemented changes to the POLSA/LPSM process, directed staff to use Niche for logging decisions, and are including a session on log keeping in Vulnerability 4 training; revised processes are in place to monitor training activity. The College of Policing believes their current approach to vulnerability training, which focuses on risk management and information gathering, is appropriate. They argue that the complexity and variability of medical conditions make specific training impractical for non-medical personnel. The Trust has introduced a Standard Operating Procedure in May 2022 which covers the provision of information following Mental Health Act assessments. The Trust has updated its Safeguarding policy to highlight the response needed when an adult discloses they have experienced sexual abuse, with two appendix documents added to the policy setting out further details. The Royal College of Psychiatrists acknowledges the lack of effective communication between neurology and mental health services. They highlight workforce issues in neuropsychiatry and support the development of integrated services in neuroscience centers in ICSs. The Association of British Neurologists will communicate suggested actions to improve communication between psychiatry and neurology teams, such as copying communications to the treating neurologist and informing neurologists of psychiatric admissions. They will also discuss these issues with the President of the Royal College of Psychiatrists.
Trevor Smith
All Responded
2021-0387 17 Nov 2021 Birmingham and Solihull
Other related deaths Police related deaths
Concerns summary (AI summary) Critical mental health information from MARAC was not accurately recorded or cascaded to police, leading to officers being unaware of the deceased's EMD status. There was also confusion and a lack of coordination during CPR efforts.
Action Planned (AI summary) The NPCC First Aid Forum will formally raise the issue of establishing a first aid (CPR) coordinator at its next meeting. The College of Policing will send out a national circular to raise awareness of the Coroner's concerns so that forces can consider a coordinator role in appropriate circumstances while the associated national guidance and training is considered. West Midlands Police have updated team briefing sheets to include reference to the CPR coordinator role and updated the Medical Plan to include direction regarding the coordination of care. All Strategic and Tactical Firearms Commanders (S&TFCs), Operational Firearms Commanders (OFCs), Firearms Tactical Advisers (FTAs) and all Authorised Firearms Officers (AFOs) are aware of this recommendation.
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) 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 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. 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. 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. 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.
Richard Boateng
All Responded
2021-0335 28 Sep 2021 South London
Community health care and emergency services related deaths Emergency services related deaths Police related deaths
Concerns summary (AI summary) Untrained non-clinicians are triaging urgent GP calls without guidance, ambulance service protocols for inter-agency information sharing are unclear, and police lack practical guidance for safely conveying patients in emergencies.
Noted (AI summary) The College of Policing acknowledges the concerns and refers to existing APP guidance on dynamic risk assessment. The NPCC will discuss ambulance availability with colleagues and the NPCC First Aid Forum will consider practical advice to forces. The London Ambulance Service has issued staff bulletins for frontline and control room staff detailing actions for 'no trace' calls, and is updating policies OP14 and OP23 to include a step-by-step process. Policy OP14 is expected to be finalised by the end of 2021, and OP23 in early 2022. NHS England details existing guidance, clinical safety officer forums, and hazard logs for digital triage. They also highlight that practices should not rely on online access for all clinical triage.