Police investigation management
210 items
2 sources
Risk of replication of past management failures in police investigations due to absence of systems ensuring compliance.
Cross-Source Insight
Police investigation management has been flagged across 2 independent accountability sources:
102 inquiry recs
108 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (102)
ANG-1 — Specialist policy on investigating indecent exposure
Recommendation: At the earliest opportunity, and by September 2024 at the latest, police forces should ensure that they have a specialist policy on investigating all sexual offences, including so-called 'non-contact' offences, such as indecent exposure.
Gov response: Home Secretary James Cleverly said: "The act of pure evil committed against Sarah shocked the nation to its core. My heart goes out to Sarah's family and to all the brave victims who came forward …
Accepted
In progress
ANG-2 — Improve guidance and training on indecent exposure
Recommendation: By December 2024, the College of Policing, in collaboration with the National Police Chiefs' Council, should improve guidance and training on indecent exposure, in order to improve the quality of investigations and management of indecent exposure cases. In particular, the …
Gov response: Home Secretary James Cleverly said: "The act of pure evil committed against Sarah shocked the nation to its core. My heart goes out to Sarah's family and to all the brave victims who came forward …
Accepted
In progress
ANG-23 — Police prioritisation of prevention
Recommendation: Immediately, Chief Constables and Police and Crime Commissioners should ensure that the prevention of sexually motivated crimes against women in public spaces is an essential part of: (i) their violence against women and girls plans; and (ii) the Police and …
Gov response: Parliamentary Under-Secretary of State Jess Phillips made a written statement to Parliament (HCWS1122) on 2 December 2025 accepting all 13 Part 2 recommendations. The government announced £13.1 million in funding to deliver a coordinated approach …
Accepted
ANG-24 — Implementation of Operation Soteria
Recommendation: By March 2026, the Home Office, working with the National Police Chiefs' Council, and the National Centre for Violence Against Women and Girls and Public Protection, should agree plans for the full, consistent and sustainable implementation of Operation Soteria across …
Gov response: Parliamentary Under-Secretary of State Jess Phillips made a written statement to Parliament (HCWS1122) on 2 December 2025 accepting all 13 Part 2 recommendations. The government announced £13.1 million in funding to deliver a coordinated approach …
Accepted
ANG-26 — Improved mechanism for converting initiatives from local to national
Recommendation: By March 2026, the College of Policing, working with the National Police Chiefs' Council, the Home Office, HMICFRS, and the National Centre for VAWG, should ensure that there are improved mechanisms in place to identify, test and roll out promising …
Gov response: Parliamentary Under-Secretary of State Jess Phillips made a written statement to Parliament (HCWS1122) on 2 December 2025 accepting all 13 Part 2 recommendations. The government announced £13.1 million in funding to deliver a coordinated approach …
Accepted
ANG-27 — Perpetrator focus and interventions
Recommendation: Immediately, the Home Office, in conjunction with the Ministry of Justice, the Department for Transport, and national and local policing organisations, should prioritise prevention activity targeting the perpetrators of sexually motivated crimes against women in public spaces. This should include: …
Gov response: Parliamentary Under-Secretary of State Jess Phillips made a written statement to Parliament (HCWS1122) on 2 December 2025 accepting all 13 Part 2 recommendations. The government announced £13.1 million in funding to deliver a coordinated approach …
Accepted
ANG-28 — Improvement of the investigation of sexually motivated crimes
Recommendation: By March 2026, the College of Policing and the National Centre for Violence Against Women and Girls and Public Protection, working with the National Police Chiefs' Council and the Crown Prosecution Service, should create a consistent and clear standard for …
Gov response: Parliamentary Under-Secretary of State Jess Phillips made a written statement to Parliament (HCWS1122) on 2 December 2025 accepting all 13 Part 2 recommendations. The government announced £13.1 million in funding to deliver a coordinated approach …
Accepted
ANG-29 — Government prioritisation of prevention
Recommendation: Immediately, the Government should take action to make it clearer that preventing sexually motivated offences against women in public is an essential part of tackling violence against women and girls. This should include: a. ensuring this Report and the prevention …
Gov response: Parliamentary Under-Secretary of State Jess Phillips made a written statement to Parliament (HCWS1122) on 2 December 2025 accepting all 13 Part 2 recommendations. The government announced £13.1 million in funding to deliver a coordinated approach …
Accepted
ANG-3 — Fundamental review of masturbatory indecent exposure treatment
Recommendation: With immediate effect, the Home Office, Ministry of Justice, College of Policing and National Police Chiefs' Council should work together to conduct a fundamental review of the way masturbatory indecent exposure is treated within the criminal justice system. The review …
Gov response: Home Secretary James Cleverly said: "The act of pure evil committed against Sarah shocked the nation to its core. My heart goes out to Sarah's family and to all the brave victims who came forward …
Accepted
In progress
ANG-4 — Research link between indecent exposure and contact offending
Recommendation: With immediate effect, the Home Office, in collaboration with the College of Policing, should commission research to establish if there is an evidence-based link between active masturbatory indecent exposure and subsequent contact offending. Where relevant, findings should then be used …
Gov response: Home Secretary James Cleverly said: "The act of pure evil committed against Sarah shocked the nation to its core. My heart goes out to Sarah's family and to all the brave victims who came forward …
Accepted
In progress
ANG-5 — Public campaign on indecent exposure criminality
Recommendation: By March 2025, the Home Office, together with the National Police Chiefs' Council, should launch a public campaign to: a. raise awareness about the illegality/criminality and legal consequences of any type of indecent exposure and boost the confidence of victims …
Gov response: Home Secretary James Cleverly said: "The act of pure evil committed against Sarah shocked the nation to its core. My heart goes out to Sarah's family and to all the brave victims who came forward …
Accepted
In progress
ANG-6 — Review sexual offence allegations against serving officers
Recommendation: By September 2024, the National Police Chiefs' Council, in collaboration with all force vetting units, and building on the results of the recent data-washing exercise, should conduct a review of the circumstances of all allegations of indecent exposure and other …
Gov response: Home Secretary James Cleverly said: "The act of pure evil committed against Sarah shocked the nation to its core. My heart goes out to Sarah's family and to all the brave victims who came forward …
Accepted
In progress
R10 — Information management standards
Recommendation: The Code of Practice must set out the standards to be met in terms of systems (including IT), accountability, training, resources and audit. These standards should be capable of being monitored both within police forces and by HMIC and should …
Gov response: The Home Secretary made a statement to Parliament on 22 June 2004, the day the Bichard Inquiry Report was published, accepting all 31 recommendations in full. The government stated it was "in principle, accepting Sir …
Accepted
Delivered
R11 — Sexual offences intelligence retention
Recommendation: The Code of Practice should have particular regard to the factors to be considered when reviewing the retention or deletion of intelligence in cases of sexual offences.
Gov response: The Home Secretary made a statement to Parliament on 22 June 2004, the day the Bichard Inquiry Report was published, accepting all 31 recommendations in full. The government stated it was "in principle, accepting Sir …
Accepted
Delivered
3 — Limit cell occupancy to maximum two people
Recommendation: The Home Office must ensure that a maximum of two detained people are accommodated in each cell at Brook House.
Gov response: All rooms across the removal estate meet standards under Rule 15(1) of the Detention Centre Rules 2001. At Brook House, no room designed for two individuals houses more than two, with no plans to change …
Accepted in Part
Delivered
7 — Introduce 28-day maximum time limit on detention
Recommendation: The government must introduce in legislation a maximum 28-day time limit on any individual's detention within an immigration removal centre.
Gov response: The government does not accept this recommendation. The government stated: 'A time limit would significantly impair the ability to remove those who have breached immigration laws and refused to leave the UK voluntarily.'
Not Accepted
HIDD-90 — Detail evidence recording and preservation procedures within the accident procedure manual
Recommendation: BR shall set out in its manual on Accident Procedure the procedures that should be followed to ensure the proper recording and preservation of evidence.
Unknown
HIDD-91 — Ensure fault finding teams are accompanied by police and photographer for evidence
Recommendation: BR fault finding teams shall report to the Railway Incident Officer who, in consultation with the Police Incident Officer, shall ensure, in all but the most exceptional circumstances, that the team is accompanied by a police officer and a photographer …
Unknown
DM-1 — Forensic analysis of Daniel Morgan's diary
Recommendation: The Panel has received advice from an independent forensic science expert it consulted, Dr Kathryn Mashiter that useful work could still be carried out on this document. It therefore recommends that the Metropolitan Police considers the operational benefits of submitting …
Gov response: The MPS were tasked to undertake further work related to the investigation and provided outcomes in its response to the recommendations. This included conducting additional forensic analysis, the results of which have since been communicated …
Accepted
Delivered
DM-2 — DNA samples from Police Officer Z31's relatives
Recommendation: The Panel recommends that the Metropolitan Police consider the desirability and explore the possibility of obtaining samples of DNA from former Police Officer Z31's relatives, to compare it with the outstanding DNA recovered from the axe.
Gov response: The MPS's homicide investigation arrangements are very different to those in place 36 years ago. According to HMICFRS, the force is now effective in investigating homicides and solves the vast majority of cases. The MPS …
Accepted
No update 2+ yrs
DM-20 — HOLMES access for independent panels
Recommendation: All independent panels and inquiries examining police investigations should be given full access to the associated HOLMES accounts at their secure premises when they begin their work.
Gov response: Since 2020, police HOLMES databases have become Cloud-based, making the system accessible for the first time via a corporately managed device for those with the appropriate security clearance and purpose.
Accepted
Delivered
DM-21 — Review archiving processes for historic material
Recommendation: In order to avoid most of the delays and difficulties inherent in this case, and in so many other unsolved cases, there is a need for a review of the processes for archiving historic material with a view to creating …
Gov response: The current Home Secretary will subsequently approve a new Code of Practice on Police Information and Records Management to replace the existing Code of Practice on Management of Police Information 2005, and it will soon …
Accepted
No update 2+ yrs
DM-22 — Secure storage for panel sensitive material
Recommendation: In any future Panel inquiry, arrangements should be made for the storage of sensitive material in the Panel's premises, in a similar manner to provision made for inquiries being conducted under the Inquiries Act 2005.
Gov response: The Government's view is that in future, specific disclosure arrangements – including in respect of information security – should be agreed between inquiries and information providers at an early stage wherever possible. Inquiries likely to …
Accepted
No update 2+ yrs
DM-23 — Retain documents in digitised form
Recommendation: It is recommended that, whenever a major incident remains under investigation or inquiry, documents should be retained in digitised form, subject to appropriate security measures and made available to those who subsequently and justifiably require access to them.
Gov response: One of the principles around which the Code is built is transparency, which includes a statement that 'Chief officers must ensure that, where appropriate, their force is transparent with the public about the nature and …
Accepted
No update 2+ yrs
DM-3 — Prevent replication of Abelard Two management failures
Recommendation: It is recommended that the Metropolitan Police introduce systems to ensure that the management arrangements which applied during the Abelard Two Investigation can never be replicated in any future investigation, and that proper management arrangements, in compliance with the Association …
Gov response: The MPS has given assurances that the management arrangements during this particular investigation (Abelard Two) would not happen under current structures and have updated the relevant conflict of interest declaration and policy. The new National …
Accepted
Delivered
DM-4 — Review HOLMES system resources
Recommendation: The HOLMES system is both an investigative tool and a quality assurance mechanism, but it requires significant resources if it is to be used properly. The Panel recommends that the Metropolitan Police conduct an investigation into the adequacy of resources …
Gov response: The MPS has conducted a capacity and capability review of resources deployed to HOLMES, with consideration of national guidance. The review was concluded in January 2022 which concluded there is sufficient resourcing for the management …
Accepted
Delivered
DM-5 — Separate SIO and Family Liaison Officer roles
Recommendation: The Metropolitan Police should ensure that the role of the Family Liaison Officer is never carried out by the Senior Investigating Officer of an investigation. There is an inherent conflict between these two roles.
Gov response: The new National Major Crime Investigation Manual (MCIM) published in November 2021 covers all aspects of major crime investigation and sets the standard for all forces alongside the relevant Authorised Professional Practice (APP) produced by …
Accepted
Delivered
DM-6 — Guidance on unlawful disclosure recovery options
Recommendation: It is recommended that the Metropolitan Police establish a process to inform police officers about the recovery options available to them when material is unlawfully disclosed.
Gov response: The MPS has now produced new bespoke detailed guidance for officers and staff when dealing with a data breach, along with the recovery options available for these circumstances or when leaked material is discovered on …
Accepted
Delivered
DM-7 — CPS guidance on disclosure for profit
Recommendation: It is recommended that the Crown Prosecution Service's additional guidance should be amended to include a requirement that the Prosecutor should consider whether the information was disclosed with a view to one or both parties securing future profit from the …
Gov response: The CPS has updated its guidance and this was published on 16 February 2022. The guidance sets out a list of non-exhaustive factors to be considered when assessing the overall criminality of a suspect, including …
Accepted
Delivered
DM-8 — Guidance on disclosing material to journalists
Recommendation: Guidance should be issued by the Metropolitan Police to enable officers to determine whether it is appropriate, necessary and lawful to disclose investigative material to journalists. That guidance should include a requirement to record by whom, to whom and when …
Gov response: The College of Policing's counter-corruption APP already outlines categories of inappropriate associations that should be recorded and what notifiable association policies should look like for police forces. This includes that any associations with private investigators …
Accepted
No update 2+ yrs
DM-9 — Regulation of private investigators
Recommendation: The Government should act on its stated intention in 2013 to require licensing measures, introduce legislation to ensure the creation and use of standards, and implement the recommendation in the 2016 review concerning the regulation of private investigators.
Gov response: The Panel recommended the introduction of licensing for the private investigator sector. The government notes the positive steps the private investigator industry is taking towards raising standards through the progress of the Association of British …
Not Accepted
FENN-108 — Review British Transport Police King's Cross performance and provide additional fire training.
Recommendation: The British Transport Police should review the performance of its officers in the King's Cross emergency and give additional fire training.
Unknown
FENN-155 — Review Fire Services Act to clarify police and fire brigade responsibilities
Recommendation: A review shall be undertaken of section 30 of the Fire Services Act 1947 to clarify the responsibilities of the police and the fire brigade.
Unknown
JB-15.1 — Clarify separation of SIO and firearms commander roles
Recommendation: There should be clearer guidance from the MPS, College of Policing and/or the NPCC on the separation of roles between the Senior Investigating Officer (SIO) and the Tactical and Strategic Firearms Commanders (TFC and SFC). The guidance should be clear …
Gov response: MPS formally responded on 28 October 2022 (paras 5-6). MO19 internal review commenced July 2021; DAC Barbara Gray authorised interim position separating SFC from investigation team. Chief Inspector Tom Williams led formal MO19 recommendations paper …
Accepted
Delivered
JB-15.16 — Requirements for sustained public protection operations
Recommendation: APP-AP should be amended to cover the following: a. Sustained public protection should never be the object of an operation unless and until there is a clearly recorded note of the possible charge(s) that are anticipated, the evidence that will …
Gov response: MPS formally responded on 28 October 2022 (para 31). MPS carefully considering recommendation. Considers sustained public protection broader than conviction and imprisonment. Welcomes further APP-AP guidance.
Accepted
Delivered
JB-15.23 — Written questions as alternative to face-to-face IOPC interviews
Recommendation: Consideration should be given to the introduction of a practice requiring, as an alternative to a face-to-face interview, the submission of a list of questions for written answer within a fixed time – failure to provide which, absent a reasonable …
Gov response: IOPC has called for fundamental reform of complaints and disciplinary system. Government announced intention to commission review.
Response Unclear
No update 2+ yrs
JB-15.3 — Document management system for firearms authorisation forms
Recommendation: In order to provide for efficacy and transparency, the NPCC and College of Policing should be tasked with providing a document management system for FA (and equivalent) forms. The system should allow for the auditing of completion and submission dates …
Gov response: MPS formally responded on 28 October 2022 (paras 9-11). Recs not addressed to MPS directly. MPS actively assisting College of Policing and NPCC. SFC/TFC command logs reviewed under NPCC project led by Ian Davies. MPS …
Accepted
No update 2+ yrs
JB-15.4 — Amend firearms authorisation forms for risk assessment and tipping points
Recommendation: There should be an amendment to FA (and equivalent) forms to: a. encourage a multidimensional risk assessment (to comply with Article 2) to minimise, to the greatest extent possible, recourse to lethal force; b. include a provision for reference to …
Gov response: MPS formally responded on 28 October 2022 (paras 12-14). Internal guidance issued to CTSFO Tac Advisors within MO19 on tailoring FA5 forms. Training time set aside for FA form usage and completion.
Accepted
Delivered
JB-15.6 — National review of contain and call out strategy
Recommendation: The NPCC should commission a national review of the frequency with which this strategic option is used and its efficacy. The NPCC should consider whether contain and call out is being given meaningful consideration in the planning of armed deployments.
Gov response: MPS formally responded on 28 October 2022 (paras 15-16). Rec not addressed to MPS. MPS made clear willingness to support NPCC review. MPS continues to train all firearms officers in containment and call out.
Accepted
No update 2+ yrs
JB-15.7 — Recording and documentation of firearms planning meetings and briefings
Recommendation: MPS Armed Policing Standard Operating Procedure (SOP) to be amended so that: a. Notes and/or audio recordings should be made of all meetings in relation to general strategy where it is envisaged that firearms may or will be deployed during …
Gov response: MPS formally responded on 28 October 2022 (paras 17-20). Internal guidance issued to all SFCs and TFCs on comprehensive minutes for planning meetings. PUoF SOP consistent with APP-AP. Recording of firearms briefings still under review …
Accepted
No update 2+ yrs
JB-15.8 — National guidance on recording firearms planning meetings
Recommendation: The NPCC and/or College of Policing should ensure that these amendments are reflected in the guidance and training given to forces nationally.
Gov response: MPS formally responded on 28 October 2022 (paras 17-20). MPS response covers recs 7 and 8 together. MPS understands College of Policing will review APP-AP in respect of recommendation 7 (a-c) and the recording of …
Accepted
Delivered
JB-15.9 — Intelligence briefing requirements during operations
Recommendation: The College of Policing's Authorised Professional Practice – Armed Policing (APP-AP) should clarify that, during the course of an operation, any relevant intelligence should be briefed out to the firearms officers even if it is appropriate, in the circumstances, to …
Gov response: MPS formally responded on 28 October 2022 (para 21). MPS conveyed willingness to assist College of Policing in review of APP-AP on intelligence briefing during operations.
Accepted
Delivered
L64 — ICO Engage with Metropolitan Police
Recommendation: The Information Commissioner's Office should take immediate steps to engage with the Metropolitan Police on the preparation of a long-term strategy in relation to alleged media crime with a view to ensuring that the Office is well placed to fulfil …
Gov response: The Prime Minister did not specifically address ICO operational recommendations in his 29 November 2012 statement. The Data Protection Act 2018 (Section 124) required the ICO to produce a data protection and journalism code of …
Accepted in Part
L68 — PACE Amendments Consideration
Recommendation: The Home Office should consider and, if necessary, consult upon: (a) whether paragraph 2(b) of Schedule 1 to the Police and Criminal Evidence Act 1984 (PACE) should be repealed; (b) whether PACE should be amended to provide a definition of …
Gov response: This recommendation was not implemented. The government did not formally respond to civil justice recommendations in the Prime Minister's statement of 29 November 2012. Section 40 of the Crime and Courts Act 2013, which would …
Not Accepted
WATE-(18) — Appoint senior officer to strategise serious staff misbehaviour complaints
Recommendation: When a complaint alleges serious misbehaviour by a member of staff, the Director of Social Services should appoint a senior officer to formulate an overall strategy for dealing with the complaint, including such matters as liaison with the police in …
Unknown
WATE-(19) — Establish senior officer liaison with police for child abuse investigations
Recommendation: Whenever a police investigation follows upon a complaint of abuse of a looked after child, the senior officer referred to in recommendation (18) or another senior officer assigned for the specific purpose should establish and maintain close liaison with the …
Unknown
WATE-(20) — Expedite disciplinary proceedings for child abuse, independent of police investigations
Recommendation: Any disciplinary proceedings that are necessary following a complaint of abuse to a child should be conducted with the greatest possible expedition and should not automatically await the outcome of parallel investigations by the police or the report on any …
Unknown
POH-11 — Apply best offer principle equally in GLOS
Recommendation: The "best offer" principle which will apply in HSSA, as explained in response to Recommendation 10, shall be equally applicable in GLOS.
Gov response: Department for Business and Trade accepts this recommendation. The "best offer" principle applies equally across GLO, HSSA, and HCRS schemes at all panel stages. This has been in effect since 12 August. DBT will retrospectively …
Accepted
Delivered
POH-13 — Close HSS Dispute Resolution Procedure when HSSA opens
Recommendation: The current Dispute Resolution Procedure in HSS should be closed once all claimants currently within the Procedure have either (a) settled their claims or (b) transferred to HSSA. No claimant who is not in the Dispute Resolution Procedure when HSSA …
Gov response: Department for Business and Trade rejects this recommendation as it conflicts with the principle of providing "full and fair" redress. Postmasters should retain the choice between continuing with the dispute resolution procedure or transferring to …
Not Accepted
POH-17 — Establish standing public body to administer future redress schemes
Recommendation: As soon as is reasonably practicable, HM Government shall establish a standing public body which shall, when called upon to do so, devise, administer and deliver schemes for providing financial redress to persons who have been wronged by public bodies.
Gov response: Department for Business and Trade acknowledges this recommendation and sees clear advantages in establishing a standing public body for financial redress. However, the government recognises that establishing such an independent redress body requires careful consideration …
Response Unclear
In progress
POH-18 — Devise redress process for affected family members
Recommendation: The Department shall devise a process for providing financial redress to close family members of those most adversely affected by Horizon. Such family members shall qualify for such redress only if they themselves, have suffered serious adverse consequences by reason …
Gov response: Department for Business and Trade accepts this recommendation. Some close family members of postmasters suffered serious adverse consequences because of the Horizon scandal. DBT is committed to establishing a redress scheme for close family members …
Accepted
In progress
POH-19 — Publish restorative justice programme by 31 October 2025
Recommendation: By 31 October 2025, the Department, Fujitsu and the Post Office shall publish, either separately or together, a report outlining any agreed programme of restorative justice and/or any actions taken by that date to produce such a programme. For the …
Gov response: Department for Business and Trade accepts this recommendation. DBT, Post Office, and Fujitsu have jointly embarked on a postmaster-led restorative justice programme facilitated by the Restorative Justice Council. Sessions began on 23 September 2025. A …
Accepted
In progress
MACP-19 — Devise ACPO Codes of Practice for open, thorough crime investigation reviews
Recommendation: That ACPO devise Codes of Practice to govern Reviews of investigations of crime, in order to ensure that such Reviews are open and thorough. Such codes should be consistently used by all Police Services. Consideration should be given to such …
Unknown
MACP-20 — Review MPS scene procedures for officer co-ordination and senior command responsibilities
Recommendation: That MPS procedures at the scene of incidents be reviewed in order to ensure co-ordination between uniformed and CID officers and to ensure that senior officers are aware of and fulfil the command responsibilities which their role demands.
Unknown
MACP-21 — Review MPS procedures for recording and retaining incident and crime information
Recommendation: That the MPS review their procedures for the recording and retention of information in relation to incidents and crimes, to ensure that adequate records are made by individual officers and specialist units in relation to their functions, and that strict …
Unknown
MACP-22 — Review MPS internal inspection and accountability processes to ensure policy observance
Recommendation: That MPS review their internal inspection and accountability processes to ensure that policy directives are observed.
Unknown
MACP-29 — Develop guidelines for handling victims and witnesses, especially in racist incidents.
Recommendation: That Police Services should together with the Home Office develop guidelines as to the handling of victims and witnesses, particularly in the field of racist incidents and crimes. The Victim's Charter to be reviewed in this context.
Unknown
MACP-30 — Proactively use local minority ethnic contacts for victim support and sensitive witness handling.
Recommendation: That Police Services and Victim Support Services ensure that their systems provide for the pro-active use of local contacts within minority ethnic communities to assist with victim support and with the handling and interviewing of sensitive witnesses.
Unknown
MACP-31 — Ensure training and use of victim/witness liaison officers for racist incidents.
Recommendation: That Police Services ensure the provision of training and the availability of victim/witness liaison officers, and ensure their use in appropriate areas particularly in the field of racist incidents and crimes, where the need for a sensitive approach to young …
Unknown
MACP-32 — Maintain the current standard of proof for criminal offences.
Recommendation: That the standard of proof of such crimes should remain unchanged.
Unknown
MACP-33 — Establish a rebuttable presumption for prosecution in the public interest test.
Recommendation: That the CPS should consider that, in deciding whether a criminal prosecution should proceed, once the CPS evidential test is satisfied there should be a rebuttable presumption that the public interest test should be in favour of prosecution.
Unknown
MACP-34 — Ensure racist motivation evidence is recognised and included at all prosecution stages.
Recommendation: That Police Services and the CPS should ensure that particular care is taken at all stages of prosecution to recognise and to include reference to any evidence of racist motivation. In particular it should be the duty of the CPS …
Unknown
MACP-35 — Consult and inform victims or families about any proposal to discontinue proceedings.
Recommendation: That the CPS ensure that a victim or victim's family shall be consulted and kept informed as to any proposal to discontinue proceedings.
Unknown
MACP-36 — CPS must personally notify victims and families of discontinuance decisions sensitively.
Recommendation: That the CPS should have the positive duty always to notify a victim and victim's family personally of a decision to discontinue, particularly in cases of racist crime, with speed and sensitivity.
Unknown
MACP-37 — Fully record and disclose prosecution discontinuance decisions to victims or families.
Recommendation: That the CPS ensure that all decisions to discontinue any prosecution should be carefully and fully recorded in writing, and that save in exceptional circumstances, such written decisions should be disclosable to a victim or a victim's family.
Unknown
MACP-38 — Empower Court of Appeal to permit prosecution after acquittal with fresh evidence.
Recommendation: That consideration should be given to the Court of Appeal being given power to permit prosecution after acquittal where fresh and viable evidence is presented.
Unknown
MACP-39 — Amend law to prosecute racist language and offensive weapon offences privately.
Recommendation: That consideration should be given to amendment of the law to allow prosecution of offences involving racist language or behaviour, and of offences involving the possession of offensive weapons, where such conduct can be proved to have taken place otherwise …
Unknown
MACP-4 — Conduct immediate HMIC inspection of Metropolitan Police Service, including undetected murders.
Recommendation: That in order to restore public confidence an inspection by HMIC of the Metropolitan Police Service be conducted forthwith. The inspection to include examination of current undetected HOLMES based murders and Reviews into such cases.
Unknown
MACP-40 — Maintain the current ability to initiate private criminal prosecutions.
Recommendation: That the ability to initiate a private prosecution should remain unchanged.
Unknown
MACP-41 — Allow victims or families to become "civil parties" in criminal proceedings.
Recommendation: That consideration should be given to the proposition that victims or victims' families should be allowed to become "civil parties" to criminal proceedings, to facilitate and to ensure the provision of all relevant information to victims or their families.
Unknown
MACP-44 — Police and Courts prevent intimidation of witnesses through bail conditions
Recommendation: That Police Services and the Courts seek to prevent the intimidation of victims and witnesses by imposing appropriate bail conditions.
Unknown
MACP-60 — Maintain current police powers for crime prevention and detection unchanged
Recommendation: That the powers of the police under current legislation are required for the prevention and detection of crime and should remain unchanged.
Unknown
MACP-61 — Require police to record all stops, searches, reasons, and ethnic identity
Recommendation: That the Home Secretary, in consultation with Police Services, should ensure that a record is made by police officers of all "stops" and "stops and searches" made under any legislative provision (not just the Police and Criminal Evidence Act). Non-statutory …
Unknown
MACP-62 — Require police services to monitor, analyse, review, and publish relevant records
Recommendation: That these records should be monitored and analysed by Police Services and Police Authorities, and reviewed by HMIC on inspections. The information and analysis should be published.
Unknown
MACP-63 — Mandate police authorities to publicise stop and search provisions and rights
Recommendation: That Police Authorities be given the duty to undertake publicity campaigns to ensure that the public is aware of "stop and search" provisions and the right to receive a record in all circumstances.
Unknown
MACP-8 — Empower HMIC to use lay inspectors for racist crime investigation inspections
Recommendation: That HMIC shall be empowered to recruit and to use lay inspectors in order to conduct examination and inspection of Police Services particularly in connection with performance in the area of investigation of racist crime.
Unknown
TAYL-I4 — Mandate written agreements between clubs and police for crowd safety responsibilities
Recommendation: There should be a written agreement between the club and the police setting out their respective responsibilities for crowd safety and control and in particular for the filling of each self-contained pen or other terraced area and the monitoring of …
Unknown
TAYL-I5 — Assign dedicated stewards or police to monitor terraced area crowd conditions
Recommendation: At each match, there should be on the perimeter track, for each self-contained pen or other terraced area, a steward (if the club is monitoring that area) or a police officer (if the police are monitoring it) whose sole duty …
Unknown
TAYL-I6 — Provide mandatory training for police and stewards on crowd density recognition
Recommendation: All police officers and stewards with duties in relation to the terraced areas and especially those with duties under Recommendation 5 above, should be fully briefed and trained with regard to the recognition of crowd densities, to the recognition of …
Unknown
TAYL-I9 — Authorise police officers to manage gate access to relieve overcrowding
Recommendation: There should be in respect of each gate in a perimeter fence (or group of gates if they are close together) a police officer authorised to decide whether or not to allow spectators through a gate to relieve overcrowding. The …
Unknown
AS-4 — Shooting Incident Policy
Recommendation: A Shooting Incident Policy should be drafted which is achievable in practice in Theatre, which is compliant with Article 2 of the ECHR and which enables the ascertainment of the relevant facts leading up to, during and consequent upon the …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
AG-1 — National Register of Armed Policing Recommendations
Recommendation: A national policing body should manage a national register of recommendations relating to armed policing, and the response to such recommendations, arising from Independent Office for Police Conduct (IOPC) reports, prevention of future death reports made in the course of …
Gov response: 11. Under the leadership of Chief Constable of Civil Nuclear Constabulary, Simon Chesterman, the National Armed Policing Portfolio Lead (NAPP) has introduced a structured Organisational Learning Process. It incorporates lessons identified from IOPC reports, from …
Accepted
Delivered
AG-5 — GMP Intelligence Policy for Armed Deployments
Recommendation: Greater Manchester Police (GMP) should design and promulgate a written policy that specifically relates to the collection, analysis and dissemination of intelligence for the purposes of planned armed deployments within the meaning of the Armed Policing module of Authorised Professional …
Gov response: 23. The Inquiry concluded that the missed opportunity to build an accurate picture of the threat presented by Anthony Grainger was a major failing during Operation Shire. This led to an exaggerated assessment of the …
Accepted
No update 2+ yrs
AR-1 — Full Review of Operation Tayport
Recommendation: I recommend that, as soon as is reasonably practicable, the MPS undertake a full, thorough review of all aspects of Operation Tayport. The review should be conducted by a senior officer appointed by the Commissioner with no inhibitions about critical …
Gov response: No formal government response published. MPS confirmed implementation on 3 June 2014 following internal review by Commander Basu.
Accepted
Delivered
AR-2 — Protocol for Post-Incident Debriefing
Recommendation: At an early date there should be liaison between the IPCC, the MPS and ACPO (and, more significantly, lawyers acting for each) with a view to establishing a protocol for the future conduct in the event of a shooting by …
Gov response: No formal government response published. MPS provided updates on 12 August 2014 confirming work on post-incident debriefing protocols.
Accepted
Delivered
AR-3 — Commissioner to Appoint Debrief Officer
Recommendation: In the event of a shooting by an MPS officer that results in death or serious injury, the Commissioner should thereupon appoint a senior officer to conduct a full, operational debriefing. The officer must have sufficient seniority to not be …
Gov response: No formal government response published. MPS confirmed implementation of senior officer debriefing procedures on 12 August 2014.
Accepted
Delivered
COVID-M1.1 — Simplify Emergency Preparedness Structures
Recommendation: The governments of the UK, Scotland, Wales and Northern Ireland should each simplify and reduce the number of structures with responsibility for preparing for and building resilience to whole-system civil emergencies. The core structures should be: a single Cabinet-level or …
Gov response: No formal response published by this government.
Accepted
Delivered
COVID-M1.3 — Improved Risk Assessment Approach
Recommendation: The UK government and devolved administrations should work together on developing a new approach to risk assessment that moves away from a reliance on single reasonable worst-case scenarios towards an approach that: assesses a wider range of scenarios representative of …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M1.4 — UK-wide Civil Emergency Strategy
Recommendation: The UK government and devolved administrations should together introduce a UK-wide whole-system civil emergency strategy (which includes pandemics) to prevent each emergency and also to reduce, control and mitigate its effects. The strategy should: be adaptable; include sections dedicated to …
Gov response: No formal response published by this government.
Accepted in Part
In progress
COVID-M1.5 — Pandemic Data Systems and Research
Recommendation: The UK government, working with the devolved administrations, should establish mechanisms for the timely collection, analysis, secure sharing and use of reliable data for informing emergency responses, in advance of future pandemics. Data systems should be tested in pandemic exercises. …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M1.6 — Triennial Pandemic Exercises
Recommendation: The UK government and devolved administrations should together hold a UK-wide pandemic response exercise at least every three years. The exercise should: test the UK-wide, cross-government, national and local response to a pandemic at all stages, from the initial outbreak …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M1.7 — Publish Exercise Reports and Lessons
Recommendation: For all civil emergency exercises, the governments of the UK, Scotland, Wales and Northern Ireland should each (unless there are reasons of national security for not doing so): publish an exercise report summarising the findings, lessons and recommendations, within three …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M1.9 — External Red Teams for Resilience
Recommendation: The governments of the UK, Scotland, Wales and Northern Ireland should each introduce the use of red teams in the Civil Service to scrutinise and challenge the principles, evidence, policies and advice relating to preparedness for and resilience to whole-system …
Gov response: No formal response published by this government.
Accepted
In progress
COVID-M2.2 — Devolved Nations SAGE Attendance
Recommendation: The Government Office for Science (GO-Science) should invite the governments of Scotland, Wales and Northern Ireland to nominate a small number of representatives to attend meetings of the Scientific Advisory Group for Emergencies (SAGE) from the outset of any future …
Gov response: No formal response published by this government.
Unknown
COVID-M2.4 — Publish Technical Advice During Emergencies
Recommendation: During a whole-system civil emergency, the UK government and devolved administrations should each routinely publish technical advice on scientific, economic and social matters at the earliest opportunity, as well as the minutes of expert advisory groups – except where there …
Gov response: No formal response published by this government.
Unknown
LAMI-93 — Require manager involvement from both agencies in joint child harm investigations.
Recommendation: Whenever a joint investigation by police and social services is required into possible injury or harm to a child, a manager from each agency should always be involved at the referral stage, and in any further strategy discussion.
Unknown
LAMI-94 — Require supervisory officers to actively ensure proper investigation of serious child crimes.
Recommendation: In cases of serious crime against children, supervisory officers must, from the beginning, take an active role in ensuring that a proper investigation is carried out.
Unknown
LAMI-95 — ACPO must produce and implement standards-based child protection service.
Recommendation: The Association of Chief Police Officers must produce and implement the standards-based service, as recommended by Her Majesty’s Inspectorate of Constabulary in the 1999 thematic inspection report, Child Protection.
Unknown
LAMI-96 — Review police protection systems for Children Act compliance and designated inspector officer.
Recommendation: Police forces must review their systems for taking children into police protection and ensure they comply with the Children Act 1989 and Home Office guidelines. In particular, they must ensure that an independent officer of at least inspector rank acts …
Unknown
LAMI-97 — Ensure child crime investigation is equal to other serious crime investigations.
Recommendation: Chief constables must ensure that the investigation of crime against children is as important as the investigation of any other form of serious crime. Any suggestion that child protection policing is of a lower status than other forms of policing …
Unknown
LAMI-98 — Social services must inform police immediately of child criminal offence referrals.
Recommendation: The guideline set out at paragraph 5.8 of Working Together must be strictly adhered to: whenever social services receive a referral which may constitute a criminal offence against a child, they must inform the police at the earliest opportunity.
Unknown
LAMI-99 — Amend Working Together for police to exclusively conduct child criminal investigations.
Recommendation: The Working Together arrangements must be amended to ensure the police carry out completely, and exclusively, any criminal investigation elements in a case of suspected injury or harm to a child, including the evidential interview with a child victim. This …
Unknown
PFD Reports (108) — showing 100 most recent
Aminata Coulibaly
Concerns: Police failed to share critical self-harm information with mental health services and contact handlers inadequately recorded severe welfare concerns, hindering appropriate assessment and response.
Response: Essex Police has implemented new training on victim care and information sharing, established a new communication framework with EPUT, and introduced new guidance and a Quality Assurance team in Contact …
Responded
Andrew McCleary
Concerns: Police officers lacked knowledge of Mental Capacity Act requirements for restraint, awareness of restraint risks, and failed to collaborate with ambulance staff or monitor the detainee adequately.
Response: Bedfordshire Police has enhanced existing mandatory Mental Capacity Act (MCA) training for frontline officers and ensures Restrictive Physical Intervention training covers risks and de-escalation. They have also introduced and embedded …
Responded
Benedict Blythe
Concerns: Pathology protocols for suspected anaphylaxis need revision to ensure appropriate sample collection and retention. Police investigations of unexplained child deaths also lack procedures for seizing and retaining crucial scene evidence.
Response: The Royal College of Pathologists notes that existing autopsy guidelines for suspected acute anaphylaxis (2018) provide specific guidance on sampling blood and stomach contents. They will query the inclusion of …
Response: Cambridgeshire Constabulary has established full liaison with Scenes of Crime Officers (SOCOs) for forensic sample preservation in child death investigations. They have also amended and re-issued internal procedural guidance, incorporated …
Responded
Andrew Dodds
Concerns: Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing mental health service contact.
Response: South Yorkshire Police has implemented a new Standard Operating Procedure (SOP) and developed enhanced briefings for officers regarding the transfer of individuals detained under Section 136 of the Mental Health …
Responded
Anthony Card
Concerns: There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial risk data from informing future assessments and potentially vital support decisions.
Response: Suffolk County Council clarifies that direct mental health provision is primarily an NHS responsibility, and they will not establish a new MASH pathway for medium risk mental health-only cases. However, …
Response: Suffolk Constabulary provides ongoing mental health training for staff, including new recruits, and is developing new vulnerability training for Autumn/Winter 2026. A multi-agency audit of NHS 111 Option 2, which …
Responded
Stuart Fowkes
Concerns: Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, leading to critical risk information being missed in subsequent actions.
Response: Devon and Cornwall Police have conducted a comprehensive review of their missing persons and vulnerable people policy, resulting in a new standard operating procedure and a dedicated point of contact …
Responded
Alexander McCormack
Concerns: Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import procedures, risking delays in risk assessment and investigation.
Response: Northamptonshire Police are in the process of creating new training presentations for all ranks, including updated training for transferring Inspectors on COMPACT file handling. The Detective Superintendent will ensure future …
Responded
Brian Ringrose
Concerns: Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also did not apply the National Decision Model or challenge inappropriate techniques, contributing to the death.
Responded
Robert Evans
Concerns: 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.
Responded
Alfie Lawless
Concerns: Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about the quality of their internal review and learning from incidents.
Responded
Carl Butler and Sean Brett
Concerns: Cheshire Police had confused report management with no officer acknowledgement system and significant delays in delivering critical ANPR/Vehicle Finder system training to control room staff.
Responded
Matthew Brierley
Concerns: 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.
Responded
Sebastian ‘Benji’ Oliver
Concerns: Police inappropriately closed a "safe and well" check based on an outdated capacity assessment, demonstrating shortcomings in training and communication with paramedics regarding patients with fluctuating capacity who abscond from treatment.
Responded
Michael Crane
Concerns: Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially reported, hindering their ability to ensure safety in critical situations.
Responded
John Hurst
Concerns: Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled with a lack of comprehensive analysis from the CJLD assessment.
Responded
Angela Mittal
Concerns: Police staff lack understanding of coercive control and its psychological harm. A new, improved national domestic abuse risk assessment tool has not been adopted due to financial and compatibility issues.
Responded
Leah Croucher
Concerns: Inadequate monitoring of a known sex offender under probation and police supervision, coupled with poor inter-agency information sharing, allowed him to breach terms and commit murder.
Responded
Elizabeth McCann
Concerns: 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.
Responded
Ashley Crews
Concerns: The absence of a local policy regarding the use of handcuffs when executing arrest warrants raises a safety concern.
Overdue
Stevyn Carr
Concerns: Inappropriate grading of vulnerable person incidents and severe lack of police resources led to significant delays in response and oversight, failing to provide timely assistance.
Responded
Samuel Curless
Concerns: 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.
Responded
Mouayed Bashir
Concerns: Ambiguity in police officers' recognition and communication of Acute Behavioural Disturbance (ABD) during restraint potentially undermined critical 'Speak Up and Speak Out' principles in emergency situations.
Responded
William Helstrip
Concerns: The initial police investigation failed to properly probe drug sourcing via the "Dark Web" and Royal Mail, leading to the irretrievable loss of critical, time-sensitive evidence.
Responded
Meghan Chrismas
Concerns: Inadequate supervision of police control room operators and the absence of effective information-sharing structures between NHS and private healthcare providers posed significant risks.
Responded
Claire Briggs
Concerns: A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.
Responded
Gracie Spinks
Concerns: Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of comprehensive and ongoing risk assessments.
Responded
Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent
Concerns: Probation Service offender records lacked clear, prominent recording of critical risk information, leading to unread vital details and insufficient domestic abuse and child safeguarding checks. Systemic issues contributed to ongoing risks.
Overdue
John Condron
Concerns: There is no agreed national protocol or specified timescale for police to inform suspects of a decision to take no further action, creating a risk of further self-inflicted deaths.
Overdue
Tamsin Dolamore
Concerns: High vacancies for detectives handling rape and serious sexual assault cases cause significant delays in securing best evidence, impacting both case quality and volume of work.
Responded
Sean Duignan
Concerns: Severe security failures at the police armoury included a chronically failing access system, a widely known override PIN, and incorrect single access permissions, allowing unauthorized access to weapons.
Responded
Neal Saunders
Concerns: Police training on restraint techniques is unclear, specifically regarding "prolonged" restraint and its application during arrest. Training also contains inaccurate medical information and lacks effective embedding methods, risking inappropriate officer responses.
Responded
Raneem Oudeh and Khaola Saleem
Concerns: 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.
Responded
Jade Hutchings
Concerns: Police officers received inadequate mental health training and lacked understanding of support services. Additionally, an early intervention scheme had an age-based prioritisation that excluded vulnerable older adolescents, missing crucial support opportunities.
Responded
Robert Evans
Concerns: HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately captured after a death, hindering investigations and preventing lessons from being learned.
Responded
Harper Denton
Concerns: Police forces failed to adopt guidance for managing violent offenders and lacked proactive information sharing to protect children. Additionally, a national register for child cruelty offenders is missing, and health visitor safeguarding assessments are not mandatory.
Responded
Brandon Pryde and David Faulkner
Concerns: A police pursuit protocol failed to provide effective Command and Control when pursuits crossed force boundaries, due to confusion, unclear communication, and misperceptions of authority. This created a significant safety risk, despite not directly contributing to these deaths.
Responded
Christopher Boughton
Concerns: A lack of communication and clear ownership between bordering police forces hindered effective tasking and transfer of investigations, resulting in search requests being mismanaged and crucial information not being disclosed.
Responded
Hannah Beardshaw
Concerns: Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of readily available entry equipment and poor document management practices.
Responded
Aliny Godinho
Concerns: Ongoing risks exist due to delayed training for Domestic Abuse Team staff and supervisors on updated policies. There is also no system for effective supervisory review of initial risk assessments and safeguarding plans.
Overdue
Carol Cole
Concerns: A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading to missed patient assessments.
Responded
Jack Taylor
Concerns: Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.
Responded
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor
Concerns: Police investigations were marred by a significant number of "very serious and very basic investigative failings," including a profound lack of curiosity and errors, with terrible consequences.
Overdue
Katrina Makunova
Concerns: Knife possession and gang affiliation were not consistently recognized as risk factors in contextual abuse assessments by police or social services. Additionally, police Child Safety Units face significant workload pressures impacting safeguarding effectiveness.
Overdue
Donna Constantine
Concerns: Police encouraging vulnerable individuals to use unmonitored work mobile phones creates risks due to a lack of off-duty response, clear escalation procedures, and proper audit trails for communication.
Overdue
Emma Day
Concerns: Systemic failures across multiple agencies including police, social services, and the Child Maintenance Service led to inadequate recording, sharing, and acting upon domestic violence risks and protective orders, leaving victims vulnerable.
Overdue
Amanda Dunn
Concerns: Police repeatedly failed to act on reports of neighbour harassment, suggesting incidents are not taken seriously enough and leading to missed opportunities to intervene and potentially prevent future deaths.
Responded
Zeyna Partington
Concerns: GMP officers lack understanding of ACT markers and policies cause delays in missing person investigations. A national ANPR system for vehicle tracking is not fully implemented, leading to missed alerts.
Responded
Jade Rayner
Concerns: Police failed to record and investigate a sexual offence allegation against a vulnerable patient, denying her victim support. There was also a lack of clear multi-agency strategy for complex cases involving trauma and alcohol misuse.
Responded
Robert Hardy
Concerns: Police failed to record an assault as a crime, preventing the provision of appropriate victim support and signposting for a vulnerable individual with known vulnerabilities.
Responded
Agnès Marchessou
Concerns: Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to search police systems for relevant history, and did not reflect on their procedural errors.
Overdue
Alfie Gildea
Concerns: Systemic failures in domestic abuse management included inadequate police training on risk assessment and coercive control, poor information sharing with CPS, and insufficient use of protective measures like bail and DVPNs.
Responded
Chelsie Greatorex
Concerns: The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.
Responded
Emily Greene
Concerns: Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and inadequate facilities, compounded by mishandling a missing person's report.
Responded
Daniel Coleman
Concerns: Managers and security failed to detect a resident living illicitly on a demolition site, exhibiting inconsistent patrols, poor record-keeping, and failing to recognise intoxication. Ineffective drug and alcohol policies for high-risk environments were also noted.
Responded
Katie Croft
Concerns: Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, and a lack of mechanisms for schools to receive assessment data further compromised child safeguarding.
Overdue
Adam Harris
Concerns: Lack of formal risk assessment for prisoners in van docks, failure to search suspects, poor handover between officers, inadequate custody record keeping, and conflicting guidance on prisoner positioning for aspiration risk were critical concerns.
Responded
Richard Carlon
Concerns: The unavailability of Approved Mental Health Practitioners delayed critical assessments, and poor inter-agency communication led to mental health services missing opportunities to re-engage with a patient.
Responded
Christine Lee
Concerns: The absence of mandatory national training for Firearms Enquiry Officers risks incorrect certification decisions. Additionally, the medical assessment system for shotgun certificates is flawed, with officers lacking skills to evaluate complex health conditions.
Overdue
Lucy Lee
Concerns: A lack of mandatory national training for Firearms Enquiry Officers and systemic flaws in assessing medical fitness of shotgun certificate applicants, including undeclared conditions and inadequate FEO skills, create risks.
Overdue
Alfred Sykes
Concerns: The report identified unspecified matters of concern indicating a risk of future deaths.
Responded
Tyereece Johnson
Concerns: The approximate age of moped riders was not communicated to the police tactical team, omitting a relevant factor for risk assessment and decision-making.
Responded
Duncan Tomlin
Concerns: Police training inadequately emphasizes the heightened risks of prone restraint with multiple breathing-affecting factors. Officers may prioritize quick removal over adequately assessing the reasons for a detainee's distress or resistance.
Overdue
Aidan Ridley
Concerns: Inadequate police call handler training led to incorrect advice not to move a patient and failure to involve ambulance services, compounded by underutilization of a new 3-way call system.
Responded
Lesley Armstrong
Concerns: Northumbria Police failed to communicate the discontinuation of an investigation, hindering the employer's ability to inform the employee and the Safeguarding Board from progressing their duties.
Responded
Dane Pearson
Concerns: Police issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to communicate the decision to drop the investigation.
Overdue
Thomas Lear
Concerns: A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile went unaddressed due to no out-of-hours coverage.
Pending
Jeroen Ensink
Concerns: Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner of mental health concerns or family-reported history.
Overdue
Keiron Bould
Concerns: Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays in handling a missing person report.
Overdue
Paul Hanton
Concerns: Concerns involve inadequate information sharing during 999 calls for AWOL patients, limited hospital CCTV access for police, and a discernible difference in police response to informal versus sectioned patients, despite similar risks.
Responded
Antony Coughtrey
Concerns: The Probation Service failed to conduct an internal investigation or Serious Incident Review after a prisoner's death on licence and had a procedural failure in referring licence breaches back to the Parole Board.
Overdue
Joshua Hamill
Concerns: Police training was ineffective in identifying mental health issues, and 'concern for safety' incidents were closed without ensuring the individual's welfare.
Responded
Terence Pimm
Concerns: Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health issues. Insufficient training also affected police in identifying immediate risk and mental health assessors.
Responded
Mark Banks
Concerns: Police failures in call handling included not contacting ambulance services as requested, incorrectly grading a high-risk call, and insufficient efforts to search for and check on the deceased's wellbeing.
Responded
Ozeivo Akerele
Concerns: Police failed to locate the deceased during an intensive search due to a critical oversight in searching a nearby disused graveyard, and subsequent efforts were inadequate.
Responded
Darran Hunt
Concerns: Inconsistent police training and guidance regarding PAVA spray use and forcible mouth searches for detained persons with objects in their mouths, conflicting with FFLM recommendations, indicates a systemic failure to implement past lessons.
Overdue
Mark Yafai
Concerns: Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to inadequate Health Care Professional involvement.
Overdue
Michelle Lawrence
Concerns: Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.
Overdue
Tyrone Lock
Concerns: Police failed to classify a vulnerable person exhibiting clear distress as such, treating him as an absconding suspect. This led to a missed opportunity for a crucial helicopter deployment, potentially preventing death.
Responded
Thomas Gallagher
Responded
Olawale Adelusi
Concerns: There was no effective system to transmit critical information regarding a detained person's self-harm risk and mental health, as detailed observations of distress were not included in formal handover documents.
Pending
Henry Hicks
Concerns: Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, implying non-compliance with the Metropolitan Police Service's standard operating procedure.
Responded
Luisa Mendes
Concerns: Police call handlers inappropriately categorised violent incidents, and there were no formal handover procedures or training for shift changes. The STORM computer system also lacked alerts for unauthorised deferrals.
Responded
Adele Blakeman
Concerns: The antiquated GMP computer system hinders officers' access to critical information, preventing adequate situation assessment. Officers also failed to consistently record pertinent intelligence on individual profiles.
Responded
Stefen Boswell
Concerns: Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for critical pursuit details, created unnecessary risks.
Responded
Mark Holdsworth
Concerns: Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon release.
Overdue
Darren Browne
Concerns: A vulnerable adult with high suicide risk was prevented from contacting family, a decision that failed to properly balance his acute needs and risks against restrictions.
Pending
Dean Joseph
Concerns: Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public confidence.
Responded
Wiktoria Was
Concerns: Police pursuits showed insufficient regard for injured third parties, and lessons from previous pursuit-related deaths were not adequately learned or disseminated. Officers lacked sufficient and rigorous refresher training.
Responded
Ronald Laidiar
Concerns: The police investigation was severely inadequate, failing to secure the scene, account for missing items, properly investigate the source of blood, or identify a key head injury, significantly raising the risk of undetected violent crime.
Overdue
Yvonne Davies and Andrew Davies
Concerns: An off-duty police officer, personally involved with the deceased, compromised the crime scene by breaking in and contaminating evidence before and after on-duty officers arrived, who then failed to secure the scene.
Pending
Michael Thorley
Concerns: There was an inexcusable delay in emergency entry and a lack of clear policy for forced entry. Police failed to thoroughly investigate the scene, overlooked crucial evidence, and did not consider potential third-party involvement, compromising the investigation.
Responded
Darren Neville
Concerns: Police officers did not adequately consider the significant risk of death associated with prolonged restraint for individuals experiencing acute behavioural disturbance.
Responded
Alice McMeekin
Concerns: Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and early discharge of a high-risk individual with significant mental health issues.
Overdue
Nicholas Rowley
Concerns: Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks in detainees.
Overdue
Lucasz Lewandowski
Concerns: Systemic failures included untimely police response, poor inter-agency communication, and inappropriate use of Mental Health Act powers due to resource limitations. Concerns also raised about non-medically qualified clinical decision-making and lack of GP communication.
Overdue
Arsema Dawit
Concerns: Police investigation suffered from premature offence classification, misleading record entries, and inadequate supervision of action plans. There was also a gap in domestic violence reporting for non-adults and a reluctance to use interpreting services.
Responded
Lee Friend
Concerns: Insufficient visibility for temporary traffic lights and absent guidance for placement near blind bends created road safety risks, compounded by a lack of clear police protocol for reporting such hazards.
Overdue
Suzanne Cammell
Concerns: Critical high-risk information about a patient's previous suicide attempt, recorded on police databases, was not effectively communicated between police forces or to frontline officers. This hindered proper risk assessment and the implementation of a Mental Health Act assessment.
Responded
Stephen Church
Concerns: A broken police command chain, insufficient staff knowledge of mental health protocols, and a critical lack of joint working between agencies delayed a Mental Health Act assessment for a high-risk individual.
Responded
Mark Duggan
Concerns: Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.
Responded