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recurance

Dane Pearson

14 Jan 2019 · Coroner Alison Mutch · Manchester (South)

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. CAWN issued without proper documentation or timeliness

    “In this case, the CAWN had been issued on limited evidence particularly regarding identification. In addition, it had been issued many months after the allegation and after the authorisation. The inquest was told that the process had not been followed relating to timeliness. There was no documentation in existence explaining the rationale for the issuing of the CAWN.”
  2. 2. lack of risk assessment and communication of CAWN

    “In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account. A risk assessment had not been carried out. In this case, officers attended at his home address and served the CAWN on him .He refused to sign it on the basis; he had no knowledge of it or the circumstances behind it. It was left with him with no clarification about what if any steps he could take in relation to it. The inquest heard evidence that he was deeply worried about it and the impact of”
  3. 3. OPUS system not updated with vulnerability markers

    “The inquest heard that OPUS the Police system did not appear to have been correctly updated with markers to flag his vulnerability.”
  4. 4. decision not communicated to individual under investigation

    “The inquest was told that he was placed under investigation for a suspected attempt burglary and possession of an offensive weapon. A decision was taken by the OIC and his sergeant that it should be NFAD. The decision was not communicated to Mr [name redacted]. The officer had not followed the process for notification of decisions to those under investigation. As a result, at the time of his death he believed he may be charged with a criminal offence.”

Linked reports

Raised again laterNatasha Hill1 May 2026 · 7 years 4 months later
Closely relatedConfidence 0.70 · moderate

This report

“In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account. A risk assessment had not been carried out.”

Later report

“Thought should be given to the creation of a young person's protection by way of creation of an extension to the CAWN for the young person, against the adult creating that safeguarding risk e.g. young person's abuse warning notice.”
Original on judiciary.uk ↗
Full chain: Inadequate CAWN risk assessment for young persons

Responses

2019-0056-Responses.pdf ↗· Greater Manchester Police

Stated action

“The College is about to release updated APP on issuing CAWNs and this will reflect the need to carry outa risk assessment. There”

Stated action

“contained in College Investigations APP will be updated to reflect the requirement to keep both victims and suspects updated on progress of cases, including informing a suspect when an investigation about them has been concluded.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error