Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0260, written 7 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jul 2015 |
|---|---|
| Reference | 2015-0260 |
| Deceased | Michael Thorley |
| Coroner | John Pollard |
| Coroner area | Manchester South |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Chief Constable, Greater Manchester Police. 1 | CORONER am John Pollard, senior coroner, for the coroner area of South Manchester 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 | INVESTIGATION and INQUEST On 9" February 2015 | commenced an investigation into the death of Michael Lee Thorley dob 3 September 1968. The investigation concluded on the 25" June 2015 and the conclusion was one of an Open Conclusion. The medical cause of death was 1a Combined opiate/opioid toxicity 4 | CIRCUMSTANCES OF THE DEATH The deceased was at his home address which is a first floor flat reached bya staircase from the ground floor. There was a telephone call made to the North West Ambulance Service, by a female voice, saying that ‘she’ was Michael Thorley and that he was unable to breathe. The caller then collapsed and nothing further was heard and an ambulance was despatched to the scene. The ambulance call taker notified the police and police officers attended. When they got to the scene they found that the outer door was locked and there was a metal grille type door over that front door, and that too was locked. Consideration was given to breaking down the door, but instead, despite two of the officers being trained in the use of wham-rams, one officer then went off to try to find the next of kin to see whether a key could be obtained to gain entry. By the time that officer returned to the flat with the next of kin (who did not have a key) some 23 minutes had passed since the police first arrived at the scene. The pathologist gave evidence to me, that had the deceased been treated with a dose of naloxone (the ‘antidote’ to morphine) immediately upon their arrival, there “is a chance that his life might have been saved”. The officers then broke down the door, which took about 30 seconds and found the deceased in the property. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — 1. There was an inordinate and inexcusable delay in gaining entry to the premises where it was known that the caller to the ambulance service had apparently collapsed mid-call. 2. There was no clearly thought-out and applied policy as to whether it was better to risk breaking down a door unnecessarily or whether to risk the life of someone who may be collapsed inside. 3. When the officers searched the premises they failed to find approximately five empty methadone bottles which were in a kitchen cupboard. 4. The telephone which was used to make the call was found (after the ambulance service re-called it), well away from the body. No explanation for this was forthcoming. This issue was not even considered as needing examination by the attending officers. 5. None of the investigating officers considered that a third party may have made the phone call and then tidied up the flat and left, locking the door from the outside. When the officers gained entry there was no drug paraphernalia nor were there any opened prescribed medication packets. There was a large quantity of prescribed medication, none of which had been opened. There was no explanation as to why or how this situation may have arisen: This despite the fact that it was known that the deceased's friend had been present the Previous night/early morning, and that she could have had a key. It was assumed that the door had been locked from the inside although there was no evidence to support that contention. 6. The Detective Inspector did not attend the scene on the day as it was deemed not a Special Procedure Death and not one where he needed to attend. The representative of the Professional Standards Branch concurred with the view expressed by the Coroner that a D.I. should turn out to this type of death. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1** September 2015. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons rare lal ot of the deceased). ! am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. Yo make representations to me, the coroner, at the time of your response, abouffhe felease or the publication of your response by the Chief Coroner. 7™ July 2015 John Pollard, HM Senior Coroner
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
GREATER MANCHESTER Sir Peter Fahy Q.P.M., M.A. P O L | C E Chief Constable Mr John S Pollard Her Majesty’s Senior Coroner South Manchester Area 1, Mount Tabor Street, Stockport 10 September 2015 SK1 3AG Dear Mr Pollard, Thank you for your Regulation 28 Report following the inquest into the death of Michael Lee THORLEY, from which | note the following concerns. t. 2: There was an inordinate and inexcusable delay in gaining entry to the premises where it was known that the caller to the ambulance service had apparently collapsed mid-call. There was no clearly though-out and applied policy as to whether it was better to risk breaking down a door unnecessarily or whether to risk the life of someone who may be collapsed inside. When the officers searched the premises they failed to find approximately five empty methadone bottles which were in the kitchen cupboard. The telephone which was used to make the call was found (after the ambulance service recalled it), well away from the body. No explanation for this was forthcoming. This issue was not even considered as needing examination by attending officers. None of the investigating officers considered that a third party may have made the call and then tidied up the flat and left, locking the door from the inside. When officers gained entry there was no drug paraphernalia nor were there any opened prescribed medication packets. There was a large quantity of prescribed medication, none of which had been opened. There was no explanation as to why or how this situation may have arisen: This despite the fact that it was known that the deceased's friend had been present the previous night/early morning and she could have had a key. It was assumed that the door had been locked from the inside although there was no evidence to support that contention. The Detective Inspector did not attend the scene on the day as it was deemed not a Special Procedure Death and not one where he needed to attend. The representative of the Professional Standards Branch concurred with the view expressed by the Coroner that a D.! should turn out to this type of death. Points 1 and 2 relate mainly to dynamic decision making and to some extent, to the availability of methods of entry. The Specialist Operational Training Unit which is responsible for training officers in both decision making and tactics will use this example during their method of entry training modules. They will highlight the need to balance the thresholds required for entry under Section 17 PACE Act with factors that indicate urgent entry is required to save life. In addition an internal message will be issued forcewide to encourage and empower officers reluctant to execute forced entry tactics in cases where there is concern for welfare. The Location address: GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS. Tel: 101 details of this case have also been shared with Detective Inspector [ggg of the GMP Vulnerability Review, who is currently undertaking work to review training, resourcing and skills required to deliver safeguarding at force, borough and local levels. It is apparent that most officers understand their powers of entry and are willing and able to force entry when it is clearly necessary and appropriate. However it seems that there are some occasions when the particular circumstances and the available information appear to cause a degree of hesitation. Our training and prioritisation is clearly emphasising public safety, and | am not aware of any policy issues that might have affected the officers’ decisions in this particular case. Pe aa Patrol sergeant fi who was spoken to by Detective Inspector on Wednesday 8" July 2015. MNS has acknowledged your concerns in relation to the quality of his search of Mr Thorley’s premises and accepted management advice. This point is also symptomatic of the oversight of this particular investigation. The discovery of the methadone bottles should have prompted further questions by the officers concerned and presented an opportunity to reconsider the investigation. This aspect has been identified in the existing action development plan oy Points 4, 5 and 6 have been subject of a review of the investigation into the death of Mr Thorley by Detective Chief Inspector Crompton of the Major Incident Team. This review focused on initial attendance, oversight of the investigation and court preparation. The findings and recommendations have been pores lial senior investigating officer , Detective Inspecto: of the Professional Standards Branch and Assistant Chief Constable Wiggett. discussed his findings and recommendations with Detective Inspector Stainton on Wednesday 2™ September 2015. is to remain on an action development plan which will continue to be managed by his immediate line manager I Specific aspects of this action plan involve recognising the circumstances that require deployment of a se stigating officer and risk factors that make the attendance of a D! more compelling| ill ratify successful completion of this action plan with Detective in due course. | understand that you have raised these points in person with |. handling of the incident has been reviewed and feedback and management advice given to the officers concerned. Whilst the investigation did go on to address the important lines of inquiry, | agree that the initial decision making and supervision should have carried out actions sooner and more thoroughly. | hope that our response will reinforce this with the individuals concerned and that our training and guidance will continue to emphasise the need for prompt action and good investigation. Yours sincerely, oS Sir Peter Fahy Chief Constable Location address: GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS Tel: 101
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