Luisa Mendes

Our Ref: 
Your Ref: Regulation 28 Report 

Mr T R G Leeper 
Assistant Coroner 

Coroners Office 
Warwickshire Justice Centre 
Newbold Terrace 
Leamington Spa 
Warwickshire CV32 4EL 

Dear Mr Leeper, 

22nd August 2016 

Martin Jelley 
Chief Constable  

Warwickshire Police 
Executive Team 
Warwickshire Justice Centre 
Newbold Terrace 
Leamington Spa 
Warwickshire CV32 4EL 

Telephone:  

Thank you for your letter dated the 30th June and the corresponding regulation 28 report 

contained therein.  Please find below a comprehensive response to the issues raised. 

It is the vision of Warwickshire Police to protect people from harm, with an aspiration of being 

great at protecting the most vulnerable.  Any improvements that can be made to meet this vision 

are taken very seriously. The death of Luisa Mendes is deeply regretted by Warwickshire Police 

and we are determined that we will do things differently in the future to try to prevent deaths of a 

similar nature. We have personally apologised to the family of Luisa for our failings. 

Specifically  in  response  to  the  concerns  raised  in  your  regulation  28  report,  I  can  update  as 

follows: 

www.warwickshire.police.uk 
www.westmercia.police.uk 

@warkspolice 
@wmerciapolice 

warwickshire police 
west mercia police 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
          
 
 
 
 
 
 
 1. The approach of controllers and call handlers to the categorisation of incidents which 

include allegations of violence. The basis for the concern is that the incident should have 

been categorised as ‘violent’ but it was not. 

I consider that the focus of controllers and call handlers should be on the need and immediacy 

of  response  rather  than  the  assessed  categorisation  of  any  incident.  This  response  should  be 

focused on the threat, harm, risk and vulnerability of all those who seek our help.   

To ensure this happens all staff have been trained regarding the identification of threat, harm, 

risk and vulnerability using the National Decision Making model (NDM) as part of their induction 

process.  As  an  additional  aide  to  appropriate  information  capture  and  decision  making,  this  is 

being  complemented  by  the  introduction  of  the  THRIVE  model,  (Threat,  Harm,  Risk, 

Investigation,  Vulnerability,  Engagement).  This  provides  a  framework  for  staff  to  consider  the 

issues  evident  in  each  individual  case  and  provide  the  most  appropriate  response,  assessing 

the needs of the caller. This training on NDM and THRIVE was refreshed to all Operations and 

Communications Centre (OCC) staff between January and March 2016.  All training will be kept 

under review with appropriate refresher training given on an ongoing basis. 

Additionally  to  add  context,  increase  professional  knowledge  and  to  aid  decision  making,  staff 

have been provided with specific inputs around protecting vulnerable people from harm. Officers 

and  staff  with  specialist  knowledge  have  provided  bespoke  training  around  high  harm  issues 

such  as  Domestic  Abuse,  Mental  Health  and  Child  Sexual  Exploitation  at  OCC  training  days. 

These  sessions  are  supported  where  applicable  by  on-line  learning  and  knowledge  checks 

provided by the College of Policing. 

More recently, we have commenced innovative one day workshops to encourage and develop 

our  staff  to  recognise  and  respond  to  vulnerability.  These  workshops  will  include  all  relevant 

staff within Warwickshire Police and are at the core of the ambition I have of protecting the most 

vulnerable in our society. To support these workshops, all supervisors and managers are being 

provided with additional inputs in how we can support our staff in dealing with the challenging 

issues  that  this  ambition  will  create.  The  workshops  are  pioneering  within  policing  and  their 

impact  will  be  subject  of  academic  assessment  by  Worcester  University.  The  workshops 

commenced in July and will have been delivered to all relevant Warwickshire officers and staff 

by December 2016. 

 
 
 
 
 
 
 
 I  have  been  reassured  that  all  our  OCC  staff  are  provided  with  appropriate  training  in  a 

consistent manner.  An experienced OCC Manager has responsibility for staff development and 

for quality assurance. 

2.  The  handover  procedures  between  controllers  coming  on  and  off  shift  in  the 

Operations and Communications Centre (OCC). The basis of the concern is that there are 

no  formalised  procedures  and  no  specific  training  in  relation  to  handovers  between 

controllers coming on and off shift. 

Compelling evidence was identified during the preparation and ultimate delivery of the evidence 

to  the  inquest  that  showed  the  handover  procedure  between  controllers  in  the  OCC  required 

improvement.  However,  the  complex  and  varied  nature  of  the  calls  received  within  the  OCC 

means  that  the  handover  process  must  be  dynamic  and  cannot  be  subject  of  an  over-

prescriptive  process.    It  has  been  recognised  that  there  was  a  need  to  reinforce  the  critical 

importance  of  passing  vital  information  between  controllers.  In  order  to  achieve  this,  changes 

have  been  made  to  the  initial  training  programme  for  controllers  and  additional  requirements 

incorporated  into  the  controller  ‘task  book’,  which  is  a  list  of  skills  that  controllers  need  to 

demonstrate  before  progression  in  their  role.    Additionally,  we  are  exploring  the  option  of  an 

electronic  reminder  for  controllers  that  will  pop-up  and  remind  them  of  the  requirements  of 

handovers when they log on to the system and commence their handover; this is dependent on 

whether  the  current  system  allows  for  such  a  development.  This  is  being  researched  and  we 

await a response as to its feasibility.  

3. The set up of the STORM computer system as it relates to deferrals. The basis for the 

concern  is  the  absence  of  any  feature  on  the  STORM  computer  system  which  will  alert 

management to the effect that an unauthorised deferral has been effected by a controller. 

There remains a difficulty with substantive technical adaptations to the STORM system as it is 

used  by  a  large  number  of  police  forces  and  other  emergency  service  providers.    After 

discussions with the company who own the system, Sopra-Steria, we have identified a change 

to  the  system  that  we  are  seeking  to  introduce  in  the  next  few  weeks  that  will  provide  some 

mitigation to the issue of unauthorised deferrals. This change is still under development and it is 

intended that it will provide an alert on all priority incidents out of time. It is recognised that this 

does  not  prevent  irregular  deferrals  being  made,  however  within  the  current  restraints  of  the 

system, is considered the best change we can deliver. 

 
 
 
 
 
 
 
 The change will be in addition to the reinforcement of the policy in relation to deferrals and the 

commitment that for a given period, all deferred priority incidents should be subject to checks to 

ensure that they were deferred with the consent of a supervisor. This will also serve to reinforce 

the  training  that  no  priority  incident  should  be  deferred  without  the  consent  of  a  supervisor.  It 

addresses  the  deferral  issue  because,  if  the  incident  in  question  has  been  deferred,  either 

rightly or wrongly, the system will automatically re-activate it and then send the relevant alerts. 

Finally,  Warwickshire  Police  and  West  Mercia  Police  are  in  the  advanced  stages  of  the 

procurement  of  a  new  Command  and  Control  system.    We  are  building  the  new  platform  with 

the  suppliers,  to  our  specifications,  which  will  include  the  changes  required  as  a  result  of  the 

learning  through  the  inquest.  This  will  include  the  correct  authority  level  around  deferring 

incidents. 

I hope that the above response adequately answers your concerns in relation to the matters 

raised.  Please be assured that we take this matter seriously and would welcome any further 

feedback you may have.  We will take all practical steps to minimise the danger to members of 

the public now and in the future. 

Yours sincerely 

Martin Jelley 

Chief Constable 

Warwickshire Police