Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0201, written 18 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jun 2019 |
|---|---|
| Reference | 2019-0201 |
| Deceased | Alfred Sykes |
| Coroner | Andrew Bridgman |
| Coroner area | Manchester South |
| Category | Other 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 THIS REPORT IS BEING SENT TO: Chief Constable of Greater Manchester Police CORONER | am Andrew Bridgman, Assistant Coroner, for the Coroner area of South Manchester 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 INVESTIGATION and INQUEST On 12" February 2018 an investigation was commenced into the death of Alfred Sykes, born 29.08.1937, who died on 11.02.18. The investigation concluded with a final hearing on 04.04.19, resumed from an adjourned hearing on 14.08.18. The medical cause of death was; 1a. Hypothermia 2. Ischaemic heart disease, chronic obstructive pulmonary disease The conclusion was; Narrative: Died as a consequence of becoming lost and unable to find his way home. 4 | CIRCUMSTANCES OF THE DEATH On the afternoon of 7" February 2018, Alfred Sykes left his granddaughters house to make his way home to Longmead Avenue, | Hazel Grove on the bus. A journey he had made many times before. | Alfred Sykes did not catch the bus. He became lost and was knowingly | last seen at about 4.00pm on Egerton Road, Great Moor asking | directions to Longmead Avenue, and if there was a football field nearby, as his house backed onto a football field. Alfred Sykes was directed | | towards the various playing fields on Woodsmoor Road, one of which is | St Georgian's Cricket Club. Alfred was reported to GMP as a missing person. On 11" February 2018, Alfred Sykes' body was found by two members of the public beneath the undergrowth and bushes in a corner of St Georgian's Cricket Club. On the evidence Alfred Sykes had made his way to that corner of the field on the evening of 7th February 2018 and had lain where he was found from that time, but he would not have survived through the first night. 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. GMP were informed that Mr Sykes was missing at around 8.00pm on 7" February. He was treated as a high risk missing person from the outset; At approximately 4.00am on 8" February a member of the public called in to report that he has seen and spoken to a gentleman of Alfred Sykes description at about 4pm on 7" February on Egerton Road asking for directions for Longmead Avenue. When the caller could not help him he then asked if there were any football fields nearby. The caller pointed him in the direction of the sports fields at Woodsmoor, at the end of Egerton Road, including St Georgian's Cricket Club. Alfred Sykes was seen by the caller speaking to other people further along Egerton Road, closer to the sports fields; At about 8.00am two police officers, with no allocated tasks at that time, took it upon themselves to conduct a search of the sports fields. The above report had been mentioned at the morning briefing but there was no plan to carry out any search of the fields. It was apparently more than 300m from the spot where the caller spoke to Alfred Sykes. The two officers attended and walked a route around the fields which did not include all of the periphery. They reported a negative result. In my opinion that search was inadequate to report a negative result, as agreed by Min her evidence; 4. On 11"" February two members of the public (one of whom knew of Alfred Sykes) and who had heard he was missing also took it upon themselves to search the fields, finding him as above. My concern is that the report from the member of the public at 4.00am on 8" February of Alfred Sykes’s last sighting was given any or any adequate consideration and action, seemingly because it was more than 300m radius a However the significance of the ighting and the information was not lost on two police officers who on their own initiative looked around the playing fields. In evidence, BB ecvisea that just two police officers for such a large area was insufficient. | agree. Had there been a greater number of officers deployed on the morning of 8" February to search the fields to which Alfred Sykes had been directed and was last seen walking towards, it is likely he would have been found that morning. The evidence is that Alfred Sykes would not have been found alive, in combination his frailties and the weather but in different circumstance (particularly the weather) the outcome might have been different for him and for others in the future. Further, earlier discovery would have; 1. lessened the anguish for the family; 2. saved resources in the continued search over the following 3 days. 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 ond to this report within 56 days of the date You are under a duty to res) R August 2019. I, the coroner, may extend the of this report, namely by 13° 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 ili and to the following Interested Persons namely daughter of Alfred Sykes, who may find it useful or of interest. | 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. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief 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.
lan Hopkins QPM, MBA Chief Constable HM Assistant Coroner Mr Andrew Bridgeman Coroner's Court 4 Mount Tabor Street Stockport SK1 3AG 6" August 2019 Dear Mr Bridgeman Re: Regulation 28 Report following the Inquest touching upon the death of Mr Alfred Sykes Thank you for your report dated 18” June 2019 in respect of Mr Alfred Sykes (deceased) and pursuant to Regulations 28 and 29 of The Coroners (Investigations) Regulations 2013 and paragraph 7, Schedule 5 of the Coroners and Justice Act 2009. Having carefully considered your report and the matters therein, | reply to the concerns raised as follows Extract from Regulation 28: 1. My concern is that the report from the member of the public at 4:00am on 8" February of Alfred Sykes's last sighting was given any or any adequate consideration and action, seemingly because it was more than 300m radius from 22 Egerton Road. Response: The information obtained from the witness who contacted the police at 0400hrs was not acted upon immediately and the Police Search Advisor/Search manager, who had already been spoken to and had provided initial search advice at 0300hrs, was not re-contacted. At this time this was still an. unconfirmed sighting and therefore activity and advice concentrated on the known place last seen and advice provide by the PolSA/Search Manager. OPUS log — 08/02/19 04:26 — Cail from witness at 0400hrs stating that at 1600hrs 07/02/19 he came across a gentleman on Egerton Road in the Davenport area asking call for Longmead Avenue & when caller couldn't say where this was asking if any football fields nearby. Caller pointed him in the direction of football field in Woodsmoor & last seen walking south on Egerton Road in direction of Woodsmoor Lane. Male was seen asking other people further along the road. Described as white male approx.80 years of age wearing dark jeans & grey fleece with dark woolly hat. Caller didn't know the males name but mentions has seen Facebook report of elderly missing person from Natalie Mills & has put two and two together. Says male didn't appear distressed in anyway but did admit to being lost. From the brief caller has passed I've located this missing report. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 ans The PolSA/Search Manager was provided with this information shortly after coming on duty at 0700hrs on the 8" February, ith confirmation that the mate the witness had spoken to was in fact Mr Sykes being obtained after O900hrs. The PolSA/Search Manager recognised the significance of the information provided by this witness and based all search advice around 300 metres of the new place last seen (PLS) of 22 Egerton Road. As guidance to a reasonable, realistic and proportionate size of search area, a 300 meters radius around the PLS is recommended and nationally recognised in order to achieve a high level of confidence. A radius of 300 metres equates to a total search area of 283,239 Square meters (or 69.9 acres). The 300 metre radius will always be a guide and natural boundaries should be used such as main roads, motormays, railway lines, fences etc. The decision on which boundaries are selected can be subjective and will be recommended by the PolSA/Search Manager allocated to the investigation. Woodsmoor Lane was selected as the boundary to the south of the 300 metre radius and as a result the fields did not form part of the search area that police resources where tasked to The PLS can move during the course of a search as more information or searching uncovers more sightings or signs. As with this investigation, eighteen reports of sightings were received by the police, there will often be reports of sightings of the missing person which turn out to be incorrect. To avoid ad hoc searching, it is therefore important that the PLS is not changed based on these reports until a confirmed sighting is received. Once the search of the 300 metres around the PLS has been completed, if the person has not been found the search should be planned according to a combination of the missing person behaviour profile and the ‘geographic profile’, In other words, link the behaviour type of the missing person to the actual terrain In addition to providing search areas for divisional Police resources to search within the 300 metre radius, the PolSA/Search Manager, in an attempt to identify a potential route, obtained the services ofa Mountain Rescue Team trailing dog Having obtained a piece of clothing belonging to Mr Sykes, the trailing dog handler commenced his search southwards on Egerton Road passing the fields and heading in the direction of Mr Sykes home address. Unfortunately during the course of the search no positive trail was achieved. It is accepted that as a result of this new information including a direction of travel, references to a sports field and confirmation that the male spoken to was in fact Mr Sykes, the search parameters should have Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS been reviewed and the fields iocated off Woodsmoor Lane should have formed part of the search area and treated as a priority. 2. However the significance of the sighting and the information was not lost on two police officers who on their own initiative looked around the playing fields. In evidence, EEE edvised that just two police officers for such a large area was insufficient. | agree. Extract from Regulation 28 Response: stated during the inquest the fields were searched by one officer, when in fact it was searched by two. The fields located off Woodsmoor Lane should have formed part of the search area and as such search trained police officers or members of the Mountain Rescue Team with the appropriate experience and training should have been deployed into the playing fields. Extract from Regulation 28: 3. Had there been a greater number of officers deployed on the morning of 8" February to search the fields to which Alfred Sykes had been directed and was last seen walking towards, it is likely he would have been found that morning. Response: If all of the fields in the direction Mr Sykes was travelling had been included within the reviewed search area based on the new PLS, then more resources with the required skills and experience would have been deployed into this area On this occasion the decision was made to depfoy Mountain Rescue Team resources towards Bramhall Park where Mr Sykes had previously been located. Deploying sufficient and suitably trained resources into the location of the fields would have increased the possibility of locating Mr Sykes earlier and potentially that morning. Extract from Regulation 28: 4. The evidence is that Alfred Sykes would not have been found alive, in combination his frailties and the weather but in different circumstances (particularly the weather} the outcome might have been different for him and for others in the future. Further, earlier discovery would have; 4, Lessened the anguish for the family; 2. Saved resources in the continued search over the following 3 days. Response: Not deploying search resources into the fields off Woodsmoor Lane likely delayed the discovery of Mr Sykes, potentially resulting in search and investigation tasks which may not have been Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS- required. If the fields were inaccessible at the material time, this would impact on the decision to search them but this would be a decision for the PolSA based on the facts presented. As with all incidents there will always be learning opportunities in order to improve the Police response and minimise future potential risks Missing Person — Review process A missing person investigation will always be led by the police division from which the person has gone missing and the role of the PolSA/Search Manager is to provide advice and manage searches. Greater Manchester Police currently have a dedicated Specialist Search Unit comprising of a Search Coordinator (PolSC) and seven PolSA’s, also referred to as Missing Persons Search Managers. These officers provide continuous 24/7 support to the force in respect of all search related matters including Missing Persons. Having a dedicated unit allows for continuity and constant peer review of investigations and the search approach being adopted. As a high risk missing person investigation becomes protracted over a period of time, the force Search Coordinator may request a peer review by a PolSA from another force with no previous involvement in the investigation or by the National Search Advisor. This allows for an independent review of the investigation and ensures that the most appropriate search tactics are being adopted. In respect of the investigation into Mr Sykes the search was not protracted however the review by a different PolSA with no involvement should have been completed as best practice. Missing Person Reviews As a result of this report, with immediate effect all high risk missing person searches being conducted by a PoISA from the Specialist Search Unit, will be reviewed by another officer on a daily basis and the Po'SC (Force Search Coordinator) appraised of the circumstances at the earliest opportunity. This will ensure that search strategies are appropriate and proportionate to the investigation whilst also allowing the PoISC to refer outside of the force if deemed appropriate. PolSA/Search Manager Continuous Professional Development In order to remain operationally competent, PolSA’s must adhere to strict criteria set by the PNSC which includes coordinating a minimum of number of searches annually and completing a minimum number of hours of continuous professional development. The activity and competency levels are overseen by the forces Search Coordinator (PoiSC). Postal address: Greater Manchester Police, Openshaw Complex, Lawton Steet, Openshaw, Manchester M11 2NS As a result of this incident, the annual PolSA/Search Manager CPD will now include refresher training by way of an exercise in respect of missing person search, using incidents that have occurred within the force or nptionally or the previous twelve months. This will ensure that officers remain operationally competent and any training issues can be appropriately addressed. ra Yours sincerely _\asicteh — lan Hopkins Chief Constable Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS.
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