Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0273, written 12 Aug 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Aug 2019 |
|---|---|
| Reference | 2019-0273 |
| Deceased | Karen Burns |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Emergency services related deaths (2019 onwards) · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Constable for West Midlands Police 2. West Midlands Police and Crime Commissioner 3. Home Secretary - Rt Hon Priti Patel MP 1 CORONER I am Louise Hunt, Senior Coroner for Birmingham and Solihull 2 CORONER’S LEGAL POWERS I 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 29/03/2019 I commenced an investigation into the death of Karen Jane Burns. The investigation concluded at the end of an inquest on 12th August 2019. The conclusion of the inquest was Suicide. 4 CIRCUMSTANCES OF THE DEATH The deceased was found hanging from a basketball net at the park on Hallmoor Road in Lea Hall Birmingham at 06.15 on 23/03/19. She left a note indicating her intentions. At 00.19 that day her ex- partner had contacted 101 to report that the deceased had threatened to smash up his car and then kill herself. The call was graded as P3 – 8 hour response despite a previous suicide attempt in April 2018. The call should have been graded as a P2 with a 1 hour response time however due to the large number of emergency calls that evening it is unlikely that officers would have responded to the call before she was found in the park. Following a post mortem the medical cause of death was determined to be: SUSPENSION BY A LIGATURE AROUND THE NECK 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. I heard evidence at the inquest that this call was graded incorrectly. It should have been graded as a P2 call with a response time within 60minutes. I also heard evidence to confirm that the large number of P1 calls that evening meant that even if the call had been correctly graded it would not have been answered as all available resources were required for the P1 calls (15 minutes response). The evidence confirmed that nearly all the P2 and P3 calls went unanswered that night. This raises a serious concern about the amount of resources available to West Midlands Police. Urgent attention is needed to address the resources available, particularly at night, as current resources are unable to deal with the large volume of cases the Force is expected to deal with. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 8th October 2019. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family. I 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. 9 12/08/2019 Signature Louise Hunt Senior Coroner Birmingham and Solihull
3 responses 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.
Kit Malthouse MP 4 Minister of State for Crime, }) Policing and the Fire Service Home Office naar SNIP ABE www.gov.uk/home-office Lynne Boyle PM to HM Senior Coroner Birmingham and Solihull Districts RECEIVED The Coroner’s Court 50 Newton Street 30 SEP 2019 Birmingham BY:___ B4 6NE = HOCS Reference: MIN/0013756/19 ~ fe Boxe, Thank you for your e-mail of 13 August and for forwarding a Regulation 28 Report to Prevent Future Deaths for Karen Jane Burns, on behalf of Mrs Hunt, Senior Coroner, Birmingham & Solihull. | am sorry for the delay in my response y S September 2019 | am very sorry to hear about this loss of life and | welcome the opportunity to identify lessons from this tragic event. The report identifies two concerns: the grading of 101 calls and thus the speed of any subsequent response; and resourcing levels in. West Midlands Police. On the concern of 101 call grading and prioritisation. Elected Police and Crime Commissioners and Chief Constables are responsible for deciding how best to manage their communications with the public, and how to respond to incidents in their force areas. However, | will ask Home Office officials to contact West Midlands Police to identify if any remedial or additional measures need to be put in place to ensure calls are handled appropriately. Regarding resourcing levels in West Midlands Police, | would like to reassure you that public safety remains the Government's number one priority and we will continue to ensure that the police are given the resources they need to do their important work. The police funding settlement for 2019/20 is significant and provides the most substantial investment in policing since 2010, with a total funding of up to £14 billion, an increase.of up to £970m compared to 2018/19, including precept, pensions funding and national investment. This settlement enables policing to meet the financial pressures they face, while continuing to recruit and fill capability gaps. More recently, the Prime Minister announced an increase of 20,000 new police officers over the next three years, and the Home Office is working with policing to consider how these officers will be allocated across forces and functions. | hope that this response provides you with the reassurance that you seek but should you require further information please do not hesitate to contact me. 0, Kit Malthouse MP
Please ask for : fC Telephone Number: wmpcc@west-midlands.pnn.police.u west midlands police and crime commissioner k Mrs Louise Hunt, Senior Coroner Birmingham and Solihull Coroner’s Court 50 Newton Street Birmingham B4 6NE By email: birmingham.coroner@nhs.net 15 October 2019 Dear Mar ue RE: Police and Crime Commissioner’s response to the Coroner’s Regulation 28 report: Ms Karen Burns (deceased) ' | would like to express my deepest sympathy to the family of Ms Burns following her sad death. | sincerely apologise for the delay in response to this report. Please see below response from the West Midlands Police and Crime Commissioner to the Coroner’s' Regulation 28 report to prevent future deaths dated 12 August 2019. The response has arisen following the inquest into the death of Karen Janes Burns, which was concluded on 12 August 2019. : The coroner’s report notes two matters for consideration: 1. The 101 call made by the deceased’s ex-partner was incorrectly graded as a P3 (response time of 8 hours) and not a P2 (response time of 1 hour): Since 2010, we have lost 2,131 officers and £175 million in resources. This has meant we have had to prioritise certain aspects of the service and have less ability to cover everything as we have done in the past. West Midlands Police has accepted that the call was incorrectly graded, which was recognised as human error. It has been discussed with the member of staff in question by management. Additional training for all control room staff will take place to ensure such errors are eliminated as far as possible. The Coroner’s report found that the wrong grading of this call made no difference to the deceased in this case since even a correctly graded P2 call would not have been responded to, due to pressure on resources on the night of 22/23 March 2019. 2. The risk created by the lack of resources available to West Midlands Police: On the night of 22/23 March 2019 most calls graded P2, and even some calls graded P1 (response time of 15 minutes), could not be reached due to the high level of demand and resources available. , Lloyd House, Colmore Circus Queensway, Birmingham, B4 6NQ 01216266060 www.westmidlands-pcc.gov.uk W@WestMidsPCC With the limited resources available, West Midlands Police aim to allocate these calls in the most efficient and appropriate way to deal with the demand for a huge range of policing activities. It is very clear that over the last few years, the West Midlands policing mission has grown. One of the ways in which it has grown is through the Police helping other services to deal with increased mental health demand. West Midlands Police recognise that response to emergency calls from the public within an appropriate time is of vital importance and they seek to ensure appropriate prioritisation based on thréat, harm and risk. Before and after the events of Ms Burns’ death, West Midlands Police has taken dramatic steps to ensure that the responsé resources it has, are allocated as quickly and efficiently as possible to all emergency calls. These include: a. Introducing a process of escalation, where dispatchers can escalate calls which they have particular concerns about; to a supervisor. This means resources can be prioritised for that call when possible. b. Introducing a process of involving the Force; Incident Manager. When response shifts become particularly busy resources from outside the area can be redeployed to response, where possible. ge (This process was employed on the night of 22/23 March 2019 and further units were allocated to assist in Birmingham East. These additional units were immediately deployed to P1 incidents requiring assistance and therefore were unavailable for allocation to any P2 incidents.) c. Introducing a “Log Closure Doctrine”. This will encourage bolder decision- making from dispatchers dealing with emergency calls to ensure resources are focussed on those calls with the most pressing needs. d. Reducing the number. of logs held by each dispatcher. Logs more than 24 hours old are now dealt with by another team:so dispatchers can concentrate only on the most critical calls without the distraction of managing older logs. Numbers of logs held by each dispatcher has decreased from around 160 (as on the night of 22/23 March 2019) to around 60. e. Changing the dispatch model, including where people sit and how they interact, to promote more efficient handling of calls. f. Changing shift patterns to build better relationships between teams and to promote more efficient handling of calls and transfer of calls between shifts. West Midlands Police takes its response to emergency calls extremely seriously. The force constantly monitor the level of resources and performance to ensure appropriate resources are _ allocated across the full range of demands which the police face. Learning from this incident has been captured and training has been provided to the call handlers ‘involved. A new Command and Control platform is also being developed to support the call -handlers and those involved in resource despatch, allowing for improved identification of resource availability and response times. This has also triggered a review of THRIVE+ training for staff. Lloyd House, Colmore Circus Queensway, Birmingham, B4 6NQ 0121 626 6060 www.westmidlands-pcc.gov.uk W@WestMidsPCC Monitoring of call response times and resolution has demonstrated that West Midlands Police’s actions taken have improved ability to respond with the limited resources available to them. | will be holding West Midlands Police to account to ensure that the changes they have already made are fully embedded and further work is done to mitigate an incident like this happening again. i Once again, | apologise for the lateness of this response and thank you for your patience. Yi iqcerely Police and Crime Com Lloyd House, Colmore Circus Queensway, Birmingham, B4 6NQ 01216266060 §www.westmidlands-pcc.gov.uk W@WestMidsPCC
Keeping our Communities Safe and Reassured Preventing crime, protecting the public and helping those in need STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES Area Coroner, Birmingham and Solihull Coroner’s Court 50 Newton Street Birmingham B4 6NE Director of Legal Services ) Your Ref: Our Ref: L14002652/JS Email: jointlegalservices@west-midlands.pnn.police.uk By email: birmingham.coroner@nhs.net Date: 8 October, 2019 Dear Sirs, Re: Regulation 28 report, prevention of future death pertaining to Ms Karen Burns (deceased) Firstly on behalf of West Midlands Police may I extend our most sincere condolences to the family of Ms Burns following her sad death. Pursuant to Regulation 29 of the Coroners (Investigation) Regulations 2013 this is the response of the Chief Constable for West Midlands Police to the Coroner’s Regulation 28 report to prevent future deaths dated 12 August 2019. The Coroner’s report and this response arise from the inquest into the death of Karen Jane Burns which was concluded on 12 August 2019. 1. The coroner raises two matters for consideration. First, the 101 call made by the deceased’s ex-partner was incorrectly graded as a P3 (response time of 8 hours) and not a P2 (response time of 1 hour). 2. West Midlands Police accepts the call was incorrectly graded. This was a human error. It has been addressed with the staff in question through management action. Further Please reply to: Birmingham Office: Joint Legal Services West Midlands Police Lloyd House, Colmore Circus Birmingham, B4 6NQ Tel: 0121 626 8317 Fax: 0121 626 8272 Staffordshire Office Joint Legal Services Staffordshire Police Headquarters PO Box 3167 Stafford, ST16 9JZ Tel: 01785 232259 Please be aware that all information provided to Staffordshire and West Midlands Police Joint Legal Services will be held and treated in confidence in accordance with the Data Protection Act 2018. It may be shared with other Force departments or third party organisations including, but not limited to, external solicitors, Counsel and, in relation to claims handling, Insurers. Personal information may also be used for statistical purposes, for fraud and crime prevention and may be checked with/disclosed to regulatory bodies. The information provided may be held electronically and/or in paper form and will be kept secure at all times. Please be aware that your personal data will be processed for the performance of tasks carried out in the public interest or in the exercise of the Police’s official authority, and to comply with legal obligations. *Calls may be monitored and/or recorded for security, quality control or training purposes. Regulated by the Solicitors Regulatory Authority WE DO NOT ACCEPT SERVICE OF DOCUMENTS BY EMAIL OR FAX L14002652/JS / 00206769 training for all control room staff is ongoing to ensure such errors are eliminated as far as possible. It is clear from the Coroner’s findings that the wrong grading of this call made no difference to the deceased in this case since even a correctly graded P2 call would not have been responded to due to pressure on resources on the night of 22/23 March 2019. 3. The second and key issue that the Coroner raises is the risk created by the lack of resources available to West Midlands Police. On the night of 22/23 March 2019 most calls graded P2, and even some calls graded P1 (response time of 15 minutes), could not be reached due to the high level of demand and resources available. 4. Within the limits of the resources available to it, it is the aim of West Midlands Police to allocate these in the most efficient and appropriate way to deal with the demand for a huge range of policing activities. West Midlands Police recognises that response to emergency calls from the public within an appropriate time is of vital importance and seeks to ensure appropriate prioritisation based on threat, harm and risk. 5. Before and since the events leading up to Ms Burns’ death, West Midlands Police has taken steps to ensure that the response resources it has are allocated as swiftly and efficiently as possible to all emergency calls. These steps include: a. Instituting a process of escalation, whereby dispatchers can escalate calls about which they have particular concerns to a supervisor so resources can be prioritised for that call when possible. b. Instituting a process of involving the Force Incident Manager when response shifts become particularly busy so resources from outside the area can be redeployed to response, where possible. (This process was employed on the night of 22/23 March 2019 and further units were allocated to assist in Birmingham East. These additional units were immediately deployed to P1 incidents requiring assistance and therefore were unavailable for allocation to any P2 incidents.) c. Instituting a “Log Closure Doctrine” to encourage bolder decision-making from dispatchers dealing with emergency calls to ensure resources are focussed on those calls with the most pressing needs. JS / L14002652 / 00206769 Page 2 d. Reducing the number of logs held by each dispatcher. Logs more than 24 hours old are now dealt with by another team so dispatchers can concentrate only on the most critical calls without the distraction of managing older logs. Numbers of logs held by each dispatcher has decreased from around 160 (as on the night of 22/23 March 2019) to around 60. e. Changing the dispatch model, including where people sit and how they interact, to promote more efficient handling of calls. f. Changing shift patterns to build better relationships between teams and to promote more efficient handling of calls and transfer of calls between shifts. 6. West Midlands Police takes its response to emergency calls extremely seriously. We constantly monitor the level of resources and performance to ensure appropriate resources are available across the full range of demands we face. Learning has been captured from this incident and training has been provided to the call handlers involved. This has also formed part of a review of THRIVE+ training for staff. A new Command and Control platform is being developed to support call handlers and those involved in resource despatch, allowing for improved identification of resource availability and response times. Monitoring of call response times and resolution has demonstrated that our actions taken a) to e) have improved our ability to respond with the finite resources available. Yours faithfully Legal Assistant Staffordshire and West Midlands Police Joint Legal Services JS / L14002652 / 00206769 Page 3
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