Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0039, written 11 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Feb 2021 |
|---|---|
| Reference | 2021-0039 |
| Deceased | Robert Hardy |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| Category | Police related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. 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: Greater Manchester Police 1 CORONER I am Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 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 7th August 2020 I commenced an investigation into the death of Robert Hardy. The investigation concluded on the 22nd January2021 and the conclusion was one of suicide. The medical cause of death was 1a) hanging. 4 CIRCUMSTANCES OF THE DEATH On 6th August 2020, Robert Stephen Hardy was found at his suspended from a ligature. home Address The inquest heard that Robert Hardy had mental health issues in the months preceding his death. On 25th July he had reported an attempt to take his life to GMP and had been taken to hospital by Police Officers. On 30th July he had reported an alleged assault to GMP involving a male he named and involving a weapon. The inquest heard that officers did not visit him to take an account and he was not signposted to any support services. The assault was not recorded as a crime by GMP until after his death. It was accepted in evidence that he was a vulnerable victim given his recent history. The inquest heard that in the 1 hours before his death he had telephoned GMP in response to the text message but ended the call. 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. – The evidence before the inquest was that GMP had not recorded the assault with a weapon as a crime within the crime recording system. It was accepted that this should have happened. The concern arises in relation to the impact this then had on the provision of and signposting of him to appropriate victim support given his recognised and known vulnerabilities. 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 April 2021. 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 following persons namely , Father of Mr. Robert Hardy, HM Inspectorate of Constabulary, Victims Commissioner for England who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of 2 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 Alison Mutch, Senior Coroner, for the Coroner Area of Greater Manchester South 11/02/2021 3
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.
A/Chief Constable
HM Senior Coroner Ms Alison Mutch
HM Coroner's Office
1 Mount Tabor Street
Stockport
SK1 3AG
Dear Ms Mutch
2 6 April 2021
Re: Regulation 28 Report following the inquest into the death of Mr Robert Hardy
Thank you for your report dated 11 February 2021 in respect of the events leading to the tragic
death of Mr Robert Hardy and pursuant to Regulations
Regulations 2013 and paragraph 7, Schedule 5, of the Coroners and Justice Act 2009.
and 29 of the Coroners (Investigations)
28
Having carefully considered your report along with the GMP PSB internal investigation report as
submitted in evidence at the Inquest of Mr Hardy we make the following observations/
recommendations to address your concerns. As a consequence, your report has already led to
detailed planning within GMP's Operational Communications Branch (OCB) to address the issues
identified. I have provided more detail of these measures below and reply to the specific issues
raised as follows
1 . The evidence before the inqu est was that GMP had not recorded the assault with a weapon as a
crime within the crime recording system. It was accepted that this should have happened.
The HMICFRS Victim Services Assessment of November 2020 identified organisational under
recording of crime and its findings are driving major improvements into our processes specifically
around the crime recording and ensuring that the minimum standards set within the National Crime
Recording Standards (NCRS) are met.
Pivotal to this improvement is the establishment of a
central Crime Recording and Resolution Unit (CRRU), which will help ensure crimes are submitted
for all relevant incidents.
-
At present, there is a reliance on the attending officer correctly recording the crime for many Grade
1 - 3 incid ents ( primarily the incidents which an officer actually physically responds to). On too many
occasions, as the HMICFRS report found, this was done incorrectly and not in a timely manner.
The specialist CRRU will alleviate many of these issues as many crime s will be recorded centrally,
very soon following the call from the victim. This new process commenced on a phased basis in
March 2021 and is on target to complete full implementation later this year.
Whilst the CRRU is being established, GMP has taken st eps to improve performance in the short
term. This has included a significant training programme for all officers and a new role for Incident
Progression Teams (IPTs) across the Force which are reviewing and ensuring that Grade 1
incidents are NCRS com pliant. This work is being quality assured by dip sample via the Crime
Standards Board which reports to the Deputy Chief Constable.
- 3
Postal address Greater Manchester Police
Lawton Street, Manchester M11 2NS
:
Cont.d pg 2 …
2 . The concern arises in relation to the impact this then had on the provision of and signposting of
h im to appropriate victim support given his recognised and known vulnerabilities.
GMP recognises the improvement required in the identification of and response to vulnerabilities.
The national THRIVE model, which delivers a consistent assessment of the threat, potential harm,
risk and vulnerability of a caller’s circumstances will, from May 2021, be used on every call GMP
receives. Training is underway for staff and a quality assurance system is being designed to test
compliance. This will enable us to safeguard vulnerable members of the public earlier.
In relation to victim support,
commissioned by the GMCA to provide victim support services. This service is designed on a
"consent - based," model, which is currently offered and referred, at the point of officer attendance.
G MP works in partnership with the Victim Support service,
GMP is currently working with Victim Support to review the point at which the offer and referral is
made, with the aim that it is made at the earliest possible opportunity. I am currently unable to
provide precise details as to the length of time this work will take however I will write to you further,
as soon as details become available.
GMP is in the process of implementing the "Making a Difference System," which is a computer
system which will give staff the opportunity to make a pre - approved offer of Victim Services via text
message and email to victims. This would be a sign - post only and would require the victim to 'self -
refer,' into the available services. This system should be implemented by May 2021.
Please let me know if you have any questions and I am happy to go into more detail on any of the
points above. We are working hard to make sure that the lessons learned from Mr Hardy's tragic
death change practice to help us improve the service we give to victims of crime in Greater
Manchester .
Y ours sincerely
A/Chief Constable
Postal address Greater Manchester Police
Lawton Street, Manchester M11 2NS
:
See every Prevention of Future Deaths report matching Police related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.