Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0350, written 19 Oct 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Oct 2021 |
|---|---|
| Reference | 2021-0350 |
| Deceased | Donna Constantine |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| Category | Police related deaths · Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: To go to National Police Chiefs Council Secretary of State for the Home Office Chief Executive of the College of Policing Victims Commissioner for England 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 23rd September 2019 I commenced an investigation into the death of Donna Constantine. The investigation concluded on the 30th September 2021 and the conclusion was one of open. The medical cause of death was unascertained. 4 CIRCUMSTANCES OF THE DEATH On 21st September 2019 Donna Ann Constantine was found at her home address after neighbours raised concerns. She was severely decomposed. Post mortem examination could not establish a cause of death due to decomposition. Donna Ann Constantine was a vulnerable adult known to multiple agencies including Mental Health Services and Greater Manchester Police. She had repeatedly expressed suicidal ideation in the past. She had taken the tenancy at from 12th August 2019. She was supported by the Housing Resettlement Worker from her temporary accommodation. She was referred to the Housing Support Service for support post her move. She sent a text message to her Housing Resettlement Worker and a Greater Manchester Police Officer whose work mobile number she had been provided with to indicate she was very unwell on 18th August 2019. She sent no text messages after 20th August 2019. Attempts to follow up dropping off her belongings were not made after 22nd August 2019. Unsuccessful attempts to contact her by the Housing Support Team were 1 not escalated. The last known activity from her phone was on 22nd August 2019. No concerns for welfare were raised in the period from 22nd August until she was found on 21st September 2019. 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 inquest heard evidence that as part of the way in which GMP have sought to embed the Victims Code and engage with victims Police Officers are actively encouraged to provide victims/vulnerable members of the community with their work mobile telephone numbers. Those given the number are encouraged to use those numbers to raise concerns with the Police. In this case that is what Donna Constantine did. However the phones are not monitored when officers are off duty or on annual leave. This the inquest heard created an ongoing risk that vulnerable members of the community would contact officers in a way e.g. text/voicemail that would not necessarily allow their contact to be dealt with immediately. The inquest was told that this promotion of contact via mobile telephone numbers was not restricted to GMP and was in fact part of a national policing approach. It had been recognised that there were risks involved in encouraging contact in this way but no solution had been identified to reduce the risk. In contrast to contact via 999 and 101 there was no clear escalation policy for officers to follow if they received calls from members of the community and no clear policy regarding the creation of an audit trail of actions taken and no way of recording the calls verbatim unlike calls to the call handling team. 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 14/12/2021. I, the coroner, may extend the period. 2 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 Interested Persons namely the family of the deceased, who may find it useful or of interest. 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 19/10/2021 Alison Mutch HM Senior Coroner 3
2 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.
Home Office
'
Ms Alison Mutch
Coroner's Court,
1 Mount Tabor Street
Stockport
SK13AG
Home Secretary
2 Marsham Street
London SW1 P 4DF
0 1 DEC 2021
HM CORONER
MANCHESTER SOUTH
DECS Reference: MIN/0197456/21
~ovember 2021
T{a~k you for your letter of 19 October enclosing a copy of the Regulation 28 Report to
Prevent Future Deaths, following the inquest into the death of Ms Donna Ann Constantine.
I was saddened to learn about the death of Ms Constantine and I would first like to express
my deepest condolences to her family for their loss.
I acknowledge your concerns detailed in your report, and should stress that police forces are
operationally independent and, as such, it is for the Greater Manchester Police, the National
Police Chiefs Council and the College of Policing to address the specific issues raised about
their ways of working as they relate to the inquest into the death of Ms Constantine.
However, I can reassure you that the NPCC and CoP, who you have named in the report and
have operational responsibilities are aware of the recommendations and are working together
to address them and respond within the requisite 56-day period.
As a department I can advise we will continue to liaise with the NPCC and CoP on the
development of policing policy and ensure that they take forward their response to your
recommendations.
Additionally, I would like to assure you that the police take their duty of care towards
vulnerable people very seriously and work hard to ensure appropriate and safe outcomes for
the public that they serve.
Improving the way in which the police respond to people who have vulnerabilities, whether
they are suspected of committing a crime or not, is of utmost importance to me and we are
playing our part to ensure that vulnerable people receive the treatment and care they need
when they come into contact with the police.
Thank you for writing to me on this important matter. I hope that my response has
demonstrated that we take the duty of care of vulnerable people seriously and continue to
work to make Improvements.
Rt Hon Priti Patel MP
Ms Alison Mutch, Senior Coroner, Greater Manchester South BN13 2PQ Email only: 14th December 2021 Dear Ms Mutch Regulation 28 Report – Ms Donna Ann Constantine We write on behalf of the National Police Chiefs Council (NPCC) and the College of Policing (the College) in relation to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, and the prevention of future deaths reports sent to the NPCC and the College, both dated the 19th October 2021. Whilst the NPCC and the College have separate and distinct responsibilities, the two organisations frequently work together on national approaches to policing policy. As such, this response is provided jointly in respect of both organisations’ separate prevention of future deaths reports. The notice sets out concerns that arose from the information received during the inquest into the death of Ms Constantine. We are very sorry to read of the circumstances of Ms Constantine’s death. Our sympathies are with her family and friends and we share your commitment to addressing the issues that contributed to her untimely loss. The notice sets out your principal concern which highlights a text message sent by a vulnerable person to a Police Officer’s mobile phone which was not being monitored and your concern that giving out officer’s phone numbers to victims was a national policing approach. In order to establish a better understanding of the circumstances in relation to this PFD we have met with the relevant leads from Greater Manchester Police and wider NPCC portfolios to discuss this fully. Firstly, it is important to note that since the death of Ms Constantine, the Victims Code was updated in April 2021, with a number of key changes having been introduced. These are: • The Code provides 12 overarching rights, so it is easier to understand and apply. • • Officers and staff must minimise contact points and provide a 'single points of It makes frequency and method of contact with the victim, victim led. contact' for information where possible. • Officers and staff have more discretion as to when it is most appropriate to offer a victim personal statement. • There is a greater emphasis on explaining 'why' certain decisions have been made The purpose of the victim’s code is to maintain contact with the victim in relation to their reported crimes, along with implementing any special measures required as a vulnerable person. It is appreciated of course that officers dealing with an investigation may wish to give their work number/email address to a victim of crime as a point of contact. This would be in order to discuss the progress of their crime or request/ gather further information as required. However, forces nationally are not (neither had they been prior to April 2021) encouraged to give out mobile phone numbers as a point of contact in an emergency or in the event of illness/concern for welfare. Should victims have an emergency they are encouraged to call 999 or 101 for a non- emergency in every case. Should an officer receive a call which indicates an emergency/concern for welfare they would be expected to call the relevant control room to report the incident which can then be recorded and allocated for attendance in the usual way. We hope that this addresses the concerns you raise. Should you have any further questions in relation to our response please send this to Yours sincerely Chair National Police Chiefs’ Council Chief Constable CEO College of Policing Page 2 of 2
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