Neil Parkes

Legal Services 
Warwickshire Police 
Leek Wootton 
WARWICK 
CV35 7QA 

Department or Station Name 

Address Line 1 

Address Line 2 

Direct Dial: xxxxx 

Fax: xxxxx 

Mr S McGovern 
Senior Coroner for Warwickshire 

17th March 2022 

Dear Mr McGovern 

WARWICKSHIRE POLICE RESPONSE TO THE REPORT TO PREVENT FUTURE DEATHS 
(REGULATION 28) in respect of NEIL KENNETH PARKES. 

Thank  you  for  your  Report  dated  20  January  2022  in  respect  of  concerns  arising  from  the 

evidence presented at the Inquest into the circumstances surrounding the death of Mr Parkes on 

14 May 2020. 

In particular, we note your concerns relate to the lack of response by Warwickshire Police to two 

calls made to 101 (the non-emergency telephone number) by University Hospital Coventry and 

Warwickshire (UHCW) whilst Mr Parkes was being cared for in hospital between 28 April and 14 

May 2020, requesting assistance in identifying him.  The key calls of concern we believe were on 

1st May and 13th May. 

Calls to Police – 

1. 29/04/20 at 11.50 hours - Call from 

 at UHCW intensive care; male brought in

with no identification, requesting help with next of kin details.

Warwickshire Police despatched officers to the scene in Nuneaton where Mr Parkes had 

been found.  The person who called the ambulance to Mr Parkes on 28 April was identified 

 
 
 
 
 
 and they were spoken to.  House to House enquiries were conducted by police officers but 

no one knew Mr Parkes/his identity or why he was there. 

2.  01/05/20 at 17:06 hours  - Call from 

, Cardio Thoracic Critical Care at UHCW 

call WP advising male admitted to hospital on 28 April had not woken up and therefore still 

not identified.  Description given to police. 

The  call  handler on  this call  made  a  check on  COMPACT  (the  system  which  relates  to 

reported missing persons) to check against the descriptive detail given. There is a note on 

this log in relation to fingerprints and the fact that the hospital would need to contact West 

Midlands Police to take prints for identification.  It is not known whether the hospital did 

contact West Midlands Police, but prints were not taken at this time. 

Our internal review noted that the check made on COMPACT at this stage was “cursory” 

and that there was no evidence this call was passed to a Supervisor or the intelligence 

team for any further advice or consideration of making contact with surrounding forces. 

The Control Room Manager has reviewed this incident with the call handler and advice 

was  given  in  respect  of  referring  calls  of  this  nature  to  the  control  room  supervisor  to 

facilitate full intelligence checks both internally and with any surrounding forces to be made. 

3.  It appears that a follow up call was made to police on 5 May.  

In response to this call, it was suggested that the Safer Neighbourhood Team could make 

enquiries  and  a  “tag”  was  placed  on  the  incident,  however  there  is  no  evidence  of  this 

being followed up directly with the SNT to advise of the nature of the enquiries required or 

any indication that this was passed to an on duty SNT team. 

There is information recorded on the call log to suggest that there was discussion at this 

stage of liaising with a Supervisor in relation to a mobile fingerprint kit but nothing has been 

endorsed on the incident by the Supervisor. 

All  staff  involved  with  this incident  have  been  spoken  to by  the  Control Room  Manager 

about undertaking a full THRIVE (threat and risk) assessment and detailed rationale for 

inclusion on the incident log to show all enquiries made and actions completed.   

 
 
 
 
 
 
 
 
 
 
 
 The log had been updated by the Safer Neighbourhood Teams who attended the location 

as  to  the  result  of  their  enquiries  with  residents.    However  the  log  was  later  closed  by 

control without any further comments recorded and marked as “closed pending any calls 

back”.   

The controller who closed the incident has been spoken to about ensuring that all logs are 

fully updated before closing. 

On 9th May, there is a further entry on this incident to cross reference it to the call from 29 

April and endorse that house to house enquiries had been undertaken following the first 

call and therefore the SNT tag was removed.  This entry has been reviewed and reported 

on as a correct, comprehensive update on the incident. 

4.  13/05/20 – UHCW contact Warwickshire Police to pass the following information: 

  Patient number 

  Circumstances of patient being found in Nuneaton and that the hospital believe the 

incident to be drink-related due to the results of the CT scan 

  The patient was on oxygen and was sedated, that his prospects were not positive 

and that he was very poorly.  The hospital were requesting his details to inform next 

of kin. 

There was discussion during this call of ways of seeking confirmation of identity and the 

possibility  of  assistance  from  the  local  authority.    It  was  agreed  that  the  hospital  would 

provide  the  required  data  protection  forms  and  photographs  to  seek  the  required 

information from police; this was actioned with the necessary forms being provided.  Sadly, 

this process was not finalised prior to Mr Parkes’ death. 

Actions and Learning Outcomes: 

Warwickshire Police conducted an internal review immediately upon CID/senior officers becoming 

aware of the issues following Mr Parkes’ death on 14 May.  The results of those initial enquiries, 

lessons  learnt  and  actions  taken  were  shared  with  Mr  Parkes  family  at  a  meeting  on  27  May 

where his family accepted the outcomes, indicated they did not want to hold individuals to account 

and  they  did  not  believe  it  would  have  changed  the  outcome  for  their  son  but  were  keen  for 

positives to come from this incident where possible. 

 
 
 
 
 
 
 
 
 
 The actions taken and organisational lessons learnt by Warwickshire Police include: 

  Taking part in the Safeguarding Panel Review to understand and identify issues with any 

partnership working and any changes required (the resulting Lessons Learned Briefing did 

not produce any reflective learning in respect of Warwickshire Police’s involvement) 

  An entry made available to all officers and staff through the Vulnerability and Safeguarding 

Newsletter on 1st December 2021 setting out lessons learnt from this Inquest.  They were 

as follows: 

o  The necessity for officers conducting hospital enquiries to ask specifically for details 

of any “unknown” or “unidentified” patients within their care.   

o  The necessity to consider researching other local incidents which may be linked to 

missing person enquiries. 

o  The necessity to take fingerprints (using the Mental Capacity Act 2005 provisions) 

where establishing identify may assist with treatment of a medical need. 

  Control Room staff have received words of advice and organisational learning has been 

circulated on the following issues: 

o  When using the “SNT” tag, ensure there is a full explanation of what is needed from 

the Safer Neighbourhood Team and who the SNT are to make contact with, 

o  Call handlers are to check whether SNT are actually on duty at the time of the call 

and consider liaising directly 

o  Any incident of note is to be brought to the attention of the OCC supervision for full 

review before closing 

o  Consideration  to  be  given  and  documented  on  the  incident  for  the  24  hour 

Intelligence Team to complete additional checks. 

o 

Incidents should be resulted with actions taken and rational for closing and just not 

just marked as “closed pending further calls” 

o  SNT to request logs to be re-opened if further actions need to be taken following 

their involvement. 

We hope that this response will provide some reassurance that the issues identified in this case 

were  taken  seriously  and  reviewed  promptly  and  that  necessary  changes  and  actions  were 

implemented by Warwickshire Police to remedy and share learning across the organisation.  The 

internal review reported to Chief Officers and to Mr Parkes’ family within 2 weeks of his death and 

learning has been appropriately cascaded to seek to ensure that our response is improved in any 

future cases of a similar nature.   

 
 
 
 
 
 We have apologised to Mr Parkes’ family and repeat here our sincere condolences for their loss.  

We wish to reiterate our commitment to seeking to ensure that our officers and staff maintain the 

highest possible standards of conduct and performance and to that end we will continue to monitor 

and share any further learning or improvements which are identified. 

Yours sincerely 

Head of Legal Services