Hannah Beardshaw

POLiCE  B• 

1 June 2022 

Chief Constable 

Ms Rachel Raheela Syed 
Bolton Coroners Office 
Paderborn House, Howell Croft North 
Bolton 
BL 1 1QY 

Dear Ms Syed 

Re  Regulation 28 report following the inquest into the death of Hannah Beardshaw 

Thank you for your report dated 13 April 2022 in respect of the tragic death of Hannah Beardshaw 
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  evidence  submitted  at the  inquest  I make the 
following observations and recommendations to hopefully address your matters of concern . 

1.  A delay in escalating the incident, resulting in  almost a four hour delay to respond to 

the incident. 

GMP revisited it's Graded Response Policy (GRP) and made changes implementing a new GRP 
on the  1 February 2022. Incidents are  now graded following  a risk assessment via the THRIVE 
(Threat,  Harm, Risk, Investigation, Vulnerability, Engagement) framework and assessed  on  the 
information received as opposed to incident type or crime category. Incidents graded  1 are high 
risk incidents that require a response time within 15 minutes, incidents graded 2 are medium risk 
incidents that require  a response time within  1 hour these are referred to as 'go now' incidents, 
incidents  graded  C  are  low risk  incidents  that can  be  responded  to  outside  of 1 hour and  are 
referred to as 'go later', C  incidents are  often dealt with by appointment at a time suitable to the 
victim in line with their needs. The new GRP incorporates escalation of grade 1 incidents to District 
Inspectors immediately following  creation  in  the event that dispatch  staff are unable to task  or 
allocate a resource; and escalation of grade 2 incidents to district sergeants within 40 minutes in 
the event that dispatch staff are unable to task or allocate a resource, the responsibility is then on 
the district inspector/ sergeant to task a resource to  respond to the incident to deliver a service 
to the public. 

All staff within  the Force Contact Centre  (FCC) have received  training  on  THRIVE  and  the  new 
GRP incorporating  escalation. At shift changeover times  if an  incident  has  not been  resourced 
within the target time frame for arrival,  staff within the FCC will re escalate to district supervision. 

Stringent measurement of attendance times are in  place with daily data produced for both  FCC 
and district colleagues. Any incidents within the grade 1 and 2 queues that are over 24 hours old 
are flagged to  District Silver Commanders by the FCC  Supervisor responsible for that district at 
the district morning pacesetter meetings, via email or Teams message if insufficient supervisors 
are  on  duty within  the  FCC  to  have a  dedicated  supervisor  per district.  These  in  the  main  are 
grade 2 incidents where efforts to speak with the caller/victim  have failed due to their availability 
and there is deemed no threat to life to warrant forced entry under S.17 PACE. 

Postal address:  Greater Manchester Police, Openshaw  Complex, Lawton Street, Openshaw, M anchester M11  2NS 

 
 Contd pg  2 ... 

District Silver Commanders are the Superintendents or Chief Inspector's based  on  each  district 
who have the responsibility for district resourcing  that day.  The  FCC Supervisor will  provide an 
update as follows: 

•  Numbers of grade 1 and 2 incidents in the incident queue for the respective district 
•  Number of deployable patrols provided by the district to the FCC 
•  Number of incidents allocated 
•  Any  incident the  FCC  wish  to  raise for example a high risk missing from  home that has 

just been created 

•  Any  incidents in the incident queue that are over 24  hours old  (these should  be very few 

and are frequently as referred to above) 

2.  A failure to make  method  of entry kits  more readily available to those trained  in their 

use. 

Each GMP District or Branch  has a Method of Entry (MOE) SPOC (Single Point of Contact) who 
is responsible for the maintenance, storage and ordering of MOE kit and equipment. Most districts 
have  one  central  storage  area  of all  MOE  kit  and  some  designated  vehicles  also  have  MOE 
equipment stored within them . 

During the initial training course, students are informed of this procedure/SOP during the delivery 
of the twelve MOE safety rules.  How this equipment is distributed is determined by the individual 
districts or branches so upon their return from training , they will  be familiarised with each district 
or Branch process.  The SPOCs also  have access to the GMP suppliers for ordering  of new kit 
and equipment as and  when it is required . 

The recommendation to the SPOC network as a result of this tragic incident has  been the need 
to  audit their equipment and  identify where there  is  insufficient  equipment available  for trained 
officers. 

The Level 3 MOE training core syllabus covers the following: 

•  Legal inputs including  National  Decision  Model (NDM),  Code of Ethics, Powers of Entry 

and Human Rights. 
•  Use of the 'Lock Puller'. 
•  Use of the 'Enforcer' 
•  Use of levers 

As of 1 April 2016, Level 3 MOE officers must complete a three hour refresher course every three 
years.  There are 192 course  spaces available  per year for Districts and Branches to book their 
front  line  officers  onto.  How they decide who  or how many need  to  attend  is  a matter for each 
District  but  skill  spread  across  teams  and  reliefs,  inclusion  within  Performance  Development 
Reviews  (PDRs)  are  all  factors  taken  into  consideration  as  long  as  the  individuals  meet the 
following criteria: 

•  Job Related Fitness Test (JRFT) to level 5.4; 
•  A 'safe to use' lift and hold assessment; 

Up-to-date Personal Safety Training (PST). 

Should  there  be an evidenced  demand for additional  courses,  the training team  would  look for 
opportunities  within  the  training  plan  to  accommodate  this.  Staff from  within  the  Specialist 
Operational  Training  Department  meet  quarterly  with  District  Resource  Management  Units 
(DRMUs) and so  understand the demand picture for training and ensure MOE training provision 
and availability remains part of this agenda. 

Postal address:  Greater Manchester Police, Openshaw Complex, Lawton Street,  Openshaw, Manchester M11  2NS 

 Cont pg  3 ... 

The learning identified from this incident will form  part of the initial MOE L3 training going forward 
with  the  package  being  updated for future  delivery.  This  will  also  be  reflected  for  new  student 
officers joining GMP on the PEQF pathway who receive initial training on legislation and powers 
of entry. 

It  is also important that the  key messages and  learning from this tragic incident are conveyed to 
all other officers, particularly front line officers. In order to do this an article will be uploaded to the 
forces internal internet site and shared with the forces organisational  learning team who  publish 
a "Top 3" lessons message each month on which the learning from this incident will be conveyed. 
There has also been an updated Chief Constables Orders submission made for inclusion on the 
GMP Intranet to cover the MOE Levels, training  opportunities and SOPs. 

3. 

Improvement in document management 

The FCC is in the process of implementing a new and improved system that will replace Sherlock. 
Sherlock, the current system, holds information on policy and procedure however there are limited 
options with this system  in terms of version  control , updates and  organisation. 
It is the  FCC's 
intention  to  replace  the  whole  system  with  a  new  platform  which  is  already  used  within  other 
departments  of  GMP.  Developers  have  been  spoken  to  who  have  confirmed  that  these 
requirements can be built in and it is anticipated to have the new system in place by August 2022. 

The project team are actively working on content which will take up to six weeks and the technical 
team  are  actively  building  the  platform  which  will  take  around  two  weeks.  The  content  will  be 
migrated to the new system on weeks seven and eight. The system will then be tested on weeks 
nine and ten and training and implementation will  be undertaken on weeks eleven and twelve. 

A  project management group consisting  of Subject Matter Experts (SME) from  each  area of the 
FCC has been set up who will review Sherlock content,  archive outdated information and update 
policies and procedures as appropriate.  Once the content is up to date it will be built into the new 
system  which  comes  with  additional  benefits  including  much  improved  version  control ,  with 
changes  time  stamped  and  saved,  usage  analytics,  which  will  help  identify  skills  gaps  and 
required  training  material  and  it  will  be  far  more  responsive  in  terms  of time  taken  to  locate 
information. 

The FCC are already familiar with the system as it is used for other tasks and so system navigation 
training  should  be  simple to implement.  Briefing  notes  and  user guides will  be  developed  and 
supervision will  be given tutorials which they will then replicate with their teams. 

Previously  there  has  been  limited  investment  in  the  FCC  both  in  terms  of  resources  and 
technology which  has  greatly  affected  its  ability  to  meet  demand.  This  approach  resulted  in 
underperformance  and  poor  staff retention  along  with  a  number  of IT challenges.  The  newly 
agreed  upon  FCC  investment  plan  demonstrates  GMPs  commitment  to  improving  service 
delivery. The FCC are in the process of recruiting in all areas of business to stabilise performance. 
Improving  standards  is  an  area  of focus  in  addition  to  investing  in  equipment,  software  and 
process improvements that underpin FCC service delivery. 

Postal address:  Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11  2NS

OFFICIAL-SENSITIVE 

Our reference number: 2021/152017 

Miss Rachel Raheela Syed 
HM Assistant Coroner for Manchester West 

Sent via email  

6 June 2022 

Dear Miss Syed 

Regulation 28 Report to Prevent Future Deaths following the inquest into the death 
of Miss Hannah Beardshaw 

Thank you for your report to prevent future deaths which I received on 14 April 2022. I am 
responding on behalf of 
, Director General of the Independent Office 
for Police Conduct (IOPC).   

One of the IOPC’s strategic priorities is to improve policing by identifying and sharing 
learning from our work. While many investigations, appeals or reviews focus on individual 
learning, we also consider whether learning or improvement is needed at an organisational 
or national level. 

We identify and share learning from our work through a variety of methods, including the 
use of our statutory powers to make organisational learning recommendations during or 
following an IOPC independent investigation.  

The IOPC has the power to make such recommendations under both section 10 to the 
Police Reform Act 2002 and paragraph 28A of Schedule 3 to the Act. There are 
differences in the scope of these powers. Section 10 recommendations may be made to 
chief officers, local policing bodies and contractors. They may be made following or before 
the conclusion of an investigation, and may therefore be used for ‘quick-time learning’. 
Paragraph 28A recommendations may be made to the same bodies or any other 
organisation. They may only be made following an investigation. Where the IOPC makes a 
recommendation under paragraph 28A, the recipient must provide a written response 
within 56 days of the recommendation being made. 

The IOPC’s independent investigation into the death of Miss Hannah Beardshaw identified 
four systemic issues where, as decision-maker for the investigation, I felt changes were 
required to policy, guidance, training, systems, and equipment to prevent similar incidents 
occurring. 

The learning recommendations were set out in the IOPC final report, and an external 
consultation process commenced with Greater Manchester Police on 25 April 2022. The 
purpose of the external consultation was to receive input and feedback on the proposed 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
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recommendations, to help refine the recommendations to ensure they were factually 
accurate, effective in addressing the issue, achievable, and timely. 

We received a response from Greater Manchester Police to the proposed 
recommendations on 16 May 2022. I understand Greater Manchester Police will share 
their proposals with you directly in response to their Regulation 28 Report to Prevent 
Future Deaths.  

On 24 May 2022, I gave approval for all four learning recommendations to be formally 
issued to Greater Manchester Police in accordance with the IOPC powers under 
Paragraph 28A of Schedule 3 of the Police Reform Act 2002. The four recommendations 
are:  

1)  The IOPC recommends that Greater Manchester Police takes steps to ensure that the 
staff within the Force Control Centre understand the importance of the escalation 
policy and the individual responsibilities laid out within the policy for escalating 
incidents when they have been left unresourced for a period of time exceeding the 
targets for that grade. GMP could consider issuing communications to staff on these 
matters and/or ensuring that they are covered in appropriate training. 

2)  The IOPC recommends that Greater Manchester Police incorporates, if possible, a 
system prompt on ControlWorks specifically for control room supervisors to alert 
supervisors when a log has been unresourced for a period of time that exceeds the 
target for the incidents grade. 

3)  The IOPC recommends that Greater Manchester Police takes steps to make method 
of entry (MOE) equipment more readily available to officers when the need for MOE 
equipment arises. This could include assigning MOE tools to MOE trained officers at 
the beginning of their tour of duty. 

4)  The IOPC recommends that Greater Manchester Police takes steps to improve their 
record keeping and archiving around when changes are made to the Call Handling 
Minimum Standards. This could be achieved by way of implementing a version control 
system on any changes to the standards, making sure to document the date of the 
change, who made the change, the reason for the change, and specifically what has 
changed compared to the previous version. In addition, previous versions should be 
appropriately archived and dated for when they were in effect from and to. 

Greater Manchester Police now have a legal obligation to respond to the 
recommendations in writing by 20 July 2022. Their response must include details of the 
action they have taken or intend to take in response to the recommendations or, why they 
have not taken, or do not propose to take, any action in response to the recommendations. 
Our recommendations will be published on our website. We shall also publish GMP’s 
response unless they make representations that all or any part of their response should 
not be published. If we receive such representations, I will make a final decision on the 
publication of GMP’s response to our recommendations.   

May I take this opportunity to thank you for your Report to Prevent Future Deaths. I am in 
full agreement that the learning that was identified by the IOPC’s independent 

 
 
 
 
 
 
 
 
 
 
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investigation may prevent future deaths and, as such, it is of vital importance that action is 
taken by Greater Manchester Police.  

Yours sincerely 

Interim Regional Director - North-West Region 
Independent Office for Police Conduct (IOPC)