Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0412, written 21 Dec 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Dec 2022 |
|---|---|
| Reference | 2022-0412 |
| Deceased | Angeline Phillips |
| Coroner | Alan Walsh |
| Coroner area | Manchester (West) |
| Category | Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: I I I 1 I 1 1 1. The Chief Constable, Greater Manchester Police Headquarters Central Park 1 Northampton Road Manchester M40 5BP CORONER I am Professor Dr Alan Peter Walsh, HM Area Coroner for the Coroner Area of I Manchester West I I I 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. t ;1 3 1 INVESTIGATION and INQUEST On the 2nd February 2021 I commenced an investigation into the death of 1 Angeline Marie Phillips, 35 years, born on the 20th December 1985. The investigation concluded at the end of the inquest on the 5th December 2022. The medical cause of death of Angeline Marie Phillips was: 1a) Toxicity The conclusion of the investigation at the Inquest was Misadventure. 4 CIRCUMSTANCES OF THE DEATH 1) Angeline Marie Phillips (hereinafter referred to as "the Deceased") died on the 30th January 2021 at her home address at 2 Wilbraham Road, Walkden, Manchester. I 2) The Deceased was found having died at her home address at 03.48 hours on the 30th January 2021, having had no contact with family or friends after 19.44 hours on the 28th January 2021. 3) On the 29th of January 2021 at 18.09 hours a friend of the Deceased contacted Greater Manchester Police by telephone and reported a concern for the welfare of the Deceased. The friend confirmed that the Deceased had been in and out of Hospital (both Salford Royal Hospital and the Royal Bolton Hospital) in the previous week following on from numerous suicide attempts. The home address of the Deceased was given to the Police as 2 Wilbraham Road, Walkden, Manchester. 4) The Call Handler graded the priority response to the reported incident under the Greater Manchester Response Policy, which was last amended to Version 1.4 on the 24th June 2019. The response was graded as Grade 2 Priority Response, which requires the radio operator to allocate the incident within 20 minutes and attendance within 1 hour from the creation of the Incident Log. 5) A police officer did not attend 2 Wilbraham Road, Walkden, Manchester and at 20.28 hours on the 29th of January 2021 a Sargent, who was the Command and Control Supervisor, made a decision that the incident was a medical matter and the North West Ambulance Service (hereinafter referred to as "NWAS") needed to deal with the incident. The incident was reported to NWAS at 20.32 hours. 6) NWAS attended the Deceased's home address at 23.06 hours and confirmed that there was no answer at the address or from any contact numbers and the Ambulance crew had left the address to attend another incident. 7) At 00.03 hours on the 30th January 2021 th'e Command and Control Supervisor noted the Incident Log "For Allocation" but a Police officer still did not attend the address at 2 Wilbraham Road, Walkden, Manchester until entry to the address was forced at 03.48 hours by police officers and the deceased was found having died in the property. 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 could 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) During the Inquest evidence was heard that: - a) The Greater Manchester Police Incident Response Policy governed the grading of an Incident in relation to priority and the response time to an Incident. . 2 I I b) In relation to the grading of the lncide.nt relating to the Deceased, which was reported at 18.09 hours on the 29th of January 2021, the Incident was graded correctly as a Grade 2 Priority Response with a response time of 1 hour but a police officer only attended more than 8 hours after the report of the Incident with the Incident having been referred to NWAS without a police officer attending. c) The Greater Manchester Police Incident Response Policy makes no reference of an option to refer the Incident to a 3rd Party, such as NWAS, but there is no specific reference in the Policy that the attendance must be by a police officer and that the responsibility to attend must not be passed to a 3rd party or any other agency. d) I am concerned that unless the Greater Manchester Police Incident Response Policy is reviewed police officers will not attend Incidents within the timescales referred to in the Policy and there will be an opportunity to pass the responsibility to 3rd party agencies, which may lead to a risk that future deaths could occur unless action is taken. 2) I request that you conduct a review of the following concerns I I I I I I a) A review of the Greater Manchester Police Incident Response Policy to consider specific reference in the Policy that the attendance must be by a police officer and that the responsibility to attend must not be passed to a 3rd party or another agency. b) When the review has taken place implement to consider the implementation of a training programme for all police officers and civilian staff involved in the operating procedures referred to in the Greater Manchester Police Incident Response Policy 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 15th February 2023 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. 3 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. 2. 3. Greater Manchester Mental Health Trust - DAC Beachcroft Solicitors Independent Office of Police Conduct Sister of the Deceased I am also under a duty to send a copy of your response to the Chief Coroner, and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 Dated 21st December 2022 Signed &:-------tAt- Professor Dr Alan Peter Walsh, HM Area Corner, ManchestElr West 4
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.
POLICE Ii 14th Feb 2023 Chief Constable Professor Dr Alan P Walsh HM Area Coroner, Manchester West HM Coroner's Court Paderborn House, Howell Croft North Bolton BL1 1QY Dear Professor Dr Walsh Regulation 28 Report following the Inquest touching upon the death of Angeline Marie Phillips Thank you for your report dated 21 st December 2022 in respect of Angeline Marie Phillips (deceased) 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 matters therein , I reply to the concerns raised as follows. Extract from Regulation 28, point 2a): "A review of the Greater Manchester Police Incident Response Policy to consider specific reference in the policy that the attendance must be by a police officer and that the responsibility to attend must not be passed to a 3rd party or another agency" Greater Manchester Police (GMP) carried out a thorough review of the Incident Response Policy (IRP) following His Majesty's Inspectorate of Constabulary and Fire & Rescue Services issuing a formal cause of concern in September 2021, where it was identified that GMP was not responding appropriately to victims of crime and safeguarding vulnerable members of our communities. 1st As a result, on February 2022, GMP implemented the current IRP which incorporates the nationally recognised risk assessment approach to incident grading known as THRIVE (Threat, Harm, Risk, Investigation, Vulnerable and Engagement). The THRIVE process has been implemented since the tragic death of Ms Phillips and represents a significant change from the procedures that were in place at that time. The THRIVE process is followed by most police forces across the country. Following THRIVE empowers Force Control Centre (FCC) officers and staff to resolve incidents in the most effective and appropriate way. Force-wide training on the IRP was provided to GMP officers and staff during its initial implementation, to ensure all of those who are required to follow the policy are clear about their responsibilities so that the appropriate grade is applied to each incident. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS Cont.d pg 2 ....... GMP undertakes a THRIVE risk assessment for all incidents. The THRIVE assessment process informs the appropriate response. GMP will deploy to an incident where it has been identified that a police response is required . However, there are incidents where GMP is not the most appropriate agency to respond to, or lead on the response to, an incident. Where the THRIVE risk assessment identifies that the response may be better provided by another agency, GMP liaises with that agency to determine how the response will be progressed. This can lead to the other agency taking over the incident or, if appropriate, a joint response may follow. THRIVE risk assessments and the liaison and decision-making in relation to deployments are documented on police systems. FCC officers and staff responsible for deploying patrols to incidents are required to revisit the THRIVE risk assessment at key points during the life of an incident, including where there is any change of circumstances and when a re-grade is required. FCC officers and staff cannot make changes to an incident, such as re-grading or closing , without a thorough risk assessment being recorded. GMP has reflected on the concerns raised within the Regulation 28 report and considers that a review of the IRP to direct police attendance at all incidents would not provide the best level of service to the public. The IRP has been reviewed in the period following Ms Phillips' death. The system that is in place now provides a robust risk assessment process which results in attendance by the most appropriate agency. Identifying the most appropriate agency to respond to an incident ensures that those in need receive the right support from those with the requisite skills at the right time. The desire to further improve the service to those in crisis has led to the design of the proposed Greater Manchester Mental Health Urgent Triage (M-HUT) team. A pilot scheme for M-HUT commenced in January 2023 and is ongoing. With regard to how the pilot scheme is operating, the M-HUT is a multi-agency team which is working within the Ambulance Emergency Operations Centre. Calls made to blue light services which involve mental health concerns and which meet a set of predetermined criteria are afforded a triage assessment by a mental health practitioner. This specialist will then advise and divert the incident to the most appropriate support to ensure the patient is given the right care at the right time. Mental health incidents identified as having an immediate threat to life still receive an emergency police or ambulance response in line with current response policies and the M-HUT will not impact on the emergency response to such incidents. The M-HUT also provides a "professionals' line" for police and ambulance resources at the scene of an incident involving mental health issues; providing advice, information, and guidance to frontline professionals which enables them to deal with the incident in the most appropriate and informed manner. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS Cont.d pg 3 .... Some of the benefits expected to result from the M-HUT pilot are: • Clear partnership decision-making and clarity of agency lead for each call made to emergency services; • The introduction of pathways to access voluntary sector, primary care and secondary care support services to give people the help they need at that time, thereby improving patient outcomes and safeguarding across Greater Manchester; • The provision of a multi-agency collaborative service offer; • To build on the foundations of the current Mental Health Tactical Advice Service, providing real time professional advice to police officers on scene; • Digital solution enhancements to improve sharing of information and partnership safeguarding in real time. The M-HUT pilot will test the intended processes and avenues to address mental health demand in a partnership context. The pilot scheme is expected to continue into mid-2023 to allow for the impact of the scheme to be fully understood across partnership organisations. The partnership response to mental health is a key strategic aim of GMP and is being led and driven under the GMP Prevention Branch. Bettering outcomes for communities across Greater Manchester and improving effective partnership working is a clear focus for GMP. Extract from Regulation 28, point 2b): "When the review has taken place to consider the implementation of a training programme for all police officers and civilian staff involved in the operating procedures referred to in the Greater Manchester Police Incident Response Policy" All FCC officers and staff received training on the IRP and THRIVE during the initial implementation. The training was delivered in a classroom environment by subject matter experts. To supplement the training GMP has designed a number of audits that are used to test the quality of IRP management and THRIVE content. In addition, the FCC Service Development Unit holds frequent briefings designed to continually test and upskill FCC officers and staff. The training is included in all new joiner programmes. I hope that this response is helpful in addressing the issues that you have raised , and in demonstrating our total commitment to learning lessons from tragic events such as those which led to the death of Ms Phillips, so that we can do our utmost to prevent such incidents from occurring in future. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS
See every Prevention of Future Deaths report matching Emergency services related deaths (2019 onwards), 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.