Sarah Holmes

Caxton House  

Tothill Street  
London   
SW1H 9NA 

8 February 2024  

Ms Janine Richards 
Area Coroner for Durham and Darlington 
H.M. Coroner’s Office 
P.O. Box 282 
Bishop Auckland 
Co. Durham 
DL14 4FY 

Dear Ms Richards,  

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

I write on behalf of the Department for Work and Pensions’ (“DWP”) in response to your Prevention 
of  Future  Deaths  Report  made  under  Regulation  28  of the  Coroners  (Investigations)  Regulations 
2013.  

I would like to take this opportunity to express my condolences, both personally and on behalf of 
DWP, to Ms Holmes’ family. 

You raised the following concerns in your report: 

(1)  The  central  cause  of  Sarah’s  mental  health  deterioration  was  her  concerns  in 
relation to a difficulty that had arisen in respect of her benefits, and the prospective 
actions she feared would be taken by the Department of Work and Pensions as a 
result.  

(2)  The  DWP  were  aware  that  Sarah  had  mental  illness  and  that  she  was  “very 
distressed” about the difficulty which had arisen, namely that she had earnt very 
slightly above, for a very short period of time, the permitted level for the benefit 
she was in receipt of.  

(3)  I have a concern about how the DWP interact with the vulnerable when there has 

been a difficulty in relation to benefits.  

(4)  Although the recordings of the calls were not available to me, I am satisfied that 
Sarah was made aware of the possible actions available to the DWP. These actions 

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 included  the  possibility  of  closing  her  claim,  referring  the  overpayment,  and 
requiring Sarah to make a new claim for Universal credit, in place of the ESA benefit 
which had been payable to her as an individual with a disability or health condition 
that affects how much they can work. No new claim for ESA could be made in this 
eventuality. I am concerned about both the availability of disproportionate action 
and the communication of this.  

(5)  I understand that the DWP are undertaking an internal investigation into this case, 
and  that  they  consider  all  correct  procedures  were  followed  in  terms  of  call 
handling, but I remain concerned that greater care needs to be taken in relation to 
how such prospective actions are communicated to those the Department knows 
to be vulnerable and distressed. 

DWP interaction with vulnerable customers 

The department supports millions of people every year and its top priority is that they get the benefits 
to  which  they  are  entitled  at  the  right  time,  and  to  ensure  they  receive  a  supportive  and 
compassionate service.  

The department is bound by laws which dictate how the benefit system is delivered and clearly define 
a person’s entitlement to benefit. The Social Security Administration Act 1992 is the main piece of 
legislation dealing with the administration of social security benefits in the United Kingdom. 

Under this legislation, DWP can only pay benefits to those who are legally entitled. However, partly 
because of processes it has in place to support vulnerable claimants, the department continued to 
pay Ms Holmes’ benefit even when a question arose about her entitlement. If a decision had been 
made  to  close  Ms  Holmes’  Employment  and  Support  Allowance  (ESA)  claim due  to  her 
earnings exceeding  the  permitted  work  (PW)  limits,  she  would  have  had  to  make  a  new  benefit 
claim. Relevantly,  Ms  Holmes’  claim  was  for  Income  Related ESA  which  no  longer  accepts 
applications. In usual circumstances, Ms Holmes would have been directed to make a new claim to 
Universal Credit. 

To  support  the  application  of  this  legislation  the  department  has  robust  policies  and  guidance  in 
place to support colleagues dealing with customers it identifies as vulnerable. I describe some of 
these below. 

Customer Experience Directorate 

The  Customer  Experience  Directorate  was  created  in  2019  to  co-ordinate  policy  development, 
guidance, and learning, as well as monitoring the implementation of change. Through this directorate 
the  department  is  examining  how  it  listens  and  learns  as  an  organisation  using  customer 
experiences, insight and data to improve the service it offers to its customers. 

The Customer Experience Advanced Support Team 

The Customer Experience Advanced Support Team (CEAST) for Working Age (WA, the business 
area ESA sits under) was established in January 2021. Its function is to support DWP colleagues 
and external partners who identify customers who are vulnerable, or have complex needs, and who 
therefore  need  more  advanced  support  in  order  to  comply  with  the  statutory  requirements  of  the 
benefit. 

WA CEAST work with Vulnerable Customer Champions (further details provided below) to provide 
specialist support to vulnerable customers and work closely with colleagues across DWP to resolve 
any complaints raised.   

Additional checks before withdrawal of benefits from vulnerable customers 

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 The  department  has  reviewed  the  processes  in  place  where  existing  benefits  are  suspended  or 
stopped  and  has  put  in  place  additional  steps  to  check  on  the  wellbeing  and  support  needs  of 
customers it identifies as vulnerable. For example, Stopping Payments guidance introduced in 2020 
ensures that payments are not stopped or suspended while the department considers a customer’s 
vulnerability. 

Measures in place to support vulnerable customers 

DWP  looks  to  maximise  opportunities  to  signpost  vulnerable  customers  towards  support.  The 
department wants to ensure that chances to flag concerns to agencies with statutory safeguarding 
responsibilities are not missed.  

DWP  frequently  collaborates  with  these  agencies.  For  individual  customers,  the  department  can 
liaise with health and social services to consider next steps, contact GPs for evidence for disability 
benefits  decisions,  or  offer  a  voluntary  referral  to  local  authority  housing  teams  (in  England)  for 
people who may be homeless or threatened with homelessness. 

The  role  of  the  Vulnerable  Customer  Champion  (VCC)  was  implemented  to  provide  additional 
support to customers. VCCs help support Decision Makers to make more informed decisions when 
dealing with vulnerable customers, particularly those that fail to attend Work Capability Assessments 
or do not engage with DWP as required under the terms of their benefit entitlement. 

The department’s national network of Visiting Officers allows DWP to meet the needs of customers 
with  complex  requirements  who  may  be  unable  to  access  its  services.  This  includes  vulnerable 
customers and those needing additional support. 

Disability  Employment  Advisers  have  extensive  knowledge  of  the  support  available  enabling 
customers with health conditions and disabilities to prepare for work and move into and remain in 
employment. They work with stakeholders and healthcare professionals meeting customer needs.   

The  department  also  has  a  detailed  mental  health  training  package  which  all  customer  facing 
colleagues undertake. This provides colleagues with learning that they can then apply to the different 
scenarios with which they may be faced. The training includes modules on appropriate actions to 
take to support customers with vulnerabilities including mental health issues.   

The package is constantly evolving, and work is ongoing to further strengthen guidance and training 
as part of continuous improvement activities. These activities benefit all our customers, especially 
the many vulnerable people who rely upon us. One of these improvements is the introduction of the 
Serious Case Panel, which was set up in late 2019. 

The Serious Case Panel meets quarterly considering themes and issues that have arisen across 
DWP service lines, in order to agree changes and improvements. It does not investigate individual 
cases but considers themes arising from a range of sources, including Internal Process Reviews, 
frontline  feedback  and  Independent  Case  Examiner  reports. The  minutes  of  its  meetings  are 
published on the GOV.UK website. 

DWP  communication  with  Ms  Holmes  regarding  the  possible  effects  of  her  work  on  her 
Employment and Support Allowance claim 

Departmental guidance on supporting vulnerable ESA customers requires details of any incapacity 
to  be  recorded  on  a  customer’s  account.  When  a  call  handler  accesses  the  customer’s  account, 
details of the incapacity are available on screen as primary and secondary disabilities. The purpose 
of this is to ensure that call handlers are aware of any health conditions which may impact a customer 
and require them to tailor their communication accordingly. 

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 DWP provides call handlers with training that helps them understand some of the issues that people 
with mental health conditions might face. However, they are not medically trained and DWP does 
not expect call handlers to have a detailed understanding of individual mental health conditions.  

The existing service assurance process includes the requirement for call handlers to check customer 
records for any additional needs each time a customer contacts the department. This, alongside the 
incapacity banner and tailored training, enables colleagues to identify and be mindful of a customer’s 
vulnerability  or  additional  needs.  This  means  that  each  interaction  will  be  assessed  against  the 
information known at that time, allowing us to adapt to the individual’s circumstances. 

As  you  are  aware, Ms  Holmes  was  in receipt  of both  ESA  and  Personal Independence  Payment 
(PIP) at the time of her death. Neither of these benefits required Ms Holmes to routinely attend her 
local Jobcentre, nor did she have regular interactions with DWP once she had been assessed as 
eligible to receive each benefit.  

Ms Holmes’ entitlement to PIP began on 21 March 2017 and remained until her death. DWP were 
not  aware  of  Ms  Holmes’  worries  regarding  exaggerating  her  health  conditions  on  her  PIP 
application, nor the impact it was having on her mental health as stated by the NHS and Police at 
the inquest. Her payments continued until her death.  

Similarly, her entitlement to ESA began on 5 April 2017 and remained until her death. ESA payments 
continued despite the doubt of entitlement in relation to Ms Holmes’ permitted work, which I will come 
to next.  

Ms Holmes telephoned the ESA enquiry line at 11:20 on 4 July 2023 as she thought she might have 
earned over the permitted work limit. The primary incapacities listed on Ms Holmes’ account were, 
“debility (other)” and “mental illness”.  

The note of the initial call from Ms Holmes stated that she was “very distressed”, however there was 
no mention of her expressing suicidal thoughts or any intention to harm herself. The telephony agent 
recognised  that  Ms  Holmes  was  distressed,  as  demonstrated  by  the  note  they  recorded  on  the 
computer system, which meant that the distress would be known to future colleagues. The telephony 
agent also arranged for a 3-hour call-back because they were unable to fully answer her query. The 
call back procedure involves an electronic message being sent to the site to which the customer is 
attached  in  order  for  a  processing  agent  to  make  contact.  Arranging  for  someone  to  contact  the 
customer  within  3  hours  is  the  correct  procedure  in  circumstances  where  a  customer  appears 
distressed but does not indicate that they are suicidal or at risk of harming themselves.  

A telephone call was made to Ms Holmes later that day at 14:04, in accordance with DWP guidance. 
The call notes confirm that “earning over the limit was discussed” and that Ms Holmes “advise[d] she 
will be reducing her hours to earn under PW limit and will send in PW1 form”. There is no mention 
of suicidal thoughts or an intention to harm, therefore no further action would have been required 
following this call. 

The ESA agent did not stop Ms Holmes’ benefit pending the receipt of a PW1 form even though her 
benefit  entitlement  was  in  doubt.  This  action  indicates  that  Ms  Holmes’  vulnerabilities  were 
recognised, and the department’s Stopping Payment guidance had been followed. Ms Holmes’ PW1 
form, along with proof of earnings, was received by the department on 14 July 2023. 

No further action was taken by DWP in relation to Ms Holmes’ ESA claim at that time and payments 
continued to be made to Ms Holmes until her death. 

Conclusion 

The full circumstances of this case have been reviewed, and the department is satisfied that there 
is  appropriate  guidance  and  support  in  place  to  allow  vulnerable  customers  with  complex  needs 
access to benefits. In addition, the department is continually looking at ways to support vulnerable 

4 

 
 customers and to build on the support it currently provides. I trust that my response addresses your 
concerns and helps to assure you of the measures DWP currently has in place and the department’s 
commitment to developing such measures.   

Yours sincerely, 

Head of National Operations Hub 

5

20th February 2024 

Dear HMAC Richards 

I write to acknowledge receipt of the Regulation 28 report dated 8th December 2023 which 
was safely received in my office on 15th December 2023. I note that a copy of this 
correspondence has also been sent to Brent Kilmurray, Chief Executive of Tees, Esk and 
Wear Valleys NHS Foundation Trust (TEWV), Chief Constable of Durham Constabulary and 
the Independent Office of Police Conduct (IOPC). 

From the outset, I would like to take this opportunity to express my sincere condolences to 
Sarah’s family following her untimely death. I can understand the distress Sarah’s family and 
friends have endured during this difficult and emotional time.  

The matters highlighted in the Assistant Coroner’s report received my priority attention and 
I have consequently discussed these matters with the Chief Constable and Force Executive 
Team. I have also been sighted on the Chief Constable’s response sent to you. 

As part of my ‘holding the force to account’ responsibility, I have been given assurances that 
organisational learning following this incident has been reflected upon, to mitigate any 
future risks. It is vital to me as the Police and Crime Commissioner for County Durham and 
Darlington for the force to demonstrate that appropriate training for police officers and 
staff is in place, robust safety plans exist, and effective policies and practices are regularly 
discussed and reviewed with TEWV to respond to calls acknowledging that such a response 
should be a partnership conversation.  

Following this report, I have been reassured that the force swiftly implemented an interim 
escalation policy with TEWV, and this is pending progress on the roll-out of the national 
‘Right Care Right Person’ approach which includes a clear escalation plan through strategic, 
tactical, and operational levels. This interim approach supports the principles of ‘Right Care 
Right Person’ and my office is supporting the force and relevant partners in adopting this 
protocol in due course. 

In conclusion, I am fully supportive that every person in crisis or nearing that point receives 
the best care and support from the right partner agency. Effective communication between 
partners is key to achieving this. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 I trust this response addresses the issues you have brought to my attention and I will 
continue to monitor the progress of Right Care Right Person being adopted across County 
Durham and Darlington, particularly the role of the Force.   

Yours sincerely 

Police and Crime Commissioner for Durham  

2

Miss Janine Richards 
HM Assistant Coroner for County Durham and Darlington 
PO Box 282 
Bishop Auckland 
Co. Durham 
DL14 4FY 

16 January 2024 

Dear Madam,    

Re: Inquest of Sarah Holmes      

I am writing with regards to the inquest of Sarah Holmes, and thank you for 
your report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 
2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 
2013.  

Thanks also to your office for providing information subsequent to that report.  

This  is  a  tragic  set  of  circumstances,  and  I  extend  my  most  sincere 
condolences to Sarah’s family and friends.  

1.  I  am  grateful for  the  opportunity  to  consider and  respond  to matters 

raised in your report which go towards the work of the IOPC.  

2.  You will know that the IOPC has a significant role to play in the Police 
Complaints  System.  And  you  will  know  of  course  that  the  “police 
complaints system” is about more than complaints against the Police, 
also covering “recordable conduct” relating to persons serving with the 
police  and  as  in  this case,  Deaths  and  Serious  Injuries  which  occur 
following contact with the police.  

3.  It is the duty of a Chief Officer to refer a Death and Serious Injury (DSI) 
matter  to  the  IOPC.    Having  received  a  referral,  we  may  thereafter 
determine that it is necessary for the matter to be investigated. Where 
that arises, we will go on to determine the form which the investigation 
should  take.  We  may  determine  that  it  is  appropriate  for  the 
investigation  to  take  the  form  of  an  investigation  by  the  appropriate 
authority  on  its  own  behalf.  This  is  often  referred  to  as  a  “local 
investigation”.  

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 4.  Where a person conducting a “local investigation” does not identify an 
indication that a person serving with the police may have a) committed 
a criminal offence, or b) behaved in a manner which would justify the 
bringing  of  disciplinary  proceedings,  the  person  investigating  shall 
submit a copy of the investigation report to us.  

5.  That  describes  some  of  the  relevant  statutory  responsibilities  in 
instances such as this. There are of course responsibilities that the we 
continue to have, such as deciding whether we agree (or not) that the 
investigation gives an indication of those things that I have detailed in 
paragraph 4. I am conscious however that your report raises several 
specific concerns which I should turn to, and that the purpose here is 
to identify action that can be taken to prevent future deaths.  

6.  Paragraphs 5 and 7 of your Report involve issues which would appear 

to relate to the work of the IOPC to which I shall now respond.  

Paragraph (5) 
“I  am  concerned that there  was a  lack  of  reflection on the  part of  the 
Police and there is no formal procedure by which lessons can be learnt 
from  such  serious  incidents,  the  professional  standards  department 
and IOPC having a limited remit in this regard.”  

7.  “Learning”,  at  an  individual  departmental  and  Force  level,  is  an 
important part of the police complaints system. At a departmental and 
Force level (in fact, at a national level), learning is formally “built into” 
the complaints system via Section 10 and Paragraph 28A of Schedule 
3, Police Reform Act 2002.  

8.  “Leading Improvement”, of which “learning” is a vital part, is a key area 
of focus for the IOPC.  We are mindful that there are opportunities for 
learning not just around the behaviour of individuals, but also around 
issues such as policy, training, practice, leadership and culture.  

9.  Please consider the following data to be provisional, in the sense that 
it may yet change, but currently, our data suggests that in the last full 
reporting  year,  1  April  2022  to  31  March  2023,  we  made  176 
organisational  learning  recommendations.  of  which  134  were  made 
under Paragraph 28A of the Police Reform Act, where recipients have 
a legal obligation to respond. 117 were accepted, 9 not accepted and 
responses are awaited for 8 recommendations.  

10. I appreciate that the volume of recommendations may not appear to 
be  overwhelming,  but  this  is  generally  an  area  of  growth  where  we 
tend to be making more recommendations for learning, year on year, 
certainly in cases which we have not investigated ourselves.  

2 

 
 
 
 
 
 
 
 
 
 
 
 
 11. It  is  worth  reiterating  that  our  recommendations  are  not  mandatory. 
They may be refused by the person or organisation to whom they are 
made.  We  cannot  require  any  person 
learning 
recommendation.  An  IOPC  learning  recommendation  should  be 
practicable  and  meaningful,  but  the  recipient  is  entitled  to  hold  a 
differing  view  as  to  whether  the  learning  recommendation  is  both 
justified, and thereafter practicable and meaningful.  

to  accept  a 

12. While a recipient is not obliged to accept a recommendation, they are 
legally  obliged  to  respond  to  a  recommendation  made  under 
Paragraph 28A (as here), and responses will generally be published. 
This includes where  a recipient does not accept a recommendation, 
as an explanation as to why it is not accepted is also required.   

13. Where a recommendation is made by the IOPC, and rejected by the 
recipient,  it  still  has  importance,  as  it  can  contribute  to  an  evidence 
base for future conversations and future learning opportunities.  

14. I think it could be said that there is therefore, a formal procedure by 
which learning can be identified from such serious events. If a matter 
is defined as a Death or Serious Injury incident, it will often have to be 
investigated.  The  terms  of  reference  for  such  an  investigation  will 
usually include, among other things, whether there is an opportunity 
for learning. In cases involving the IOPC, as here,  we will expressly 
consider the opportunities for learning.  

15. I think this shows that learning is an important area for the IOPC. But 
I fully accept that our role could be considered to be of “limited remit”, 
in 
that  our 
recommendations are simply that – recommendations.  

that  we  do  not  of  course  see  all  cases,  and 

16. We did have a statutory and formal involvement in this tragic case, and 
we  would  hope  that  the  formal  involvement  of  the  Professional 
Standards  Department  and  the  IOPC  would  help  precipitate  some 
reflection. “The system” itself does encourage reflection. I would add 
here,  that  this  matter  was  formally  investigated  by  the  Professional 
Standards  Department,  and  the  Investigating  Officer,  the  IOPC  and 
thereafter the  Appropriate  Authority,  were  all  relatively aligned  as to 
the opportunities and need for learning.  

17. Regarding  any  lack of  refection  in  respect of  individuals, forgive me 
but I do not believe it would be appropriate for me to comment further, 
beyond the findings that we reached on the case. I believe that such 
matters should better be addressed by the Appropriate Authority and 
the Police and Crime Commissioner.  

Paragraph 7 
“I am concerned that IOPC recommendation 3 in this case, namely that 
the messaging from senior management to the control room was a 

3 

 
 
 
 
 
 
 
 
 
 negative factor in this case, and should be revisited, was not accepted 
by senior officers who gave evidence at the Inquest.” 

18. I understand that the evidence from officers at the Inquest was that 
they did not agree with our recommendation, asserting that policing 
decisions were not influenced by SMT messaging, and instead were 
entirely based upon risk. Our determination was not that policing 
decisions here were not risk based. But our view is still, without being 
determinative, that there is evidence which could suggest that the 
messaging from the SMT did negatively influence the decision 
making of control room staff.  

19. The substance of that messaging features in the FIM’s statement, 

provided during the investigation, and it is difficult to understand why 
it would feature in that way if the officer did not think it was relevant.  

20. We have not taken a definitive position on whether policing decisions 
in this matter were entirely appropriate and properly reflective of the 
risk that presented at the time, and so it would not be appropriate for 
me to do so at this stage. However we are on record as 
acknowledging that police staff, applying a THRIVE assessment, had 
tried to deploy Police at 14:37 on 11 July 2022, and that this decision 
was reversed by the FIM.  

21. It is also appropriate to point out that the investigation conducted by 
the Professional Standards Department did consider that log in 
particular. It is understandable that each officer must conduct their 
own assessment of the presenting risk and reach their own 
conclusions as to the available options. But to be clear, the 
investigation by the Professional Standards Department expressed 
the opinion of the Investigating Officer, that there had been sufficient 
grounds at that time for police officers to enter Ms Holmes’ address 
under Section 17 PACE.   

22. We issued some contextual narrative around the recommendations 

that we made in this case. That narrative said,  

“The comments made by the FIM and supervisor could suggest that 
the message passed by the Senior Management Team had 
negatively influenced the FIM and Supervisor’s decision making in 
respect of this incident…”.  

23. Our view was that there was evidence which could suggest that the 
messaging from the Senior Management Team had negatively 
influenced the FIM and Supervisor’s decision making. We did not 
definitely conclude that that was the case, as our role is not to be 
that determinative on matters which would ordinarily be decided by a 
Court or other tribunal.  

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 24. We did receive a reply from the appropriate authority to our 

recommendation on 21 April 2023. That reply said,  

“Durham Constabulary acknowledges that messaging from Senior 
Management has influenced the Force Incident Manager’s decision 
making in this case. This was discussed at a recent development 
day for Force Incident Managers with a view to clarifying the force 
position and ensuring that operational decisions are always based on 
an objective assessment of threat, harm, and risk. The 
implementation of RCRP/Op Accelerate (see response to 
22/172495/001, above) will further clarify the force position and will 
support staff in making future risk-based decisions”. 

25. We have taken the appropriate authority’s acceptance of our 

recommendations at face value and having been assured of the 
quick time resolution to our recommendations, that would ordinarily 
be an end to our involvement in the area of learning in a matter such 
as this.  

26. The evidence provided by the officers at the inquest does not sit 

entirely squarely with the acceptance of our recommendation by the 
appropriate authority, and we will be seeking some further clarity 
from them in this regard.  

27. We understand that officers are expected to provide their own 

accounts and express their own views when giving evidence, and 
that this will not always align with how those things have been 
viewed by the appropriate authority. But it is difficult to see how 
learning can truly be successful if, at the end of the process, it does 
not encourage introspection and reflection at an individual level.  

Please do not hesitate to contact me if there is anything else that we may 
help with or clarify.  

Yours faithfully  

Operations Manager  
Independent Office for Police Conduct (IOPC) 

5

Response to Regula�on 28 Report for HM Coroner Rela�ng to the Inquest Touching upon the Death 

of Ms Sarah Holmes 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed maters giving rise to concern.  In my opinion 

there is  a  risk  that  future  deaths  could  occur  unless ac�on  is  taken.   In  the  circumstances  it  is  my 

statutory duty to report to you. 

The MATTERS OF CONCERN are as follows:- 

(1)  The  escala�on  in  risks  that  Sarah  presented  with  which  included  highly  dangerous  and 

impulsive thoughts of harming herself were not appropriately reflected in a robust safety plan,  

and it was not thought appropriate to liaise with family and friends who may have provided 

an essen�al safety net when Sarah was alone,  and at obvious risk of the impulsive thoughts 

of  self  harming  returning,  in  the  absence  of  any  ongoing  professional  support.    Although 

evidence was heard about further training and improvements that have been made in respect 

of safety planning and around issues of confiden�ality, I remained concerned that such issues 

could arise again. 

Durham Constabulary Response 

The overall responsibility in respect of safety planning for Ms Holmes lies with the health 

provider, in this case for Tees, Esk and Wear Valley Mental Health Trust (TEWV).  Durham 

Constabulary have subsequently worked closely with TEWV to develop a strong partnership 

plan  to  respond  to  calls  in  the  future,  acknowledging  that  such  a  response  should  be  a 

partnership conversa�on. 

(2)  There  remains no  policy  in place between Mental Health services and the Police as to the 

appropriate agency to undertake welfare checks and in par�cular there is no formal procedure 

to escalate maters when Mental Health professionals are concerned that life or limb is at risk 

and the Police do not agree and decline to assist.  The College of Policing authorised guide to 

professional prac�ce is clear that forces should ensure they have a policy on mental health 

 
 
 
 
 
 and that although certain issues are required to be subject to local opera�ng protocols with 

mental  health,  ambulance  and  other  providers,  there  are  other  issues    that  should  be 

determined by policy which would also ensure that services which operate across mul�ple 

health commissioners and providers to establish basic minimum requirements to determine 

police contribu�on to any local agreement with other providers. 

Durham Constabulary Response 

Durham Constabulary recognises the addi�onal value of a documented escala�on approach 

to provide clarity for opera�onal staff and has progressed priority ac�vity in this regard. 

Following  the  Coroner’s  raised  concerns,  the  force  has  swi�ly  implemented  an  interim 

escala�on policy, pending progress on the roll out of the na�onal ‘Right Care, Right Person’ 

approach, which includes a clear escala�on plan through opera�onal, tac�cal and strategic 

level  command  bands.  TEWV  has  been  engaged  throughout  and  consulted  with  in  the 

development of this policy. Force Incident Managers, Cri�cal Incident Managers and Force 

Silver Commanders have been trained in rela�on to the policy. The Force has also liaised 

with  Street  Triage  MH  Prac��oners  based  in  the  Force  Control  Room  who  are  a  crucial 

partner when dealing with the response to incidents involving mental health. 

HM Coroner will be aware that there is na�onal work being undertaken to standardise the 

approach to incidents where an individual’s mental health is a factor.  The na�onal project 

is known under the �tle ‘Right Care, Right Person’ (RCRP) and is aimed at ensuring a person 

in  crisis  or  nearing  that  point  receives  the  best  care  from  the  right  agency.    Durham 

Constabulary  has  not  yet  implemented  this  policy  approach,  but  the  interim  escala�on 

approach acts to support those principles.  A Force Project Team has been established to 

progress the na�onal approach locally. 

(By means of context, RCRP provides Police Forces with a consistent approach supported by 

legal advice and training support. Each Force is reviewing the na�onal package.) 

Durham Constabulary is engaging with all relevant partners and held a strategic mee�ng in 

December 2023 as part of an extensive consulta�ve approach. Durham Constabulary will 

con�nue to work with partners in a joint mul�-agency governance structure for developing, 

implemen�ng, and monitoring the RCRP approach locally. The project is led by the Assistant 

Chief Constable supported by a dedicated Superintendent. 

 
 This project will develop policies and procedures rela�ng to concerns for welfare, dealing 

with persons detained under the Mental Health Act, the transporta�on of persons detained 

under the Mental Health Act and persons reported missing from health care facili�es.   The 

force is confident that these policies and procedures will build on exis�ng good prac�ce and 

further improve the service to those in crisis or nearing that point. 

(3)  The Police did not accept the concerns of the Mental Health professionals in this case and 

placed undue reliance upon the Mental Health teams earlier decision to send Sarah home and 

that her car was back at her home address, and failed to take sufficient account of the highly 

unusual and uncharacteris�c presenta�on therea�er in her not engaging with mental health 

staff, and the con�nuing passage of �me when no one had been assured that Sarah was safe 

and well, in the context of numerous highly dangerous impulsive acts in the proceeding hours. 

No comprehensive  evalua�on  seems to have taken place as to the increasing concerns for 

Sarah’s welfare and whether the threshold for police ac�on, including whether to force entry 

was met. 

Durham Constabulary Response 

The  force  accepts  HM  Coroner’s  observa�on,  and  it  is  now  more  clearly  defined  in  the 

interim  Force  Escala�on  Policy  the  requirement  to document  clear  ra�onale for  decision 

making on the Force Command and Control system. This has been highlighted in the training 

to support policy implementa�on.  This specifically extends to recommended ques�ons to 

be asked of mental health professionals or other third par�es to beter understand their 

rela�onship with the person in crisis and therefore inform subsequent ac�ons. 

The  Joint  Decision  Model  (JDM)  and  Risk  Principles  as  defined  by  na�onal  Approved 

Professional Prac�ce (APP) will be u�lised by all commanders to support decision making. 

This will be underpinned by THRIVE assessment which is used for all incidents reported to 

Durham Constabulary.  (For informa�on, the JDM is the recognised decision model for all 

emergency services responders.)  THRIVE is a structured framework to evaluate and manage 

a policing response.  The acronym stands for Threat – the threat posed to oneself or others; 

Harm - the poten�al consequences or damage that may occur from the threat; Risk – this 

relates to the risk assessment quan�fying the likelihood and severity of the poten�al harm 

occurring; Inves�ga�on – this component focuses on iden�fying and gathering the relevant 

informa�on as appropriate to the incident; Vulnerability – an assessment of the individual’s 

 
 
 vulnerabili�es  or  factors  which  increase  their  risk  of  harm  and  Engagement  –  which 

emphasises the importance of partners in our response and involves developing a response 

plan which iden�fies from the outset the importance of collabora�on. 

(4)  I am concerned that poli�cal arguments were at play in terms of “who should assume the risk” 

in this case and a push back against third party agencies reques�ng police assistance were 

implicated in the decision not to deploy officers rather than a comprehensive evalua�on of 

risk  and  an  apprecia�on  of  what  Mental  Health  professionals  were  atemp�ng  to  convey 

which was that Sarah’s life was at risk. I am concerned that I heard evidence that there have 

been other occasions where Mental Health professionals believed someone was at serious 

risk of harm (life or limb) and the Police have declined to act. 

Durham Constabulary Response 

The  escala�on  policy  makes  clear  when  the  police  will  atend  in  rela�on  to  relevant 

legisla�on to support agencies repor�ng a concern for a person’s welfare where there is a 

life at risk or there is a risk of serious harm. Policing powers have been defined within the 

escala�on policy. This has been developed in conjunc�on with mental health partners and 

will  be  reviewed  in  more  detail  as  part  of  the  RCRP  project and  further  developed  in 

consulta�on with partner agencies.  

(5)  I am concerned that there was a lack of reflec�on on the part of the Police and there is no 

formal procedure by which lessons can be learnt from such serious incidents, the professional 

standards department and IOPC having a limited remit in this regard. 

Durham Constabulary Response 

To  supplement  the  escala�on  policy  there  will  be  a  review  procedure  which  will  occur 

monthly to review any lessons learned. This will be co-ordinated by the Force Mental Health 

Lead, and builds on exis�ng review approaches rela�ng to other incident types that have 

been  seen  as  good  prac�ce  by  His  Majesty’s  Inspectorate.  There  is  already  a  review 

procedure in place in rela�on to Sec�on 136 deten�ons and persons reported as missing 

from Health Care Facili�es, whereby Police and TEWV convene to discuss issues/concerns 

and this will be expanded to include concern for safety type incidents involving concerns for 

 
 
 
 
 a person’s welfare. Any lessons learned will be communicated to Force Incident Managers, 

Cri�cal Incident Managers, Silver and Gold Commanders via structured training sessions co-

ordinated  by  Opera�onal  Planning  who  are  responsible  for  command  level  training  and 

CPD. 

The Force is using the findings of this inquest as part of the training material to support the 

new escala�on policy. 

(6)  There is no specific guidance in place for the Police as to how to assess the level of risk when 

requested to undertake a welfare check and to assist other agencies who have no power to 

force entry, no clear ra�onale was recorded for the Police decision not to u�lise their powers 

under s17 of PACE, and given the poli�cal pressures at play that there may s�ll be a reluctance, 

pending  the  implementa�on  of  ‘Right  care,  Right  person’  and  any  other  appropriate  local 

policies between various services, to ensure opera�onal decisions are evidence based on an 

objec�ve  evalua�on  of  the  risks, aided  and  assisted  by  other  professionals  such  as  mental 

health professionals, who may be able to give crucial informa�on to inform the assessment of 

vulnerable persons who may be at serious risk. 

Durham Constabulary Response 

The escala�on policy does now define the policing powers to support the assessment of risk 

when dealing with welfare checks. Decision making is guided by the Joint Decision Model 

and APP risk principles. The policy specifically highlights the need to consistently review and 

assess  the  risks  when  there  is  a  change  in  informa�on  or  intelligence.  The  policy  also 

mandates  the  requirement  to  record  and  document  decisions  taken  in  rela�on  to 

deployment of police resources. 

RCRP will ensure that all frontline officers and commanders will be trained with a na�onal 

training package and local guidance. RCRP is a na�onal policing approach and the Force will 

adopt that protocol in due course.  It’s important to highlight that we aren’t simply wai�ng 

for  the  implementa�on  of  Right  Care  Right  Person,  and  the  implementa�on  of  the 

escala�on policy now will provide structure, guidance and governance to future decisions. 

 
 
 
 (7)  I am concerned that IOPC recommenda�on 3 in this case, namely that the messaging from 

senior  management  to  the  control  room  was  a  nega�ve  factor  in  this  case,  and  should  be 

revisited, was not accepted by senior officers who gave evidence at the Inquest. 

Durham Constabulary Response 

Durham Constabulary does accept the IOPC recommenda�on. The escala�on policy clearly 

outlines the powers and legisla�on to inform the response to requests for welfare checks.  

For the avoidance of doubt, the refreshed training input has paid special aten�on to this 

area  to ensure  there  is  no  doubt  among  opera�onal  staff and  decision  makers  as to  any 

nega�ve aspects that were highlighted by HM Coroner.

Office of the Chief Executive 
West Park Hospital 
Edward Pease Way 
Darlington 
Co Durham 
DL2 2TS 

Ms J Richards 
HM Assistant Coroner 
For County Durham and Darlington 

9 February 2024 

Dear Ms Richards, 

Re: Response to Report to Prevent Future Deaths issued on 08.12.2023 in relation to 
Sarah Holmes 

I am writing to you in response to the Prevention of Future Death (PFD) Report issued to Tees, 
Just a short note at this stage to 
Esk and Wear Valleys NHS Foundation Trust (TEWV, or the Trust) on 08.12.2023 following 
acknowledge receipt of your 
letter dated XXXX  2017 bringing 
the inquest touching the death of Sarah Holmes. I note that the PFD Report issued has been 
to my attention concerns raised 
directed to both TEWV and Durham Constabulary, on the basis you have concerns in respect 
by your above named constituent 
of both organisations. I have provided a response below in respect of concerns 5(1) and 5(2) 
in respect of XXXXXXX 
of your PFD Report as it appears those are the matters where your concerns are directed to 
TEWV (with the second of those also being a matter for the Police to respond to). I set out 
I have asked for an investigation 
below your concerns, as well as the response from TEWV in respect of each matter: 
to be carried out into the 
concerns raised by XXXXX 
1.  The  escalation  in  risks  that  Sarah  presented  with  which  included  highly 
following which I will send a 
dangerous  and  impulsive  thoughts  of  harming  herself  were  not  appropriately 
detailed reply to you. 
reflected in a robust safety plan, and it was not thought appropriate to liaise with 
With kind regards 
family and friends who may have provided an essential safety net when Sarah 
was  alone,  and  at  obvious  risk  of  the  impulsive  thoughts  of  self  harming 
Yours sincerely 
returning,  in  the  absence  of  any  ongoing  professional  support.  Although 
evidence  was  heard  about  further  training  and  improvements  that  have  been 
made  in  respect  of  safety  planning  and  around  issues  of  confidentiality,  I 
remained concerned that such issues could arise again.  

Colin Martin 
The Trust acknowledges HM Assistant Coroner's concerns in respect of robust safety planning 
Chief Executive 
and this is a key priority across all Trust services.  

Date 
To  provide  some  context  to  our  response  in  respect  of  Sarah's  care,  as  confirmed  at  the 
inquest, the mental health worker(s) who assessed Sarah on 10 July 2022, acknowledged the 
varying methods of self harm that Sarah undertook in the days leading to her death, and took 
this into account as part of their assessment. It was heard that the plan for Sarah to return 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 home was very much made in collaboration with her. The mental health worker had considered 
the safety plan that Sarah had written with her community team and all options for treatment, 
including  hospital  admission  were  explored  with Sarah. It  was confirmed  that,  as would be 
expected by the Trust, the clinicians tried to go with the least restrictive options that would be 
the most beneficial for the patient. It is not accepted by the Trust that there was an absence 
of any ongoing professional support; a plan was in place for the crisis team to contact Sarah 
on  the  evening  of  10  July  2022,  and  for  her  Care  Co-ordinator  to  continue  to  engage  and 
support after the weekend, on 11 July 2022.  

At the time the plan was formulated, Sarah was reported to be no longer feeling distressed, 
was future planning, positive, bright, chatty and talking spontaneously. She wanted to resolve 
the  issues  around  her  benefits  and  move  forward,  and  was  not  having  ongoing  suicidal 
thoughts. She remained calm and engaging, with plans to see a friend later that afternoon.  

It is acknowledged that the mental health workers asked Sarah if they could contact her family 
or friends, and she asked that they didn’t, as she did not want to worry her family when the 
crisis was felt to have passed. The inquest heard that the mental health workers felt they could 
not break confidentiality as there was not considered to be any immediate risk to Sarah, or 
others, and it was felt that Sarah had the capacity to make that decision.  The mental health 
workers considered breaching confidentiality and weighed up the risk of Sarah going home 
without  the  support  of  a  friend,  against  the  risk  of  losing  the  strong  therapeutic  trusting 
relationship  that  Sarah  had  built  up  with  services  that  would  come  with  beaching  her 
confidentiality. They felt that as Sarah had always worked with services, she would engage 
with the plan that she had collaboratively created on this occasion.  The inquest heard how 
the mental health worker had reflected on this difficulty where patients have capacity to decline 
that family and friends are contacted, and has taken this on board in their future practice.  

The Trust Serious Incident Investigation found that there was potentially a missed opportunity 
to contact Sarah's family or friends following the assessment, although this was a finding made 
with the benefit of hindsight.  

Clinicians have a common law duty of confidentiality to patients such that personal information 
provided in confidence, such as between a patient and a healthcare professional, can only be 
disclosed  with  a  legal  authority  or  justification.  Often,  that  legal  authority  will  come  from  a 
patient's consent, but where that isn’t forthcoming, clinicians have to consider whether or not 
there is sufficient justification to breach a patient's confidentiality. The Trust recognises the 
difficult position clinicians are faced with when considering this, particularly where the patient 
is considered to have capacity, and the risks are not felt to be sufficiently high at that moment 
in time, to justify a breach. 

In addition, clinicians also have their professional codes to adhere to. For nursing staff, the 
relevant section on the Nursing and Midwifery code provides: 

"5. Respect people’s right to privacy and confidentiality  

 
 
 
 
 
 
 
 
 
 As a nurse, midwife or nursing associate, you owe a duty of confidentiality to all those 
who are receiving care. This includes making sure that they are informed about their 
care  and  that  information  about  them  is  shared  appropriately.  To  achieve  this,  you 
must:  

5.1 respect a person’s right to privacy in all aspects of their care  

5.2 make sure that people are informed about how and why information is used and 
shared by those who will be providing care  

5.3 respect that a person’s right to privacy and confidentiality continues after they have 
died  

5.4 share necessary information with other health and care professionals and agencies 
only when the interests of patient safety and public protection override the need for 
confidentiality  

5.5  share  with  people,  their  families  and  their  carers,  as  far  as  the  law  allows,  the 
information they want or need to know about their health, care and ongoing treatment 
sensitively and in a way they can understand." 

The Trust has in place Common Sense Confidentiality guidance which considers how we work 
with carers where a service user states we cannot share information with their family / people 
close to them. This useful guidance is currently under review to provide further clarity to staff. 
In addition, discussions have already taken place at the Trust Fundamental Standards Group 
on 22 November 2023, to consider how this guidance can be further improved. Although plans 
are early in development, the intention is to create an updated guidance document to inform 
carers and support staff with decision making around confidentiality and information sharing. 
In addition, the Trust intends to develop a Trust-wide communication plan to disseminate the 
updated guidance. More information can be provided on this if required, as the information is 
collated  and  shared.  However,  in  Sarah’s  case  this  guidance  is  not  likely  to  have  led  to  a 
different decision being made by the clinicians who clearly thought this through. 

It  is  noted  that  HM  Assistant  Coroner  has  acknowledged  that  evidence  was  heard  at  the 
inquest about the implementation of training and improvements around safety planning and 
confidentiality. To reiterate, in accordance with the action plan developed as a result of the 
Trust investigation, the Trust has already; 

•  Re-shared the safety summary and plan information from the Intouch page on the Trust 
Intranet  with  all  team  members  to  improve  the  knowledge  and  quality  of  safety 
summaries  and  plans.  A  copy  of  the  first  page  of  the  3  sections  covered  has  been 
provided,  however,  the  full  documents  can  be  shared  if  required  –  particularly  that 
which relates to 'Creating and Updating a Safety Plan'. 

•  A  video  providing  a  presentation  on  Safety  Plans  has  been  reshared  with  staff 

(https://vimeo.com/819417803/e915314e18?share=copy). 

 
 
 
 
 
 
 
   
 
 •  Reflective  practice sessions  have  now taken  place to  discuss  the  learning from  this 
incident. There has also been discussion in huddles regarding safety planning and also 
on using the 'need to know' section to ensure core information is included in the safety 
plan. There has also been individual practitioner reflection around discussing risks with 
families,  maintaining  the  trust  in  a  therapeutic  relationship  and  the  circumstances 
where confidence has to be broken, to mitigate risk.    

•  Literature  is  being  developed  and  disseminated  across  the  Trust  in  relation  to  key 
learning  from  the  patient's  journey.  In  addition,  the  Patient  Safety  Team  will  be 
undertaking Teams meetings to discuss the same.  

•  Supervision  sessions  are  carried  out  monthly  to  evidence  that  learning  has  been 

embedded. 

•  Carer awareness training has been carried out. 
•  Consent and confidentiality has been discussed in Team meetings and supervision. 

Separately  to  the  learning  identified  as  a  result  of  the  Trust  investigation,  HM  Assistant 
Coroner is aware that the Trust has ongoing assurance around assessment and management 
of  risk  via  the  Quality  Assurance  Schedule  (QAS).  Senior  Clinical  Staff  complete  monthly 
audits  to  monitor  the  quality  of  narrative  risk  assessment  and  risk  formulations  and  safety 
plans being produced by staff, the audits also  consider evidence of co production with the 
service  user  and  involvement  of  families  /  carers.  The  findings  from  these  audits  are  then 
discussed and scrutinised at the Specialty Governance Group to identify whether any further 
action is required. Anything that remains a concern following the monthly audit is added to 
team meeting agendas for discussion to ensure that improvements can be implemented on a 
rolling basis. These actions also inform the overarching Adult Mental Health Action Plan which 
is  reviewed  and  implemented  by  the  governance  action  planning  sub-group.  The  Quality 
Assurance Schedule is monitored by the Trust's Fundamental Standards Group and reports 
into  the  Care  Group  Board  and  Executive  Board  to  ensure  monitoring  through  the  Trust's 
governance structures. NHS England, the ICS, the CQC and our partners see the audit results 
at the Quality Board which is a part of mandated support and focusses on the quality of care 
at TEWV. These results are showing an improving picture and identify the teams that require 
more support to improve. 

2.  There remains no policy in place between Mental Health Services and the Police 
as to the appropriate agency to undertake welfare checks and in particular there 
is no formal procedure to escalate matters when Mental Health professionals are 
concerned that life or limb is at risk and the Police do not agree and decline to 
assist. The College of Policing authorised guide to professional practice is clear 
that forces should ensure they have a policy on mental health and that although 
certain issues are required to be subject to local operating protocols with mental 
health,  ambulance  and  other  providers,  there  are  other  issues  that  should  be 
determined  by  policy  which  would  also  ensure  that  services  which  operate 
across  multiple  health  commissioners  and  providers  to  establish  basic 
minimum requirements to determine police contribution to any local agreement 
with other providers.  

 
 
 
  
 At the time of Sarah's involvement with services, there was no specific policy in place between 
TEWV and Durham Constabulary as to the appropriate agency to undertake welfare checks, 
however,  the  agencies  have  worked  together  to  develop  an  Interim  Policy  pending 
implementation  of  'Right  Care,  Right  Person'  (RCRP).  This  Interim  Policy  will  be  entitled 
'Interim Concern for Safety Escalation Policy' and has been collaboratively created between 
Durham  Constabulary  and  the  Trust.  The  Interim  Policy  'provides  a  process  to  support 
decision making in relation to Police attendance at concern for safety incidents'. The aim of 
the Interim Policy is to provide 'a framework for escalating incidents of concern for safety and 
welfare  checks,  in  which  a  decision  is  made  for  Police  not  to  attend  and  partner  agencies 
disagree'.  

The position remains that only the Police have the power to force entry into a property under 
section 17  Police  and  Criminal  Evidence  Act  1984  (PACE)  in circumstances to save  life  or 
limb, or prevent serious damage to property. TEWV staff are encouraged to always use their 
best endeavours to make enquiries by telephone and in person to establish the wellbeing of a 
patient where concerns have been raised.  

I can reiterate the position that was explained at the inquest, that TEWV is currently working 
very closely with Durham Constabulary (along with other relevant stakeholders) with regard to 
the introduction of 'Right Care, Right Person' (RCRP). This will supersede the Interim Policy 
that  has  been  developed  and  provide  a  more  detailed  Policy  and  framework  for  TEWV, 
Durham Constabulary and other partner organisations to work within in carrying out welfare 
checks.  The  Trust  has  attended  an  event  in  October  and  December  2023  with  Durham 
Constabulary to establish work streams to implement the model, and is actively working with 
all partner agencies to progress this.  

With regards to the concerns around escalation, the Interim Policy confirms that if there is a 
situation whereby Police and mental health services disagree on which agency should take 
primacy for the concern of welfare report, the Interim Policy will be triggered. It sets out the 
roles and responsibilities of each level of Police command and details of who concerns should 
be escalated to within each organisation where such disagreements arise. The Interim Policy 
also includes an out of hours provision. 

In addition, prior to the implementation of the Interim Policy, the Trust committed to preparing 
a  patient  safety  briefing  regarding  actions  to  be  taken  when  a  dispute  arises  with  partner 
agencies. This has been completed and circulated to all clinical teams. I understand a copy 
was also provided to HM Assistant Coroner. The briefing provides a clear message to staff in 
respect of communication and escalation in circumstances where it is apparent that 'opinions 
of the level and immediacy of risk posted to an individual differs between organisations and 
that this may result in a delay in response'. Pending the introduction of RCRP, this provides 
staff with practical and appropriate guidance to so far as possible, manage patients in a safe 
and consistent manner.  

I trust that this provides assurance that these concerns have been taken very seriously by the 
Trust and we will continue to strive to improve the service that we offer.  

 
 
 
 
 
 
 
 Our Chief Nurse, Medical Director and I have made repeated offers to meet with the Coroners 
in the Durham and Darlington jurisdiction and all offers have been declined. We do meet with 
other Coroners, and we are aware of some of our partners who meet with Coroners in this 
jurisdiction. I would like to repeat our sincere offer to meet at your convenience and discuss 
the developments at TEWV and how we are working with our partners and the people who 
use our services to improve care.  

Yours sincerely 

Brent 

Chief Executive