Prevention of Future Deaths reports · 2024

Stevyn Carr

Regulation 28 report to prevent future deaths, reference 2024-0198, written 15 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report15 Apr 2024
Reference2024-0198
DeceasedStevyn Carr
CoronerJames Thompson
Coroner areaGateshead and South Tyneside
CategorySuicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 

 - Chief Constable - Northumbria Police 

1 

CORONER 

I am James Thompson, Assistant Coroner, for the coroner area of Gateshead & South 
Tyneside 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

On 22nd November 2021 I commenced an investigation into the death of Stevyn CARR, 
34 years old. The investigation concluded at the end of the inquest on 6th March 2024. 
The conclusion of the inquest was Drug & Alcohol Related. 

The medical cause of death was; 

1a Cardiac Arrhythmia 
1b Chronic Excess Alcohol Consumption and Use Of Amphetamine 

I found at inquest, Stevyn Carr died on 16th November 2021 at 17 Lytchfeld, Leam Lane, 
Gateshead from a cardiac arrhythmia caused by the toxic effects of him voluntarily 
consuming a quality of alcohol and amphetamines at some point prior to his death. His 
intention in doing so was not to end his life. 

4 

CIRCUMSTANCES OF THE DEATH 

Stevyn Carr contacted Northumbria Police on the evening of 15th November 2021 at 
7.22pm. His contact with police call handlers and emergency operators was difficult to 
understand, due to on balance to his intoxication. He did ask for ‘Help’ and he was told 
police would attend. The calls to police were assessed a Grade 2 response - normally 
within an hour. No police attended until they entered Stevyn Carr’s address at 12.02pm 
on 16th November after members of his family contacted the police at 10.38am to 
express their concerns for him. He was discovered dead when police entered his home. 

On the evidence heard it was not possible to ascertain whether earlier police attendance 
would have altered the outcome. 

From the first call to police to his discovery by police a period of 16 hours 40 minutes 
elapsed. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths 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) The evidence I heard at inquest indicated the level of police response should have 
been classed as a Grade 2 Vulnerable to ensure a more timely response. 
(2) No oversight of the incident took place for over 9 hours and at that a comment was 
made that there were no resources able to attend, but no other options/alternatives were 
pursued. 
(3) The family of Stevyn Carr contacted police some 15 hours after the first call to the 
police and after this a further 1 hour and 23 minutes elapsed before police went to his 
address and found him. 
(4) I heard evidence at inquest that a number of incidents were ‘delayed’ for a significant 
period for lack of police resources and this position was common place at that time. 
(5) I have asked for evidence to satisfy me that the position in terms of police attendance 
has improved both within the area Stevyn Carr died, but across the Northumbria Police 
force area. The evidence I have received is difficult to interpret and not comprehensive. I 
am concerned whether the changes to the management of incidents and/or training in 
relation to the grading of incidents by Northumbria Police has improved since Stevyn 
Carr’s death, to the extent that the timeliness of police response to requests from the 
public for assistance is improved and is improving. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and your 
organisation 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 11th June 2024. 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons - 

The family of Mr Stevyn Carr. 
HM Chief Inspector of Constabulary and HM Chief Inspector of Fire & Rescue Services. 

I am also under a duty to send the Chief Coroner a copy of your response.  

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or of interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

9 

15th April 2024                                            James E Thompson 

Signed  - 

2

Responses

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.

Response from Northumbria Police (PDF)
Chief Constable 

Force Headquarters 
Middle Engine Lane Police Station 
Middle Engine Lane  
Wallsend  
Tyne & Wear  
NE28 9NT 

Mr James Thompson 

HM Assistant Coroner for Gateshead and South Tyneside 

BY EMAIL 

11 June 2024 

Dear Mr Thompson, 

IN THE MATTER OF STEVYN CARR - REGULATION 28 RESPONSE 

I refer to your regulation 28 report (“the Report”) dated 15 April 2024 addressed to the Chief 

Constable. The Chief Constable has requested that I respond on her behalf. 

Improvements since November 2021 

Since  Stevyn’s  sad  death  in  November  2021  there  have  been  a  considerable  number  of 

changes  to  processes  and  procedures  in  the  Control  Room  which  have  resulted  in  an 

improved police response to incidents: - 

Overall,  since  November  2021  we  have  improved  both  the  time  to  answer  999  and  non-

emergency calls alongside improvements in the attendance times for incidents. This combined 

means we are able to respond to calls for service in a timelier manner.  

- 

- 

A 44 second improvement in answering 999 calls. 

An 8-minute improvement in answering 101 non-emergency calls. 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 

- 

A 4-minute improvement to the average response time for a priority 1 incident. 

A 15-minute improvement to the average response time for a priority 2 incident.  

There  have  been  improvements  across  the  department  in  terms  of  the  identification  of 

vulnerable victims and incidents which have centred around the THRIVE assessment made 

by the contact handler, which looks to identify threat, harm risk, investigative opportunities, 

vulnerability and level of engagement at the first point of contact, but also through the life of 

the  incident  with  further  THRIVE  assessments  completed  when  required.  THRIVE  has 

become a standing agenda item on the Protected Learning Days for Communications staff 

which includes best practice alongside areas of learning.  

Internal  business  assurance  has  been  undertaken  which  shows  improved  identification  of 

vulnerability, highlighting the interventions mentioned have supported the improved recording 

of vulnerable incidents. November 2021 recorded 28% of grade 2 incidents as vulnerable with 

May 2024 seeing a 7% increase at 35%.  This is an increase which has slowly developed and 

is being maintained over time.  

In relation  to the actual  incident, it  is  believed this  would now be  identified as a vulnerable 

incident  but  a  definitive  response  to  this  cannot  be  provided  as  each  assessment  is  a 

subjective assessment made by an individual. We have however implemented an enhanced 

process  for  Grade  2  incidents  that  were  not  attended  within  SLA  to  ensure  a  continued 

assessment of the risk.  

This process includes escalation for delayed incidents.  At times of peak demand or where 

other incidents are occurring which must take precedence and require multiple resources, then 

if a response to a Grade 2 incident is delayed a Resource Controller re-contacts the caller to 

update  them,  assess  any  changes  to  the  THRIVE  (Threat,  Harm,  Risk,  Investigation, 

Vulnerability, Engagement) risk assessment, consider whether further safeguarding advice is 

relevant and update the incident, considering whether there is an increased importance to the 

incident deployment. 

There is now a full time Risk Management Desk in place, whose responsibility is the ongoing 

assessment  and  mitigation  of  risk  within  vulnerable  incidents.  If  a  caller  is  classified  as 

Vulnerable from their initial Grade 2 (G2V) call then in the event the incident is not responded 

to within one hour the Risk Management Desk will re-contact the caller and undertake a full 

review of their risks and vulnerabilities and assess if the incident requires a change of grading. 

 
 
 
 
 
 
 The re-contact of a caller occurs if we are unable to attend an incident within an hour. At times 

of higher demand when attendance may be delayed further this process is repeated to ensure 

our victims are kept updated but also that we continually re-assess the risk and prioritisation 

of deployment. 

Recognising that our performance for non-emergency incidents could be improved, a review 

of  the  deployment  model  has  been  completed. This  review  has  led  to  the  introduction  of  a 

Grade 3 response which will have dedicated resources to deploy to the incidents within  24 

hours  of  the  caller  contacting  the  police. The  response  will  be  diarised  in  accordance  with 

victim availability and will be serviced by single crewed officers. Incidents which will remain 

graded as G2 incidents will be those with elements of vulnerability or other time critical issues. 

This change to the grading structure enables Communications staff and frontline officers to 

identify which non-emergency incidents require a timelier response, to enable them to deploy 

resources more appropriately.  

Since  this  incident  the  “Right  Care,  Right  Person”  (RCRP)  process  is  also  now  live  within 

Northumbria  Police.    RCRP  is  an  initiative  which  has  been  implemented  nationally  within 

policing  and  seeks  to  ensure  that  the  most  appropriate  agency  responds  to  requests  for 

assistance  from  members  of  the  public.  Incidents  for  RCRP  are  still  risk  assessed  using 

THRIVE, but the most appropriate agency to engage with the caller may not always be the 

police.  All  Communications  staff  have  received  training  in  RCRP.  The  force  incident 

management system (Storm) has been altered so that Communications Department staff may 

use call scripts to assist in their decision making. The Risk Management Desk, which is staffed 

with  experienced  police  officers,  conduct  a  secondary  review  for  incidents  where  the  Call 

Handler is uncertain if an incident fits the criteria for RCRP. 

In  addition,  since  the  incident  each  Response  Team  now  has  a  dedicated  Sergeant  who 

reviews incidents and assists the Communications Department in assigning resources.  This 

ensures a swifter level of service. 

The Force moved to a new Operating Model on the 4th March this year which included a re-

alignment of staff to each of the 6 area commands and a more enhanced leadership structure 

for  each  area.  This  means  that  there  are  increased  officer  numbers  working  in  response 

policing giving us a better ability to meet calls for service in a timely manner aligned to more 

focussed leadership and accountability. Although the model has only been running for a short 

period of time it is evident this has had a positive impact with improvements in the percentage 

of incidents attended within our stated times, a 13.3% improvement in grade 2 incidents and 

 
 
 
 
 a 15.1% improvement in vulnerable grade 2 incidents against the year before. There is also 

high-level oversight and scrutiny of response times during the daily Pacesetter meeting, which 

is chaired by the Force Gold Commander. We expect still further improvement in our response 

times as we embed this new force operating model.  

Conclusion 

Northumbria Police takes its responsibility to respond to emergencies extremely seriously.  We 

are committed to continuous improvement to the service we provide to our communities.  How 

we respond to the public when they need us forms a significant part of the service we provide, 

which we seek to improve through enhanced call and incident management. We have invested 

significantly in this area and continue to do so. 

Yours sincerely 

Head of Communications

Related reports

Other reports by James Thompson

See all →

More reports categorised “Suicide (from 2015)”

See all →

Track Suicide (from 2015)

See every Prevention of Future Deaths report matching Suicide (from 2015), 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.