Prevention of Future Deaths reports · 2024
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 report | 15 Apr 2024 |
|---|---|
| Reference | 2024-0198 |
| Deceased | Stevyn Carr |
| Coroner | James Thompson |
| Coroner area | Gateshead and South Tyneside |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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
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.
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
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