Anugrah Abraham

Date of report	14 Jan 2025
Reference	2025-0024
Deceased	Anugrah Abraham
Coroner	Joanne Kearsley
Coroner area	Manchester North
Category	Suicide (from 2015) · Police related deaths · Service Personnel related deaths
Source	judiciary.uk record · original PDF
Responses published	2

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. EE National Police Chief's Council (NPCC)
2. ER — Chief Executive Officer, College of Policing

3, DE West Yorkshire Police

CORONER

| am Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North

CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013

INVESTIGATION and INQUEST
On the 15" March 2023, | commenced an investigation into the death of Anugrah Abraham (“Anu”).

Anu died on the 4"° March 2023 in Woodland near Red Rock Lane in Bury. He was 21 years old.
The medical cause of death was confirmed as 1a) Hanging.

| recorded a conclusion of Suicide recording the circumstances as follows: “The deceased was a
serving West Yorkshire police officer. He had been on annual leave since the 16" February 2023.
He was due to return to work on the 4"" March 2023. The prospect of returning to work is likely to
have been a source of distress to the deceased. On the 3 March 2023 in the early afternoon he
left his home address. There was nothing in his behaviour which gave rise to concerns from his
family. At 22:50 hours when he had not returned home, Greater Manchester Police were contacted
and he was reported missing. In the early morning of the 4° March 2023 the deceased was located
in a wooded area near Red Rock Lane, Radcliffe. He had died as a result of hanging with the intention
of ending his life.”

CIRCUMSTANCES OF DEATH

In 2021 Anu had joined West Yorkshire Police (“WYP”) under the Police Constable Degree
Apprenticeship programme (“PCDA’”). This was in conjunction with Leeds Trinity University (“LTU”).
At the time it was only possible to join the police if you already had a degree or undertook at degree
alongside training to be a police officer. In 2021 the application programme was online and there
was no face to face assessment. In addition, a decision had been taken by WYP Chief Officers to
remove the in-force interviews.

Of note, Anu had not achieved the grades required at A level to undertake a stand alone policing
degree.

Prior to commencing the PCDA there is no evidence of Anu having any issues with his mental health.

The court heard from a large number of witnesses in respect of various aspects of the PCDA and
how it operated in practice.

| found as a matter of fact that :

there should have been closer working between the Central Assessment Unit in WYP, in
particular the student officer's assessor and the District Sgts who had day to day line
management responsibilities for the officer.

Anu had emerged from his 12 week training at Carr Gate on a development plan. This was
not immediately known to his District Sgts and also raised concerns as to the decision to
place officers onto patrol when they had failed to demonstrate the skills required of them.
Anu was subject to what were described as “Stage 1 meetings in accordance with Regulation
13 of the Police Regulations 2003”. Within WYP, use of regulation 13 had developed into a
series of staged meetings. Anu was subject to a “stage1” meeting. It was not immediately
clear where the process for implementing various stages of Regulation 13 emanated from. In
Anu’s case his District Sgts were not aware Anu was subject to such a review as this
information was not shared with them.

The lack of shared information between those tasked with the various aspects of Anu’s
management led to mixed, inconsistent messages to Anu as to how he was developing and
performing.

On the 24" September 2022 Anu was referred to Occupational Health (“ODU”) the waiting
time to be seen was three months. He was not seen until the 15" December 2022. The
referral had been for a back injury but also his mental health. There was an inadequate
assessment of his mental health and a lack of consideration of any adjustments required
given his mental health issues were linked to his work and the PCDA.

During this time he also accessed the Employee Assistance Programme and was referred to
a counsellor. In October 2022 it was recorded that he was suffering from severe anxiety and
severe depression. This was linked to the PCDA programme and his work. He reported
having suicidal thoughts. This information provided to the counsellor was not shared with
WYP.

On the 4" January 2023 Anu had a lengthy meeting with one of his Sgts following which he
attended a quarterly review. The serious concerns WYP had as to Anu’s ability were not
shared or reflected in the quarterly review.

There was a lack of clarity and understanding as to what options were available to students
if they wanted to leave the PCDA programme after 2 years but continue with the degree
element. Evidence was contradictory as to whether there academic credits could be used to
continue on a degree albeit they may have to fund any remaining years.

On the 13" January 2023 Anu made direct contact with the OHU where it was acknowledged
he appeared to be in “intense mental distress.” Whilst he was spoken to again later that day,
there was no plan documented that he would be seen or re-contacted by OHU, this appeared
to be because Anu had made direct contact and it had not been a referral from a senior
manager. Anu should have been offered a face to face appointment.

On the 23% January following further concerns about Anu’s work he had a meeting with a
District Sgt and was advised he was being placed on a further development plan. A
subsequent email was sent to Anu by his Sgt setting out his development. During the course
of this meeting Anu indicated he felt suicidal. An urgent referral was made to OHU. The
subsequent email to Anu in no way was reflective of a caring approach to an individual who
was expressing suicidal thoughts.

Following this urgent referral to OHU an appointment was offered for April 2023. Anu should
have been offered an urgent face to face appointment.

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 will occur unless action is taken. In the circumstances, it is my
statutory duty to report to you.

The MATTERS OF CONCERN are as follows:-
National Police Chiefs Council and West Yorkshire Police

1.

The court heard that most OHU referrals within police forces now relate to mental health
issues as opposed to physical health issues. Despite this, there are no specialist Registered
Mental Health nurses recruited into WYP OHU. Indeed the court heard the situation within
WYP may be indicative of the national picture.

2. Following Anu’s death there was no investigation into the quality of care afforded to him by
the OHU within WYP. Hence at the time of the Inquest, there had been no reflection by
practitioners as to the quality of care provided and no learning in respect of processes and
procedures. It was accepted that following the Inquest there were matters which would be
considered. The lack of investigation meant learning from deaths in order to prevent future
deaths was not addressed.

National Police Chiefs Council National Wellbeing service

3. The court heard as to the increase in mental health issues amongst Police Officers nationally.
Despite this, the question of what imminent adjustments should be made or considered once
an officer discloses suicidal thoughts, was unclear. This is before an OHU appointment. In
this case Anu’s mental deterioration was reportedly directly linked to his role as a police
officer. It is acknowledged that this is a difficult issue and there will be issues such as
confidentiality to consider.

College of Policing

4. Whilst the court heard there are now different routes into policing and there is no longer a
requirement to undertaken a degree. The court heard from a significant number of officers
who had undertaken the PCDA. Many of the witnesses told the court of the impact this route
into policing had on them at the time, including the levels of stress they incurred. The PCDA
does continue to operate.

College of Policing and National Police Chiefs Council

5. Ensuring there is a full understanding across Police forces as to the PCDA and the sharing
of accurate information with all those involved in the management of student officers so there
is clear documented records and understanding as to how a student officer is progressing
and whether they are likely to become an efficient constable.

6. Consideration of the Regulation 13 process for PCDA students and how this works in practice
across forces.

—
ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe each of you
respectively have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely 12"
March 2025. |, 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.

COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:-

Family of Anugrah Abraham
National Police Chiefs Council
College of Policing

West Yorkshire Police

Leeds Trinity University

| 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 from. 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.

Date: 14 January 2025 sere JUS

Responses

2 responses 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 College of Policing and National Police Chiefs Council (PDF)

Mrs J Kearsley
His Majesty’s Senior Coroner
HM Coroner’s Court
Floor 2&3 Newgate House
Newgate
Rochdale
OL16 1AT

By email:

Dear Mrs Kearsley,

12 March 2025

Ref:

RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

The College of Policing and the National Police Chief’s Council acknowledge the matters of

concern raised in the Regulation 28 Report to Prevent Future Deaths dated 14 January
2025, concerning Anugrah Abraham. The suicide of Anu Abraham, a serving student officer
on the ‘Police Constable Degree Apprenticeship’ (PCDA) with West Yorkshire Police, was a
tragedy. The inquest has identified important learning for policing in relation to support for
new police constable joiners to the service and processes during their probation period.

This joint response addresses the matters of concern directed to the College of Policing
(the College) and the National Police Chiefs’ Council (NPCC). The Director of the National
Police Wellbeing Service (NPWS), Andy Rhodes has also contributed.

• The College was established in 2012 as the professional body for policing in England

and Wales, its remit includes supporting professional development; sharing
knowledge and good practice; and setting standards to drive consistency in key
areas of policing.

• The NPCC brings police forces in the UK together to help the service coordinate
operations, reform, improve and provide value for money. As well as leading the
national operational implementation of standards and policy, the NPCC works with
the College on the joint development of national approaches, for example, through its
workforce portfolio.

• The National Police Wellbeing Service (NPWS) sits within the College and also
works closely with the NPCC. It was launched in 2019 to provide support and
guidance for police forces across England and Wales to improve and build
organisational wellbeing.

As the body responsible for setting standards for police constable initial education, the
College provides national programme specifications, curriculum, and associated guidance
for four ‘police constable entry routes’ (PCER). Forces design and deliver local PCER

programmes in accordance with our requirements and often (including, for the PCDA) in
collaboration with higher education institution (HEI) partners. The national documentation is
subject to continual review and updating, including through close engagement with relevant
NPCC national policing leads. The College also works with forces and HEIs to support their
continual improvement of local PCER programmes.

We accept the Coroner’s findings. Our response to this Regulation 28 report describes
actions the College and NPCC will undertake to embed learning from your findings, through
continuous improvement processes. The response also outlines a range of recent and
ongoing nationally led work that relates to enhancing the student officer experience and
support. It outlines activity connected with the national optimisation programme for PCER,
which launched in April 2023, and which is led by the College and overseen by an NPCC
chaired PCER Optimisation Group.

Forces acquire a licence from the College to design and deliver their own local PCDA
programmes, in collaboration with HEI partners. The College will be introducing a number of
changes to our national programme specification for the PCDA to respond to the inquest
learning. The changes will be to strengthen wording and provide extra clarity, creating
impetus for collaborations to review their approaches in these areas and make any
improvements as required. In all cases the College will:

• apply the changes to the national specifications for all four police constable entry
routes (PCDA, the ‘degree holder entry programme’, the route for holders of a
degree in professional policing and the new ‘police constable entry programme’);

• have changes adopted in the next iteration of the specifications, due for release in

April 2025;

• commence review of how forces have responded to the changes in the 2025/26

annual programme monitoring (in particular, the College will request evidence about
how collaborations reassure themselves of the quality, consistency and
appropriateness of relevant provision and policies through internal review
mechanisms);

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• use this monitoring as an opportunity to seek out and share promising, innovative

practice, to encourage continuous improvement in these critical aspects of
programme design, delivery, and review.

Our full response is appended below. If you would like to discuss any of the content or
require any further information, the Head of Recruitment and Initial Education at the College
is available to assist. Louise.Meade@College.Police.UK

Yours sincerely

Chief Executive Officer
College of Policing

Chair

National Police Chiefs’ Council

Page 3 of 9

APPENDIX: Detailed Response

Matter of Concern 1. Provision of Mental Health Nurses

The Chief Medical Officer of Policing, Professor John Harrison has national oversight of
Occupational Health provision within forces. He is aware of the Regulation 28 report and is
communicating this concern to all forces through the Occupational Health practitioners’
network.

Matter of Concern 2. Duty of Care & Organisational Learning

The Director of the National Police Wellbeing Service provided evidence at the inquest and
as the Co-Chair of the NPCC Health & Safety Wellbeing Board initiated a review into
national oversight, governance, and assurance. In addition to this, the Board has
communicated the areas of concern to all forces so as raise their awareness of the
organisational learning outcomes and how these are best adopted and applied within
forces.

The Board has national oversight of force activity and will continue to monitor the
implementation of the recommendations raised.

Matter of concern 3: imminent adjustments when an officer discloses suicidal
thoughts

The national suicide action plan was launched in July 2024, and this was raised during the
inquest in terms of force compliance, line manager guidance and also the proposal to fund
national mental health crisis line exclusively for police officers and staff.

The NPCC Health Safety and Wellbeing Board is responsible for supporting forces to fully
adopt the action plan. The duty of care to implement the national suicide action plan sits
with each employer and a self-assessment review is scheduled for September 2025.

The mental health crisis line will be rolled out nationally from April 2025 with an ambition for
all forces to be covered by March 2026. The crisis line will provide managers with a degree
of support when faced with an ‘imminent’ risk because they will be able to promote and
signpost staff towards it. However, it is the view of the NPCC Health Safety and Wellbeing
Board that, when faced with disclosures of such a serious nature, managers should
consider supporting the member of staff to access urgent NHS services via their GP or local
mental health crisis services. The NPCC Board will clarify this issue with forces by end April
2025.

Page 4 of 9

Matter of concern 4. Student officer welfare in relation to the Police Constable Degree
Apprenticeship (PCDA)

Strengthening language in our national programme specifications

Sufficient student officer support is one of the eleven core requirements for local PCDA
programmes, as set out in the current College of Policing national specification for this
police constable entry route. There are requirements for collaborations to support the
student officers with their learning and well-being and with managing the challenge of
becoming a police officer, while potentially managing wider responsibilities/ issues in their
lives. The specification further raises that 'there may be many other ways that student
officers need support and forces should endeavour to cater for these.'
In response to this Regulation 28 report, the College will strengthen wording in relation to
this core requirement. Amended text will include that student officer support provided by
collaborations should account for potential risks to student officer mental health and well-
being. Further, where the specification says, ‘lack of support in any one area could result in
student officers deciding to leave the police service’, extra text will be added ‘and carries
risk in relation to the mental health and well-being of the student officer.’
The College will communicate and follow-up responses to these changes, as described in
the letter above, with the broad remit of focusing extra attention on mental health and well-
being support.

The national optimisation programme for police constable entry routes (PCER)

As presented in the College evidence during the inquest, a national optimisation
programme has been underway for all PCER programmes since April 2023. The
programme is led by the College and designed to deliver the objectives of the ‘National
Police Chiefs’ Council’ (NPCC) Optimisation Plan released in November 2022. A core
objective is ‘improved student officer experience, enhancing well-being and retention’.
The optimisation programme is drawing on an extensive body of knowledge and learning
about how to design and deliver the police constable entry routes. The PCDA was first
launched in 2018 and around 18,000 new officers have joined policing through this route
since then.

Progress to date

Restructured curricula and new assessment requirements were released for all routes in
late 2023 as part of the optimisation programme. These changes to national standards are
focused on ensuring local programmes are vocational in nature and able to use best
practice to make programmes effective and engaging. This includes an integrated
approach, whereby multiple learning outcomes are delivered and assessed collectively, for
example, through scenarios and simulations. Such approaches have educational benefits,
including providing safe opportunities to develop and practice workplace skills. They also

Page 5 of 9

create opportunity to streamline programmes and reduce workload demands on new
joiners.

For the PCDA and ‘degree holder entry programme’ it is now explicit that workplace

assessment can be credit-bearing towards the linked professional policing qualification,
hence reducing the need for additional assessment connected with these programmes.

The optimisation programme also has a range of activity focused on promoting a truly
collaborative approach to PCDA and ‘degree holder entry programme’ design and delivery,

between forces and their education partners. A new recruit survey we held in 2021, 2022
and 2023 revealed the programmes could feel disjointed in nature, with insufficient overlap
between force and HEI delivered elements. Strong partnership approaches will lead to
better student officer experiences.

The revision of the curriculum and assessment requirements at the start of the optimisation
programme was a collective endeavour between forces, HEIs and the College. This spirit of
joint working has been fostered throughout the optimisation programme, for example with
joint national practice sharing events. A new national procurement framework was launched
at the start of 2024, for forces to use for contracting HEI initial education partners.
Collaborative, optimised practice and strong governance is embedded within contracts as
standard, using this framework.

As well as promoting and supporting changes to the design and delivery of local
programmes, national optimisation activity has included the launch of the new ‘police
constable entry programme’ (PCEP). This route can be delivered entirely in-house by
forces, without external accreditation – hence it offers a joining route for new officers that do
not want to study for an academic professional policing qualification. 37 forces are due to
be live with the route by the end of financial year 2024/25.

Upcoming (2025/26)

In October 2024 the Secretary for State for Education approved simplified statutory
assessment requirements for the PCDA, to come into effect from 1 April 2025. The PCDA
will move to the regulated profession, fully-integrated degree apprenticeship model - the
same as the nursing degree apprenticeship. This change frees up more opportunity to
adjust assessment methods, again to make them more vocational in nature. Pressure on
student officers will be reduced by a change to the ‘end-point assessment’ (EPA). The EPA
will become a final approval process, with all assessment of the student officer having
already been completed. It is also explicit (in College supporting guidance for the changed
EPA) that forces and their education partners can consider alternatives to the final 10,000
word written dissertation.

The upcoming changes to the PCDA have been widely communicated, including through a
briefing to all chief constables, police and crime commissioners, force finance and learning

Page 6 of 9

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and development leads and to HEIs involved in PCER delivery. There was also coverage in
the professional policing online press. The College has been promoting and enabling
collaborative problem-solving, bringing together forces and university partners to share
ideas about how to make the most of the opportunities posed by the new PCDA standard.

Changes allowed under the new apprenticeship standard can be introduced for existing
cohorts, where it is manageable to do so. Cohorts undertaking the former EPA already
benefit from a reduction in the pass-mark from 50% to 40%, introduced and agreed with the
Institute for Apprenticeships and Technical Education (IfATE) in July 2023.

Learner support roles, including tutor constables, are critical to the successful delivery of all
PCER programmes. Throughout the optimisation programme there has been activity to
promote and support their professional development. Building on this, the College will
imminently be releasing a new, extended tutor constable training package which forces will
be able to deliver flexibly in-house. The training is designed to align with the new tutor
constable standard and curriculum, which the College released in 2024. The training will
include content on student officer well-being.

Continuous improvement

Optimisation programme benefits measurement activity will continue in 2025-26, including
work to gather insight into how local PCER programmes have been re-shaped.
The College will be embedding new national approaches to promoting continuous
improvement of local programmes. The College will be working to identify promising and
less promising approaches to design and delivery through its annual monitoring of local
PCER programmes and review of national data (for example on retention rates). The
College will be supporting forces with their own local evaluation of programmes,
encouraging stepped-up approaches that enable deeper insight into student officer
experiences, well-being and satisfaction.

Matter of concern 5. Sharing of information regarding student officer progress

The inquest hearing revealed that early concerns regarding Anugrah Abraham’s progress
on the PCDA programme were not appropriately shared, neither with him nor with all
relevant assessors and managers. This is counter to the intentions of core programme
requirements set by the College, including core requirement seven concerning student
officer support. Forces and education partners are required, for example, to provide
guidance to student officers to enable their progression through the programme. This
guidance should include regular verbal and/or written assessment feedback to student
officers, as well as ‘regular opportunities to review their progress and goals to revise their
individual learner plan to meet their targets’.

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A11

Core requirement eight concerns programme staffing, including that there is clarity on
responsibility and accountability for each role involved in programme development, delivery
and maintenance. The College will add extra text to this core requirement, to make a more
explicit requirement that there are policies/ processes/ governance in place to ensure
appropriate communication and sharing of information between roles. This is particularly
important for the PCDA programme, where both forces and education partners, including
multiple teams within forces, are involved in delivery, assessment and providing support to
student officers.

The College will also adjust core requirement one (programme governance and
management) to add a specific expectation that records will be kept and appropriately made
available, in relation to how a student officer is progressing and whether they are likely to
achieve full operational competence as a police constable.

As well as the imminent new tutor constable training and already released associated
standard, the College is developing a new assessor module for its well-established
“Training Essentials Programme”. The new assessor module has been piloted in three

forces and is undergoing further development, ready for wider use by forces in 2025. This
training complements the College assessor standard released last year, and both address
the assessor role in providing feedback.

The College is working with forces to develop and launch a new national ‘Professional
Development Review (PDR) strategy’ and supporting guidance in 2025. It will be promoting

and supporting a consistent approach to PDR within forces. Regular PDR conversations
can play an important role in supporting officer wellbeing, motivation, performance,
accountability, and career progression. By facilitating one-to-one conversations with
managers, they create opportunity to review and reposition goals, resolve
challenges/issues, support resilience and discuss continuing learning and development.
While not directly raised as a matter of concern the College will, as part of communicating
changes to PCER programme specifications, raise the importance of reviewing transition
arrangements and guidance for student officers that want to or may benefit from moving to
an alternative entry route, including policies and guidance for gaining credits towards an
alternative qualification (where relevant).

Matter of concern 6. Consideration of regulation 13 processes for PCDA students

The College will ensure that the response to matter of concern 5 (above), on the sharing of
information, will specifically reference the sharing of information about concerns with
performance and any associated processes that are commenced. However, regulation 12
and 13 of the Police Regulations 2003 are the responsibility of the Home Office and
developing guidance for forces on their use is outside of the remit of the College. The
Home Office is cognisant of the need to provide more comprehensive guidance on the use
of regulation 13 to assistant forces with its consistent use. This was a finding of the Home
Office review of the process of police officer dismissals (published in September 2023)

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and the Home Office has given a recommendation to itself to develop the extended
guidance.

Changes to the national apprenticeship standard for the PCDA, described under matter of
concern 4 (above) are relevant to concerns about regulation 12 and 13 notifications for
PCDA student officers. The lowering of the EPA pass-mark from 50% to 40% in July 2023,
has directly reduced the risk that student officers could fail their PCDA programme and
hence risk a regulation 13 notification because of their academic performance. The
additional forthcoming major changes to the EPA, which will come into effect from 1 April
2025, will reduce this risk further. Under the new PCDA apprenticeship standard, all
assessments of PCDA student officers will have been completed prior to the EPA. Further,
there is extra clarity that collaborations have flexibility around assessment methods used in
year three. There are opportunities (supported by the wider optimisation programme work)
to streamline processes, reduce workload burden on student officers and spread-out
assessments to reduce pressure in the final programme year.

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A13

Response from West Yorkshire Police (PDF)

Headquarters
PO Box 9
Laburnum Road
Wakefield
West Yorkshire
WF1 3QP

Deputy Chief Constable

Ms J Kearsley

Deputy Chief Coroner and HM Senior Coroner for Manchester North

Via email to

Friday, 7th March 2025

Inquest touching the death of Anugrah Abraham

Dear Ms Kearsley,

Thank you for your letter of 14th January 2025 and for sharing the ‘prevention of future deaths’ report

in relation to the tragic death of Anugrah Abraham. Anugrah’s death has impacted the West

Yorkshire Police family greatly and reflection on events has taken place on many levels, and of course

our thoughts remain with his loved ones and close colleagues.

Please find below the response from West Yorkshire Police in relation to your prevention of future

deaths report.

1. There has been an increase in the ratio of mental health related issues to physical health issues

being referred to our Occupational Health department, but these fall within the expertise of

occupational health clinicians who are trained to provide advice to both employees and

employers regarding these conditions.

It must be reinforced that the Occupational Health department (“OH”) is a specialist advice

service relating to the impact of work on health and health on work. It is not a treatment service

and the normal expectation for anyone with a crisis presentation, whether physical or mental

health is that they present to primary care or the Emergency Department of the local NHS

provider. Because treatment for mental health conditions is not a service provided by OH, they

do not employ specialist treatment providers such as registered mental health nurses. If

A14

anything, this would likely further confuse the situation by creating an expectation of treatment

provision.

Regarding the adequacy of response to an urgent request, at that time the provision of an

appropriately staffed OH team would have better addressed the issue of waiting times more

pertinently than the specialist background of team members. Fortunately, the clinical staffing

levels have improved, and the team is currently fully staffed.

Frequency of updates in mental health training to existing staff is far more relevant and effective,

and this is the response determined as appropriate by West Yorkshire Police. There are annual,

formal Continuous Professional Development training events that are sourced and provided ad-

hoc, but other events also include: Bi-monthly case discussions where mental health cases are

raised alongside hot topics; Audit plan which includes audit of mental health cases and individual

and team learning. The Senior OH Nurse Advisor is also undertaking a Post Graduate Certificate

in Psychological Trauma as part of her development and development of related processes. This

is provided by the University of Chester. In addition to the above, the OH team have also recently

reviewed training and development and identified additional training requirements, one

example of this being a nurse who had previously acquired the Diploma in OH Nursing, now

upskilling to the degree (BSC in OH) through Cumbria University.

It is important to confirm that the West Yorkshire Police Occupational Health function will be

subject to an independent external audit of service provision, the operating model, etc., to

understand whether the function remains appropriately resourced and modelled to meet

current and future service delivery demands. The review is being undertaken by Acorn

Occupational Health Ltd who are a Safe Effective Quality Occupational Health Service accredited

organisation. This audit is expected to be completed by April 2025. Ultimately, the findings of

the review will be considered by the Force’s Service Delivery & Change Group (SDCG) which

comprises the Force’s most senior leaders and is chaired by the Deputy Chief Constable.

2. An informal post-incident briefing was held with relevant members of the OH team at the time.

It should be noted that the OHU did not undertake formal serious incident analysis (SIA) until

after the inquest on the guidance of the IOPC. The learning that was identified in the SIA related

to the addition of recording frequency of suicidal ideation, and the recording of informal team

advice/conversations. As a consequence, the Assessment of Suicide and Self Harm protocol was

updated to include this learning, and it is now embedded into normal practice. There has also

been the introduction of a recorded message informing callers where to obtain crisis support

on initial telephone contact with the OH team.

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The following are the key points arising from a review in November 2024 of events and clinical

history. Feedback was presented from those involved in the clinical case and the inquest. An OH

whole team discussion to agree changes took place:

What went well.

• The waiting time at triage was made clear to the referring manager

• Signposting of support was made to the referring manager

• A high standard of compassionate care was offered by the OH Nurse Advisor

• Team support following the incident was excellent

What could have gone better.

• A vague self-referral was accepted

• The frequency of suicidal ideation should be recorded

• Protective factors should be recorded

• There should be better documentation of risk discussions between the clinical team

• Clear understanding of the advisory role of OH

• Although the OH Nurse Advisor contact was an informal contact, it was inappropriately

referred to as a Consultation during the Inquest

• The service level agreement of 5 days for a Management Referral appointment is

inappropriate.

• The IOPC advised not to discuss the case due to their proceedings, should a formal case

review have taken place in the interim?

Learning/Actions

• That the OH answerphone message should include advice for the National Police Wellbeing

Service ‘Oscar Kilo’ Crisis line number.

• Discussions between the clinical team regarding risk should be documented as an edit to

the clinical note.

• Where suicidal ideation is being discussed, the frequency should be recorded as part of the

risk assessment.

• Protective factors should be recorded as part of self-harm/suicide risk assessment.

•

It is proposed that the OH page should include the National Police Wellbeing Service ‘Oscar

Kilo’ Crisis line number.

• Contact Force Legal Services to provide inquest feedback.

• The service level agreement target is to be abandoned as unrealistic.

A16

•

Introduction of 90mins appointments for individuals referred with more than one health

condition including mental health.

• Escalation to Force Medical Advisor for student officers referred due to their mental health.

If you require and further information from West Yorkshire Police about our actions and progress

following your report, please do not hesitate to contact me.

Yours sincerely,

Temporary Deputy Chief Constable

A17

The report

Responses

Related reports

Other reports by Joanne Kearsley

More reports categorised “Suicide (from 2015)”

Track Suicide (from 2015)