Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0118, written 4 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2025 |
|---|---|
| Reference | 2025-0118 |
| Deceased | Alfie Lawless |
| Coroner | Chris Morris |
| Coroner area | Manchester South |
| Category | Suicide (from 2015) · Police related deaths |
| 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 THIS REPORT IS BEING SENT TO: Chief Constable Manchester Police CORONER I am Chris Morris, Area Coroner for Greater Manchester (South). CORONER’S LEGAL POWERS , Chief Constable, Greater 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 31st July 2024, an inquest was opened into the death of Alfie Lawless, who was found dead at his home on 10th July 2024, aged 19 years. The investigation concluded with an inquest which I heard on 28th February 2025. A post mortem examination determined Mr Lawless died as a consequence of hanging. At the end of the inquest, I recorded a conclusion of Suicide. CIRCUMSTANCES OF THE DEATH Mr Lawless died having suspended himself by the neck with a ligature. Mr Lawless’s mental health had deteriorated in the aftermath of an incident on 18th May 2024 which led to him being found outdoors in Manchester City Centre partially clothed and with a head injury, but with no specific recollection as to what had occurred. Amphetamine was subsequently detected as being present in Mr Lawless’s system around this time, which he maintained he had not ingested voluntarily. Police officers attended in response to a 999 call made by a member of the public, and an investigation commenced in respect of the crime of battery / common assault pursuant to s39 Criminal Justice Act 1988. This investigation was later closed following difficulties in establishing contact with Mr Lawless. Mr Lawless had used cocaine prior to his death. 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. – The court heard evidence from a Detective Sergeant from Greater Manchester Police’s Professional Standards Branch (‘PSB’) as to valuable learning which has been identified following her review and critical analysis of the police response to the initial 999 call made on 18th May 2024 and the subsequent police investigation. In the light of this, I am concerned as to the length of time it took for Mr Lawless’s death to be recognised by Greater Manchester Police as a Death or Serious Injury within the meaning of s12 Police Reform Act 2002: something which appears only to have occurred after a statement for the purposes of the inquest was requested from a senior officer asked to review previous police contact with Mr Lawless. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29th April 2025. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, together with members of Mr Lawless’s family and Greater Manchester Police’s legal department. I have also sent a copy to Greater Manchester Combined Authority who may find it useful or of interest. 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. Dated: 4th March 2025 Signature: Chris Morris, Area Coroner, Manchester South.
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.
Stephen Watson QPM Chief Constable HMC Christopher Morris Area Coroner Manchester South Via rt 17 Apri 2025 Dear Mr Morris Re Regulation 28 report following the inquest into the death of Alfie Lawless Thank you for your report dated 4" March 2025 in respect of the tragic death of Alfie Lawless pursuant to Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 and Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009. Having carefully considered your report and the evidence submitted at the inquest | make the following observations and recommendations to hopefully address your matters of concern. The MATTERS OF CONCERN are as follows. The court heard evidence from a Detective Sergeant from Greater Manchester Police’s Professional Standards Directorate (‘PSD’) as to valuable learning which has been identified following her review and critical analysis of the police response to the initial 999 call made on 18th May 2024 and the subsequent police investigation. In the light of this, | am concerned as to the length of time it took for Mr Lawless’s death to be recognised by Greater Manchester Police as a Death or Serious Injury within the meaning of s12 Police Reform Act 2002: something which appears only to have occurred after a statement for the purposes of the inquest was requested from a senior officer asked to review previous police contact with Mr Lawless. The Professional Standards Directorate has reviewed its internal processes for when assessing incidents relating to Death or Serious Injury (DSI). Cases that are referred into PSD for assessment under Section 12 of the Police Reform Act 2002 are primarily undertaken by the Appropriate Authority (AA) on the Assessment Team, the front door into the PSD, but are also undertaken by AA’s from across the Directorate. To ensure that a common standard is applied to this assessment, a new form has been designed requiring the AA to not only include their rationale behind the decision around whether the DSI criteria had been met, but also what material they have considered in order to make this decision. This form was designed in consultation with the AA’s within the PSD and the final version has been circulated to the AA’s within the Directorate for their immediate use. Material which the AA should consider in order to assist in their assessment will include; Incident logs, the Senior Investigating Officer Reports, Missing from Home Reports, Police Coroners material, CCTV, 999 call logs and any other material deemed to be relevant. Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS Cont.d pg 2 .... The form also includes a section relating to learning opportunities, which will be returned to the relevant staff member or department to ensure that feedback is given at the earliest opportunity. The form once completed will be saved to the relevant PSD case for future reference. The PSD’s Organisational Learning team will also monitor the forms and any learning that is a risk to the organisation will be escalated to the forces Tactical Organisational Learning Board for wider discussion. The PSD will adhere to Police Regulations by ensuring that mandatory referrals are made, without delay, and in any case not later than the end of the day after the day it first becomes clear that it is a matter which must be referred. We will also ensure that AA’s attend formal training in relation to DSI, which is provided by an external company. The PSD Senior Leadership Team will undertake a period of monthly dip sampling in order to ensure that this process is embedded. There will be a roll out of DSI awareness training both internally and across the Greater Manchester Police (GMP) in order to raise awareness and understanding. This will take the form of force intranet articles which will outline the definition of a DSI and when to refer into the PSD. The PSD AA’s also provide a monthly input on the Detective Sergeant / Detective Inspector dealing with Death course at GMP’s training school specifically relating to DSI and what is expected when referring a case into the PSD. It is anticipated that by introducing these measures it will ensure that DSI’s and learning opportunities are identified at an early stage resulting in the coroners officers being notified and referrals being made to the IOPC in a timely manner. Yours sincere Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS
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