Sophie Cotton

Ms Rebecca Sutton 
Assistant Coroner 
County Durham and Darlington 

23 July 2025 

Dear Ms Sutton, 

Preventing Future Deaths Report – Sophie Ann Louise Cotton 

Thank you for providing the College of Policing with a copy of your report dated 27 May 2025 following 
the death of Sophie Ann Louise Cotton. We extend our sincere condolences to her family and all those 
affected. 

We have carefully considered the matters of concern raised in your report and provide the following 
response on behalf of the College of Policing. 

1.  During the 16:44 call, by following the “Right Care, Right Person” procedure there 

was a refusal to the request that the police attend, even when a family member was 
expressing the view that there was a real and immediate risk to life. 

In relation to the operational elements and decision-making processes, we have been in contact with 
Durham Constabulary and understand that a full response to these points is being provided. 

Right Care Right Person (RCRP) is a national initiative that aims to ensure that vulnerable people get the 
right support from the right services. The College host the implementation toolkit for RCRP, which 
provides national guidance for all forces to follow., it applies to calls for service about: 

•  concern for the welfare of a person 
•  people who have walked out of a healthcare setting 
•  people who are absent without leave (AWOL) from mental health services 
•  medical incidents 

RCRP has been developed under the National Partnership Agreement (NPA) which sets out the support 
of all key agencies including NPCC, Home Office, Department for Health & Social Care, NHS England, 
Association of Police and Crime Commissioners, and College of Policing. 

RCRP is based on the legal position that the police owe responsibility to take all reasonable measures to 
assist where there is either: 

 
 
 
 
 
 •  a real and immediate risk to the life of a person (European Convention on Human Rights (ECHR) 

Article 2) 

•  a real and immediate risk of that person being subject to serious harm or other inhumane 

treatment (ECHR Article 3) 

Where the legal thresholds are met, the police are under a duty to respond to incidents, and in addition, 
to respond to incidents involving crime. 

The College of Policing worked with the NPCC to create and publish the national Right Care Right 
Person implementation guidance toolkit. The section that specifically relates to the force control room 
can be found on the following link https://www.college.police.uk/guidance/right-care-right-person-
toolkit/force-control-room-implementation-guidance  

2.  During the 16:44 call the “Right Care, Right Person” advice to contact mental health services 

appears to have disregarded the fact that the mental health crisis team do not have the power to 
enter locked premises and so would require police attendance to facilitate entry to the premises. 

The College RCRP guidance reaffirms the position as set out within the case of Syed v DPP [2010] 
EWHC 81 (Admin) in relation to the powers of entry available to the police. The toolkit states ‘There is no 
specific power of entry to carry out a concern for welfare check…’ 

The framework encourages forces to work with partners to identify any gaps in service, including to work 
with the Fire and Rescue Service, who have similar powers available to effect entry in emergency 
situations, and who have the appropriate skills, training and equipment to effect entry where necessary. 
However, based on the force’s risk assessment on the information known at the time, if the force’s 

assessment of risk does not amount to a risk to save life and limb, the police do not have a power to 
effect entry into a person’s home for the purpose of undertaking a welfare check. 

Ongoing monitoring and work is being undertaken with partners with regards to powers of entry to 
ensure all partners are aware of the legal parameters in which all agencies operate, including for all 
agencies to understand the specific legal powers available to them, and to ensure all options are being 
considered. 

3.  During the 16:57 call there was no decision for police to attend, even though this was the third 
caller (and second professional caller) that had expressed serious concerns about Sophie 
Cotton. 

The toolkit outlines two separate routes for escalation processes covering ‘real-time escalation’, which is 
at the point of the call being received, as well as ‘partnership escalation’, which ensures partners have 

the ability to escalate concerns arising, especially where emerging themes are identified. The guidance 
advises forces to ‘to review the effectiveness and impact of RCRP, and to capture use of the escalation 
process.’ It is imperative that where decisions are subjected to an escalation process, and decisions 
have changed, that this is communicated to the call taker as soon as practicable. 

 
 
 
 
 
 
 
 The toolkit also provides advice and guidance to forces on their development and implementation of 
RCRP. As part of this guidance, it sets out that forces should ensure police officers and staff understand 
the interoperability between RCRP and non-RCRP-incidents and that policies are clear and easily 
accessible, specifically for control room staff and call handlers. 

Whilst the College sets out the national implementation guidance and toolkits for RCRP, it is for each 
force to undertake risk assessments in line with their own established control room procedures and force 
policy, as well as any agreements in place at a local level, when deciding which incidents they will 
respond to. 

The College collates all information in respect of concerns that are raised, and reviews these against the 
toolkit and guidance provided to forces. The toolkit is subject to ongoing review and where necessary 
amendments will be made. The College continues to encourage forces to follow the guidance within their 
development of RCRP and provides ongoing support and advice to forces. 

4.  Although there is a procedure in place to have a negative “Right Care, Right Person” decision 

reviewed by a supervisor, this causes additional delay in circumstances when attendance could 
be extremely time sensitive. 

The College have been in contact with Durham Constabulary who have highlighted that they have 
reviewed their policies and procedures in line with the College of Policing toolkit and Approved 
Professional Practice in response to the concerns raised, to ensure efficiency and effectiveness in their 
response to calls for service. 

The concerns raised will also be communicated with all forces within the national tactical delivery Board, 
where learning can be shared. The College continually reviews the content of the toolkit guidance to 
ensure forces are provided with the tools, training, and support to effectively implement and deliver 
RCRP. 

We hope this reassures you of our continued commitment to supporting police forces in reviewing and 
refining operational processes and policies in response to concerns raised. 

Please do not hesitate to contact us should you require any further information. 

Yours sincerely 

Chief Executive Officer 
College of Policing 
E:

Response to Regulation 28 Report for HM Coroner Relating

to the Inquest Touching upon the Death of Ms Sophie Ann

Louise Cotton

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) During  the  16:44 call,  by  following  the  “Right Care,  Right  Person”  procedure

there was a refusal to the request that the police attend, even when a family

member was expressing the view that there was a real and immediate risk to

life.

Durham Constabulary Response

At the time of the 16:44 call 

 (mother) did express concerns

about her daughter relaying information regarding previous incidents.  The call

handler asked if there had been any threats made on this occasion and was

told that there had not been.  Mrs Cotton states that she is probably overthinking

but is worried about her daughter.  There had not been any contact over the

weekend and there was no new information from the previous call.  Mrs Cotton

confirms that her son is going to go back to the address again.  It is confirmed

to  Mrs  Cotton  that  on  the  information  provided  at  that  time  that  it  is  not

considered that there is a real and immediate risk and that the police will not be

attending.  It is confirmed that the call will be subject to review by a supervisor

as  standard  practice.    All  calls  are  assessed  based  upon  the  information

supplied at the time of the call.  All such calls received by Durham Constabulary

are entered onto the Force Command and Control System (Smart Storm) and

all incidents remain active until reviewed by a supervisor as only they can close

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 a call on the system. Durham Constabulary is committed to providing the best

service  possible  to  the  public  and  in  assessing  whether  any  lessons  can  be

learnt from this tragic incident.

Deputy  Chief  Constable 

  instructed  Assistant  Chief  Constable 

,

portfolio lead for public contact and response policing to undertake a review of

the  events  prompting  HM  Coroner’s  concerns.    As  a  result, 

convened a working group to fully and properly consider the matter.

Recommendations  have  been  made  to  improve  the  system  with  the  aim  of

strengthening the policy ensuring that the needs of the public are met.  More

details can be found below.

Mrs Cotton has been spoken to and is being kept up to date during this review

process  so  that  she  is  aware  that  Durham  Constabulary  is  taking  this  very

seriously  and  are  carrying  out  a  full  review  aimed  at  improving  the  system

where possible.  The recommendations for improvements in the system have

been  discussed  with  the  College  of  Policing  who  have  confirmed  that  the

improvements and system overall are in line with the National Toolkit for Right

Care, Right Person.

(2) During the 16:44 call the “Right Care, Right Person” advice to contact mental

health  services  appears  to  have  disregarded  the  fact  that  the  mental  health

crisis  team  do  not  have  the  power  to  enter  locked  premises  and  so  would

require police attendance to facilitate entry to the premises.

Durham Constabulary Response

At the time of the 16:44 call the matter had been assessed as not having an

immediate need  or  risk to life or  limb, it was considered to be  a  concern  for

welfare and as such Durham Constabulary would not have a power or right of

entry.

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 The Coroner will be aware that the police have a right of entry under Section

17 of the Police and Criminal Evidence Act, but only in certain circumstances.

The appropriate part of Section 17 is:-

“ Entry for purpose of …..

(1)  Subject to the following provisions of this section, and without prejudice

to  any  other  enactment,  a  constable  may  enter  and  search  any

premises for the purpose

a)  …………

(e) of saving life or limb or preventing serious damage to property.”

The Courts have provided guidance in relation to the use of Section 17 and in

particular in the case of Syed v DPP [2010] EWHC 81 (Admin), police officers

explained  to  the  court  that  they  considered  that  a  concern  for  welfare  was

sufficient to entitle the officers to enter the property through their power under

s.17(e) PACE. However, the High Court explained at [12] that, contrary to the

officer’s understanding:

“Concern for welfare is not sufficient to justify an entry within the terms

of section 17(1)(e). It is altogether too low a test. I appreciate and have

some sympathy with the problems that face police officers in a situation

such as was faced by these officers. In a sense they are damned if they

do and damned if they do not, because if in fact something serious had

happened, or was about to happen, and they did not do anything about

it because they took the view that they had no right of entry, no doubt

there  would  have  been  a  degree  of ex  post  facto criticism.  But  it  is

important to bear in mind that Parliament set the threshold at the height

indicated by section 17(1)(e) because it is a serious matter for a citizen

to have his house entered against his will and by force by police officers.

Parliament  having  set  that  level,  it  is  important  that  it  be  met  in  any

particular case.”

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 Many calls for welfare concerns that the police attend, and force entry result as

‘false alarms’ where the person is fit and well and not in crisis and this results

in distress to them, even if well intentioned.

The referral to contact the Mental Health Crisis Team would have been so that

they  could  have  made  additional  checks,  and  they  may  have  been  in

possession of additional information that Durham Constabulary did not have.

For example, Sophie may have been in touch with them for assistance and be

receiving it.  They could also make enquiries as to whether was in or had been

in hospital that would have assisted.

(3) During the 16:57 call there was no decision for police to attend, even though

this was the third caller  (and  second  professional caller)  that had  expressed

serious concerns about the Deceased.

Durham Constabulary Response

During  the  call  at  16:57  no  decision  was  expressed  to  attend,  however  that

matter  was  escalated  as  part  of  the  Standard  Protocol  by  the  Control  Room

Supervisor  to  the  Force  Incident  Manager  who,  based  upon  the  cumulative

effect of the calls made the decision for Policer Officers to be deployed to attend

and  effect  entry  to  allow  the  appropriate  services  access  to  the  premises.

Police logs confirm this decision but unfortunately this decision to attend was

not communicated to the caller or the family.  It is recognised that this should

have been communicated and is a point of learning.  Measures have been put

into place to seek to prevent such a recurrence of the failure to communicate.

(4) Although there is a procedure in place to have a negative “Right Care, Right

Person”  decision  reviewed  by  a  supervisor,  this  causes  additional  delay  in

circumstances when attendance could be extremely time-sensitive.

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 Durham Constabulary Response

The working group reviewed the position with regards to when a decision not

to  attend  is  given.   It  is clearly not possible to  attend  every  call  in relation  to

welfare concerns and in most cases the police are the wrong organisation to be

involved in any event, nor would they have a power of entry.   Often Durham

Constabulary is asked to attend premises without the support of Mental Health

Services also attending and even if officers have forced entry they have limited

powers as to what they can do.  A person cannot be forced to for example to

attend hospital as legislation supports that a home is a place of safety which

can only be interfered with in limited circumstances.

Durham Constabulary recognises that there need to be safeguards within the

system for speedy and timely reviews of decisions not to attend and 2 specific

recommendations  have  been  made  to  improve  the  current  system.    These

recommendations  have  been  approved  and  discussed  with  the  College  of

Policing who have confirmed that they are line with the National Toolkit for Right

Care, Right Person (RCRP)

These recommendations will be implemented as soon as is practicable, with a

target date of mid-July 2025 for full implementation.  Good progress is already

being made..

Once the recommendations have been introduced every decision not to attend

will  result  in  a  review  of  police  systems  for  further  intelligence  to  support  or

amend the decision on attendance or otherwise under RCRP principles. These

initial  checks  will  be  to  review  previous  incident  logs,  checks  on  local  and

national police and partner systems. These checks will be done by a member

of the control room staff and most likely by a dispatcher.

In  addition,  if  the  decision  under  RCRP  remained  that  no  police  would  be

attending  then  a  review  by  the  shift  supervisor  would  be  carried  out.    Such

review would be a matter of routine and would be done as soon as reasonably

practicable,  as  soon  as  is  reasonably  practicable,  but  in  any  event

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 expeditiously.  The decision on whether to attend could change at any stage in

this review process.   Any change in decision would be communicated to the

caller.

On  a  second  call  about the  same  person  within  a  12  hour  period  where  the

answer  on  the  first  call  was  for  the  police  not  to  attend  there  will  be  an

immediate escalation to the Supervisor who will carry out a further review as

soon as possible.

If  at  this  stage  the  decision  remained  that  the  police  would  not  be  attending

there would be no reason to contact the called again as they will have been told

that  the  police  would  not  be  attending  by  the  Call  Handler.      If  the  decision

changed  so  that  the  police  would  be  attending,  then  the  Supervisor  will

recontact the caller and update.

Any additional calls within the 12 hours from the first call will be subject to the

same review process as detailed above.

Durham Constabulary is confident that the additional measures strengthen the

policy and will meet the aims of serving the public.

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Durham Constabulary

Deputy Chief Constable

Chief Constable’s Office
Constabulary Headquarters
Aykley Heads
DURHAM
County Durham
DH1 5TT

Tel. No.:  101
Web Site: www.durham.police.uk
Our Ref: DCC

(Sent via email)

Date:16/07/2025

FAO HM Assistant Coroner Rebecca Sutton

Dear Ms Sutton

I am writing in response to the Regulation 28 Report to Prevent Future Deaths, generated from the
inquest touching on the death of Sophie Cotton.

As recipient of the notice, I wanted to personally assure you that the Constabulary take such
communications very seriously and I personally tasked Assistant Chief Constable 
 with a
full review of the case and the police actions.  The outcome and actions from that review are attached
alongside this response.

Of course, should you or your office require any further information, please do not hesitate to recontact
and we will do all we can to support.

Yours sincerely

 Constable

www.durham.police.uk

17th July 2025

Dear HM Assistant Coroner Sutton

I write in response to the Regulation 28 report dated 27th May 2025 which was initially
shared with my office by Deputy Chief Constable 

.

As my office had not received a formal request for a response, subsequent enquiries were
made with the Coroners Service Manager for County Durham and Darlington, and it was
confirmed in writing on 12th June 2025 that there had been an oversight on your part and a
formal response will also be required from the Police and Crime Commissioner.

I note from the correspondence received that a copy of the coroner’s report has also been
sent to:

 Deputy Chief Constable 


Chief Executive Officer of the College of Policing, 

, Durham Constabulary

From the outset, I would like to take this opportunity to express my sincere condolences to
Sophie’s family following her untimely death. I can understand the distress Sophie’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 been reassured that a Gold Command Structure was swiftly put in place by Assistant
Chief Constable 

.

A thorough review has since taken place and although it has not highlighted any significant
failings in the use of, and implementation of the ‘Right Care Right Person’ (RCRP) policy, the
review of the incident(s) has resulted in two specific points of organisational learning and
recommendations to be implemented and progressed. Durham Constabulary has also
consulted with the national mental health co-ordinator to ensure the response is aligned to
national practice.

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 to respond to calls.

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 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.

I trust this response addresses the issues that have been brought to my attention and I will
continue to monitor the delivery of the ‘Right Care Right Person’ model being adopted
across County Durham and Darlington, particularly the role of the Force.

Yours sincerely

Police and Crime Commissioner for Durham

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