Elaine Tarbuck

Timothy Brennand 
HM Senior Coroner for Manchester West   

29 August 2025 

Re Regulation 28 Report   Elaine Tarbuck 

Dear Mr Brennand 

Thank you for your report dated 7 July 2025 concerning the tragic death of Elaine Tarbuck. We extend 
our sincere condolences to her family and all those affected. 

We have carefully considered the matters of concern raised in your Regulation 28 report. This response 

of the Right Care, Right Person (RCRP) approach, particularly regarding the role of the police in welfare-
related calls and the issue of forced entry. 

Clarifying the Role of the Police in Welfare Calls 

The College recognises the public expectation that emergency services will respond swiftly and 

powers of entry is clear: unless there is a real and immediate risk to life or of serious harm (as defined 
under Articles 2 and 3 of the ECHR), or a crime is suspected, police powers to enter a private dwelling 
are limited. 

The RCRP toolkit, developed in partnership with the NPCC and other national agencies, reinforces this 
legal position. 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  

It explicitly states that there is no general power of entry for welfare checks reaffirming 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 

It also encourages forces to work with partners particularly the Fire and Rescue Service
who may have the appropriate powers, training and equipment to gain entry in such circumstances.  
Please see an extract below and relevant link: 

Protocols will need to be developed at a local partnership level to set out the lines of responsibility for 
each agency. Once agreed, these changes to ways of working must be communicated to staff within 
each agency and guidance provided.  

https://www.college.police.uk/guidance/right-care-right-person-toolkit/senior-responsible-officer-sro-role 

 
 Addressing Delays and Improving Call Handling

The College is reviewing the RCRP toolkit to ensure it provides clearer guidance on the assessment of 
risk in control rooms, including how to handle ambiguous or borderline cases where the threshold for 
police attendance may not be immediately clear.

Clarifying Responsibilities for Forced Entry

The confusion over which agency should take responsibility for forced entry is a key learning point. The 
RCRP guidance encourages local partnerships to develop clear protocols that define roles and 
responsibilities in such scenarios. These protocols should be communicated effectively to all frontline 
staff to avoid hesitation or uncertainty during time-critical incidents.

We are working with forces and partner agencies to support the development and dissemination of these 
local agreements, and we will highlight this issue at the next meeting of the National RCRP Tactical 
Delivery Board to ensure national learning is shared.

Responding to Concerns About the RCRP Model

The intent of RCRP is to ensure individuals received the most appropriate care from the most 
appropriate agency. However, we understand the concerns and recognise that its implementation must 
be sensitive to the nuances of real-world emergencies. The College continues to monitor the impact of 
RCRP and is committed to refining the guidance based on operational feedback and case reviews such 
as this. 

Commitment to Continuous Improvement

The College remains committed to supporting forces in delivering lawful, proportionate, and effective 
responses to concern-for-welfare calls. The concerns raised will also be communicated with all forces 
within the national tactical delivery Board, where learning can be shared.  We will continue to:

Review and update national guidance based on emerging learning

Support forces in developing local protocols with partner agencies

Promote national consistency through the RCRP Tactical Delivery Board

Encourage a culture of continuous improvement and reflective practice

We hope this response provides assurance of our commitment to addressing the issues raised and to 
preventing future deaths in similar circumstances. Please do not hesitate to contact us should you 
require any further information.

Yours sincerely,

Chief Executive Officer
College of Policing

Chief Constable

Mr Timothy Brennand
Senior Coroner
Manchester West

g  GREATER MANCHESTER

r POLICE

26 th August 2025

Dear Mr Brennand

RE: Regulation 28 report following the death of Elaine Tarbuck

Thank you for your report dated 7th July 2025 in respect of the death of Elaine Tarbuck pursuant paragraph
7,  Schedule  5,  of  the  Coroners  and  Justice  Act  2009  and  regulations  28  and  29  of  the  Coroners
(Investigations) Regulations 2013.

Having carefully considered your report, I make the following observations and recommendations in relation
to  the  matters of  concern,  which  are  understood  to  be  the  following broad  areas  -  the  evaluation  and
assessment of concern for welfare (CFW) calls (including information gathering and training in these areas),
forcing entry and  the appropriate agency to  do  so  and ensuring the  appropriate agency responds to  such
incidents.

GMP’s handling of CFW relating to Mrs Tarbuck

GMP were contacted at 1131 hours on the 29"' March 2025 and informed of a concern for Mrs Tarbuck. This
call was made via 999 by a friend of Mrs Tarbuck who  was present outside Mrs Tarbuck’s address. Having
attended for  a pre-arranged visit to  his  friend, he  couldn't get a response from  Mrs  Tarbuck and thought
something was wrong.

The caller was informed that the  police were not  the most appropriate agency to  attend this incident and
the caller was signposted to the North West Ambulance Service (NWAS) as a more appropriate agency to
progress the concern. During this call no information relating to Mrs T arbuck having a history of falls nor any
perception that  Mrs Tarbuck was  to be considered at high risk to have suffered intentional physical harm
was disclosed to the police call handler (and GMP understand there was no concern that Mrs Tarbuck may
have deliberately self-harmed).

The police call handler was informed that a family member believed there was a possibility Mrs  Tarbuck
could have fallen inside the premises and the caller stated that he did not believe Mrs Tarbuck to have fallen
but that she could be deceased inside the property. This comment was made by the caller in response to
the police call handler suggesting that an ambulance would be the most appropriate agency to respond to
a person believed to have suffered a fall.

 Cont.d pg 2

GMP’s  response to  CFW  under  Right  Care,  Right  Person  (RCRP)  aligns  with  its  legal  obligations under
Articles 2 and 3 European Convention on Human Rights (ECHR) (right to life and prohibition of torture). As
such  it  is  imperative that  call  handlers  fully  understand the  nature  of  concern to  allow  for  an  effective
assessment as  to  whether police deployment is required.  Both  aforementioned comments should have
elicited  further  questioning  from  the  police  call  handler  to  understand  the  circumstances  and  risks
associated with this incident and the basis of these comments but unfortunately this further questioning did
not take place.

At  the  time  of  call handling, appropriate questioning had  not  been  carried  out.  Very  few  questions were
asked by the police call handler to understand the circumstances and risks associated with this  incident.
The call handler did not thoroughly question the caller to fully understand the  incident being reported and
they appear to have already formulated the  assumption that  NWAS were the  most  appropriate agency to

manage this CFW before all the information was gathered. Appropriate feedback has been provided to the
call handler involved.

GMP accepts that there were  suboptimal elements to the  way in which the  concern for Mrs Tarbuck was
handled, including a lack of professional curiosity in the level and manner of questioning, the language used
and that  insufficient information was  gathered to  support the  identification and  assessment of  risk.  The
RCRP  assessment  tool,  designed  to  support  call  handlers  to  identify  the  most  appropriate  agency  to
progress the incident, was not completed until after the call had ended.

The family of Mrs Tarbuck were of the view that she may have fallen and it transpired that Mrs Tarbuck had
in fact  fallen within the  premises.  NWAS  accepted the  incident and responded within a timeframe they
deemed appropriate for the nature of  concern and utilised the  Greater Manchester Fire & Rescue Service
(GMFRS)  Gaining Entry Memorandum of Understanding (MoU)  processes as intended (outlined further in
this report).

It  is  acknowledged  that  the  questioning and  identification  of  risk  was  sub-optimal, meaning there  was
insufficient evidence or good reason to confirm either a location or a physical health need (both of which are
required deployment criteria for NWAS).  As the caller and Mrs Tarbuck’s daughter believed she had indeed
fallen and/or was deceased within her home address, however, further questioning by the police call handler
would  likely  have  identified  the  evidence  to  support  the  notion  that  NWAS  was  the  most  appropriate
emergency agency to attend to address a medical concern.  As as such, the advice to contact NWAS was in
line with RCRP principles.

This  incident has  subsequently been the  subject of  a debrief between GMP  and  NWAS  and  NWAS  have
stated that  a lack  of  reasonable grounds to  support both  a confirmed location and  a confirmed physical
health concern would likely, in future, result in NWAS refusing to respond. Should there be any disagreement
between  agencies,  there 
is  a  professional  inter-agency  escalation  procedure  in  place,  enabling
communication to take place between agencies swiftly and  directly.  GMP acknowledge this position and
understand that this has  been the  operational stance of NWAS since the implementation of  RCRP within
Greater Manchester.

 Cont.d pg 3

Right Care, Right Person

Right Care Right Person (RCRP) is a national approach supported by the  Home Office and the College of
Policing designed to  ensure that  people of  all ages, who  have physical, mental health and/or social care
needs, are responded to by the right person, with the right skills, training, and experience to best meet their
needs.

GMP’s  RCRP  project was  developed under  the  oversight of  Greater  Manchester’s  Deputy  Mayor.  Each
thematic response pathway was agreed prior to launch with relevant partners including (but not limited to)
local authorities, health services (including NWAS) and mental health service providers.
RCRP was launched in Greater Manchester on the 30 th September 2024.

Under  RCRP, when  a concern for  welfare (CFW)  is reported, GMP will strive to identify the  nature of the
concern and either deploy police resources or signpost the caller to the most  appropriate agency to meet
their needs.

CFW calls are often complicated and can consist of numerous issues across various thematic areas. Whilst
RCRP aims to  signpost the caller to the most  appropriate service to meet  their needs, it is acknowledged
that this  may  not  always be possible, and the complexity of  such calls  may require the  services of more
than one organisation to support the subject of the CFW call.

In  cases  involving more  than  one  concern, GMP  will  signpost  to  the  most  appropriate  organisation  to
address whichever concern GMP feels is the most pressing or primary concern.

The  RCRP  policy  and  procedure  is  predominantly  aimed  at  staff  and  officers  within  the  Force  Crime,
Contact and  Operations (FCCO)  branch who  manage all  incoming 999  and  101  calls  to  GMP,  including
those relating to a CFW. However, the policy will also enable officers and staff throughout the organisation
to ensure they act  in line with the principles of RCRP. It aims to ensure that any response to a request for
service is  focused on  the needs  of  the  individual and  where necessary, partner agencies are  engaged to
provide the most appropriate response.

GMP’s RCRP policy seeks to affirm the police's duty to deal with core policing responsibilities, which are:

(cid:127)  To prevent and detect crime;

(cid:127)  To keep the King’s peace;

(cid:127)  To protect life and property.

If the initial RCRP assessment identifies that police are the most appropriate agency to respond, resources
will be deployed in a manner and timescale appropriate to the identified risk. This response will be in line
with  current deployment timescales (i.e. Immediate or  grade 1  incidents -  within 15  minutes; Priority or
grade 2 - w i t h i n  1 hour; and all other incidents for progression via a more ‘slow time’ response).

If an initial RCRP assessment identifies that police are not the most appropriate agency to take ownership,
the caller will be informed of this decision and then signposted to the most  appropriate agency to address
the concern.

 Cont.d pg 4

In Greater Manchester, aligned to  national RCRP principles, the following thematic areas and associated
signposting pathways have been designed to assist in handling CFW calls under RCRP:

(cid:127)  Physical Health

(cid:127)  Mental Health

(cid:127)  Social Issues

Understanding the nature of concern

By assessing each CFW call via an RCRP assessment tool, call handlers should be able to determine the
nature of  the  concern.  The  RCRP  assessment tool  is  a bespoke question set  which  is  built  into  GMP’s
command and control system, meaning call handlers have immediate access to the relevant question set
at the time of incident creation and importantly whilst obtaining information from a caller reporting a CFW.
It has been designed to assist call handlers to identify the nature of the concern and whether the police are
the most appropriate agency to respond or whether the CFW can be better facilitated by a partner agency.

A  number  of  GMP  policies  outline  an  expectation  for  call  handlers  to  be  professionally  curious  when
handling initial calls with the aim of correctly identifying and assessing risk. The RCRP-policy is no exception
to this. The following relevant passages are all found within the RCRP policy and procedure document:

(cid:127)  Call handlers/CRROs (Crime Recording and Resolution Officers) should ask questions of the caller
to ensure that the circumstances of each call are fully understood so a decision can be made as to
whether it is a matter for the police to  accept. As such  call handlers should remain professionally
curious and ask any questions, they deem relevant.

(cid:127) 

It  is  paramount  that  call  handlers/CRROs  recognise  any  identified  risk  and  if  necessary  are
professionally curious to ensure understanding. It is acceptable to question informants to quantify a
perceived risk.

(cid:127)  Often when people are reporting an incident to the police, they are not clear as to  what they want
the  police  to  do.  The  importance  of  understanding  what  is  being  reported  should  not  be
underestimated. Call handlers/CRROs have a key role to play here in asking questions to the caller
to  understand the  detail. As  well as using the  RCRP assessment tool, call handlers /  CRROs  are
expected to refer to the service standards as set out in Sherlock (defined below) and encouraged to
ask further questions in order to be satisfied as to the exact nature of the call.

Handling Physical Health concerns
The concern for welfare incident relating to Mrs Tarbuck was considered a physical health concern by the
police call handler and as such the caller was signposted to contact NWAS.

GMP are not the most appropriate agency to respond to physical health matters. Call Handlers are trained
to use the RCRP assessment tool which assists them in identifying whether an incident involves a real and
immediate risk to life or risk of serious harm, but they are not trained to triage physical health concerns or
identify a suitable operational response to such concerns.

As such, under RCRP, GMP will not ordinarily provide a policing response to physical health concerns.

 Cont.d pg 5

NWAS are the appropriate organisation to remotely assess physical health concerns reported to them, by
members of the public and GMP.

Where the nature of a CFW call relates to a physical health concern, GMP will signpost the caller to the NHS
and/or NWAS. GMP will only respond to physical health concerns when there is an associated immediate
risk of harm to a partner agency /third party or there is a requirement for police to assist (via a specific police
function/core responsibility).

Under the physical health pathway, if the caller thinks their concern is a physical health emergency they are
signposted to contact NWAS via 999.

A partnership agreement formalising this  physical health pathway was  signed by representatives of  GMP

and NWAS in October 2024, but it was informally in place prior to this time.

In April 2024, NWAS clarified their operational stance that they will provide emergency ambulance services
for  people  with  a  confirmed location. NWAS  has  defined ‘confirmed location’ to  capture circumstances
whereby the caller has  evidence or good reason to believe that the patient or service user is at a location,
and who have a confirmed physical health issue, or mental health need with a co-associated physical need.

NWAS has defined a ‘confirmed physical or mental health complaint’ to  capture circumstances whereby
“the caller has evidence or good reason to believe that the patient or service user is currently suffering from
a physical or mental health issue that requires an ambulance response”.

Right Care, Right Person training

Prior to  the  launch of  RCRP, all relevant staff  were  provided with  training overseen by  a Detective Chief

Inspector from GMPs RCRP project team. Initial training was delivered in May 2024, followed by refresher
sessions in September 2024.

This training covered various RCRP elements including areas pertinent to incidents similar to the handling
of the concern for Mrs Tarbuck as outlined below;

(cid:127) 

(cid:127) 

(cid:127) 

(cid:127) 

(cid:127) 

Identifying  Real,  Immediate  Risk  to  Life:  Assessment  Criteria:  This  section  of  the  training
provides guidance on the specific criteria used to determine if there is an immediate threat to life
in line with Article 2 ECHR, including factors such as the presence of weapons, threats

of  violence, and  signs of  severe distress. It  defines what  is meant  by real and immediate as per
policy and lists definitions of the specific incidents the police will still be responsible for.

Response Protocols: This section detail steps to  be taken when  an immediate risk is identified.
This  includes  contacting emergency  services  if  other  services  are  needed, responding to  the
incident and taking ownership of it.

Referral Process: Lists steps for referring individuals to appropriate partner agencies. This includes
sign posting callers to appropriate physical health services and the use of the medical contingency
process.

THRIVE Quality (THRIVE - Threat, Harm, Vulnerability, Investigation, Vulnerability, Engage) is the
standardised format for risk assessment used by GMP call handlers.

 Cont.d pg 6

An  explanation of  the  THRIVE  model,  which  is  used  for  assessing and  responding to  various  situations
involving risk was captured within the training. This includes understanding the different components of the
model and how they apply to real-life scenarios.

(cid:127) 

(cid:127) 

Quality  Assurance:  Measures 
the  quality  and  consistency  of  THRIVE
assessments.  Examples  were  provided  of  good  quality  THRIVE  assessments  shortly  after
implementation to ensure better understanding of what was acceptable.

to  ensure 

Risk  Principles: Outlining the  College  of  Policing Risk  Principles to  remind  participants of  the
necessity to make good decisions backed by strong rationale and documentation.

Call handlers were initially supported by a number of subject matter experts (SME’s) from the RCRP project
team  who  had  enhanced training and  knowledge of  RCRP.  The SME’s were  available 24/7  to  embed the
principles of RCRP and support call handling staff when handling CFW calls.

For the two-week period after RCRP went live in GMP, on-site support was also provided by SME’s from the
Metropolitan  Police  Service,  who  launched RCRP  in  November  2023  and  Humberside  Police  who  are
credited with developing RCRP and who went live in 2020.

Gaining entry on behalf of NWAS

In  April 2024,  GMP, NWAS  and  GMFRS signed the “Gaining Entry  Memorandum of  Understanding”.  The
purpose of the MoU is to  outline a process to guide NWAS in circumstances whereby they needed to gain
entry into premises to  assess patients who  require an emergency clinical assessment.  Under  this  MoU,
GMFRS are the primary agency to support NWAS when forced entry is required at a premises. GMFRS will
utilise their powers under the Fire and Rescue Service Act 2004, specifically Part 2 section 11, which notes:

(1)  A fire and rescue authority may take any action it considers appropriate—

(a) in response to an event or situation of a kind mentioned in subsection (2);
(b) for the purpose of enabling action to be taken in response to such an event or situation.

(2)  The event or situation is one that causes or is likely to cause—
(a)  one or more individuals to die, be injured or become ill;

If NWAS require assistance with gaining entry they will contact North West  Fire Control (NWFC).  NWAS
must have allocated a resource to the given address or to be already in attendance for GMFRS to  attend a
category one  call.  NWAS  provide  a  category one  response ‘for  people  with  life-threatening injuries and
illnesses’.

GMFRS will only attend category two, three and four incidents once NWAS resource is in attendance. NWAS
provide a category two response ‘for people whose injuries and illnesses may not be life-threatening but still
require emergency care’ and  a category three response ‘for  people who  require urgent help, but  it isn’t an
emergency’. If GMFRS cannot respond to a request to force entry owing to other emergency situations then
NWFC will request that GMP attend.

These measures were agreed by all three organisations (GMFRS, NWAS and GMP) and ensure that support
to force entry can be provided to NWAS by either GMFRS or GMP when required.

 Cont.d pg 7

The  most  relevant legislation  relied  upon  by  police  to  effect  entry  when  dealing with  a  CFW  is  Section
17(1 )(e) Police and Criminal Evidence (PACE) Act 1984 which states that a constable may enter and search
premises for the purpose of saving life or limb or preventing serious damage to property.

The case of Syed v Director of Public Prosecutions [201 0] EWHC 81 (Admin) provides guidance in relation
to the police use of S17 PACE when the reason for their entry was a concern for someone’s welfare.

In Syed v DPP, the court ruled that “Concern for welfare is not sufficient to  justify an entry within the terms
of  s. 1 7(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 s. 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”.

Whilst  the  findings  of  Syed  v  DPP  do  not  bar  police  from  utilising their  powers  under  S17  PACE  when
responding to  a CFW,  it  is clear  that  the  threshold for  police to  force  entry is higher (saving life  and  limb
having been  interpreted in  Baker  v  Crown  Prosecution  Service  [2009]  EWHC  299  (Admin)  as  meaning
‘apprehended serious bodily injury’) than  that  required by the  fire  and  rescue services under  the  Fire and
Rescue Services Act 2004 (situations...likely to cause...individuals to die, be injured or become ill).

In addition to the  lower threshold required for GMFRS to force entry, the deployment of GMFRS resources
to  CFW  incidents provides an  improved service to  the  communities of  Greater Manchester by  improving
response times (as it is often the case that GMFRS has a greater capacity than police to respond promptly
to  requests to  force  entry in  support of  NWAS). GMFRS  also  often  has  ready  access to  more  advanced
equipment to effect entry than that carried by response police officers, thereby facilitating earlier access to
the patient.

The  Gaining Entry  MoU  provides  clear  roles  and  responsibilities  for  each  agency  when  forced  entry  is
required by NWAS, removing any potential confusion between agencies as to who will attend to force entry.

In the case of Mrs Tarbuck, having signposted the caller to NWAS, all relevant agencies were clear in their
understanding of the  Gaining Entry MoU.  As NWAS were the agency taking the lead on this CFW, GMFRS
would be the primary agency to force entry, if requested to do so by NWAS.

Learning and subsequent developments

Since  the  implementation of  RCRP  in  September  2024,  GMP  has  undertaken  a  series  of  measures  to
improve compliance and mitigate risks.

GMP have reviewed the application of RCRP in a number of cases since its introduction. Learningfrom those
reviews  has  identified  themes  of  sub  optimal  information  gathering  and  risk  assessment,  lack  of
professional curiosity  and  a  proclivity  to  signpost  callers  to  NWAS  when  a  confirmed  physical health
concern has not been identified.

 Cont.d pg 8

As such, a number of measures have been implemented to address these concerns.

To support understanding of, and adherence to RCRP policy, including the expectation that call handlers are
professionally  curious  and  fully  understand  the  nature  of  concern,  enhanced  scrutiny  and  oversight
processes have been set up within the Force Contact, Crime and Operations branch (FCCO) of GMP.  Such
scrutiny includes performance audits, dip sampling, use of personal performance plans where necessary
and a bespoke "FCCO Performance Dashboard", which pulls together audits and tracks key metrics such as
RCRP toolkit compliance and accuracy of signposting.

To support improved information gathering a new RCRP assessment tool was developed in early 2025. This
new assessment tool was developed with the  aim  of supporting call handlers to better navigate the  often-
complicated  nature  of  CFW  calls  and  their  interdependencies  with  other  areas  of  business.  This  new
assessment tool is currently undergoing testing within the FCCO.

The  proposed  assessment  tool  will  seamlessly  link  various  thematic  areas  into  one.  It  will  provide  a
framework that  will allow call handlers to navigate multiple themes without a having to shift their mindset
from one policy area to another.

The assessment tool currently in use covers only CFW and then signposts the user to consider other policy
areas  such  as  missing persons (without navigating the  user  through such  processes). The new  toolkit is
expected to cover the following areas:

(cid:127)  CFW (Mental health, Physical Health, Social Issues)

(cid:127) 

Improved CFW & Crime outcomes

(cid:127)  Missing Persons

o  Missing Adults
o  Missing Children

(cid:127)  AWOL Patients

(cid:127)  Walkout from Healthcare

(cid:127)  Child concerns -  Child information sharing processes.

As part of their daily business, call handlers often use a computer system within GMP known as Sherlock.
Sherlock is a directory that contains guidance and service standards that call handlers can access to better
understand the area of business relevant to the call they are handling.

As part of the RCRP implementation, a number of  new guidance documents were produced and installed
into the Sherlock system to support call handlers understand relevant RCRP processes and police functions
and obligations in relation to CFW calls. These guidance documents are located in folders thatare accessed
by call handlers if/when they require additional guidance. Call handlers need to understand which piece of
guidance is relevant at the relevant point of incident handling, often multiple pieces of information would
need to be accessed for a single call.

Within the  proposed assessment tool, this  guidance is presented on  screen at relevant points within the
question framework, meaning that users see the right information at the right time, displayed alongside the
relevant question of the assessment tool.  This obviates the need to search Sherlock to find a particular

 Cont.d pg 9

piece  of  information, thus  presenting opportunities to  improve consistency  of  service  and  reduces the
possibility of misunderstanding and the mis-categorisation of a particular incident.

This upgraded version is currently undergoing testing and is expected to be rolled out by November 2025.

Whilst testing of the new RCRP assessment tool is ongoing, GM P’s RCRP project team is currently reviewing
the  current assessment tool to  ascertain if  amendments can  be  made to  better  support call handlers in
understanding the  nature of  concern and  to  ensure they  are professionally curious when  managing CFW
calls. This work is currently focusing on the wording and order of the question scripts as well as considering
whether further questions can be added to the assessment tool to improve service delivery.

Actions have already commenced to amend the language of both toolkits to incorporate NWAS’ definitions
of  ‘confirmed  location’  and  ‘confirmed  physical  health  need’  to  ensure  improved  consistency  and
understanding between GMP and NWAS when handling CFW  incidents. Within the proposed assessment
tool these definitions will appear on screen, to prompt call handers to ask the pertinent questions to identify
the concern.

Training and education have been central to our improvement strategy. Bespoke workshops for the Service
Development Unit  and  leadership teams  are  planned to  be  delivered  during the  week  commencing 1st
September 2025. These workshops are designed to effectively calibrate managers and SPOCs, using recent
case studies and inquest findings to refresh their knowledge of RCRP pathways and policy.

Relevant staff have received additional training around the THRIVE model to ensure consistent and effective
risk  assessment  and  decision-making  across  all  RCRP-related  incidents.  Initial  THRIVE  training  was
delivered to all staff between August 2023 and February 2024, and all new staff continue to receive THRIVE
training  as  part  of  their  induction. This  model  underpins  GMP’s  approach  to  prioritising  incidents  and
allocating resources, ensuringthat responses are proportionate, appropriate, and aligned with the  principles
of RCRP. Where audit findings identify issues with the application of THRIVE assessments, staff are required
to undertake refresher training and are subsequently monitored and supported to ensure compliance and a
clear understanding of the model

To support the ongoing understanding of RCRP, further training has been developed that will align with the
proposed assessment tool.  This training has been created within the Nearpod system. Nearpod is a third-
party training platform which allows users to  access modular training relevant to  their training needs  and
provides bite-sized yet informative inputs, available when required to upskill staff. This training is currently
being utilised, pending the trial of the new assessment tool.

RCRP  refresher training for  call  handling managers and  supervisors is  currently being developed  by  the
original RCRP training team with support from the RCRP project team as well as upskilling inputs for GMP’s
Service development Unit  (SDU - the unit responsible for auditing and reviewing RCRP incident handling).
This training and upskilling is expected to be in place by the end of 2025.

GMP’s RCRP project team are working closely with NWAS and other police forces, including those in which
RCRP has been implemented for a longer period, to understand working practice within other force areas to
identify and benchmark best practice that can be quickly adopted by GMP to further improve standards.

 Cont.d pg 10

GMP’s FCCO branch oversee the application and compliance of RCRP by call handling staff. Overseen by
Rebecca Greaney, Head of Contact Management and Business Transformation, who has provided the below
overview of remedial measures to address issues identified in the handling of RCRP incidents.

FCCO have implemented a new governance framework to mitigate further risk which includes a fortnightly
SLT meeting, which will bring together Business Leads and Superintendents across all areas of the Branch.
The agenda will cover:

(cid:127)  Tracking performance.  To monitor performance, GMP has developed a live dashboard that tracks
key  metrics  for  RCRP-related  incidents.  These  include  whether  callers  were  signposted  via  an
agreed  pathway.  Initial  audit  data  from  February  2025  indicated  that  87%  of  incidents  were
signposted correctly.  Subsequent audits conducted in June and  July  2025  (n=277)  show  marked
improvements with signposting accuracy having increased to 94%.

(cid:127)  Fortnightly SDU feedback using amended audit methodology (this complements a wider change to
the FCCO audit plan whereby Managers and Business Leads will be required to audit the work of the
teams to offer consistency and reassurance).

(cid:127)  Track  individual supportive  performance  plans  across  the  teams  including  supervisors  if/when

necessary.

(cid:127)  Track Robotic Processing Audit (RPA) results

GMP’s commitment to  continuous improvement is  demonstrated through the establishment of the  RCRP
Learning Group  (RCRPLG), chaired by  ACC  Matt  Boyle  in  his  capacity as  RCRP Gold.  The  RCRPLG was
established in March 2025 and runs on a bi-monthly basis, with the most recent meeting held on 1 5th July
2025.  It  serves  as  the  primary forum  for  reviewing operational practice, thematic  concerns, and  policy
matters related to RCRP. Its purpose is to identify learning, support professional development, and ensure
consistent and  coordinated improvements across the  organisation. The  group  works  closely with  GMP’s
organisational learning structures  and  considers  both  internal and  national best  practice.  Membership
includes representatives from key branches and partner agencies, ensuring that learning is embedded and
shared effectively.

Additional work  is  ongoing to  further  educate call  handlers around  signposting and  the  communication
strategy has been revisited. This ongoing activity includes:

(cid:127)  Northwest  Ambulance  Service  (NWAS)  knowledge  sharing  -  to  strengthen  collaboration  and
understanding,  weekly  meetings  have  been  introduced  between  the  FCCO  and  NWAS  Senior
feedback  and  concerns  regarding  signposting  between  both
Leadership  Teams  to  share 

organisations.  NWAS  will  also  support  weekly  GMP  performance  meetings  (held  with  team
managers and supervisors on a 5x week rota) to share case studies and learning.

(cid:127)  Knowledge-sharing visits between FCCO  and  NWAS  commenced on  14th  July  2025  and  remain
ongoing, with the most recent taking place on 4th August 2025. GMP control room staff visit NWAS’
control rooms to promote better partnership working and understanding of organisation issues and
impact.  These visits include first and second line leaders, with identified supervisor SPOCs tasked
with cascading learning across their teams.

 Cont.d pg 11

(cid:127)  10x  supervisor SPOCS (Specialist Point Of  Contact) identified -  2x per  call handling team. These
SPOCS will attend the  NWAS  site visits and  have been  tasked with  cascading the  learning to  the
individuals across their teams on their return. They will also be tasked with upskilling their staff and
will spend time with GMP’s RCRP subject matter experts to  further educate them  on the thematic
challenges identified across the Branch.

(cid:127)  Communication strategy - Wider communication has been circulated to supervisors and managers
within the FCCO as a reminder about expectations, standards and behaviour particularly addressing
the key risks.  Communication strategies have been reinforced through digital wallboards and regular
messaging  to  supervisors  and  managers.  These  communications  are  designed  to  maintain
awareness of key RCRP principles and support continuous improvement. Recent examples include
the  use  of case studies from live incidents and inquests to  highlight learning points, the  sharing of
audit findings to identify areas for improvement, and reminders about correct pathway usage under
the  RCRP  framework. These  targeted  messages ensure  that  staff  remain  informed, aligned,  and
equipped to apply the policy consistently.

(cid:127)  Robotic Process Automation (RPA) and technical enhancements -  RPA has been implemented and
can be flexed as required to measure performance and standards. Current priorities are to target the
use of formal end statements, THRIVE and Police National Computer Checks.  The RPA is limited to
a quantitative compliance check rather than a qualitative assessment but allows compliance issues
to  be  addressed quickly and  individuals to  be  managed via  performance plans  if  required and  the
behaviour persists. Technological enhancements are also being pursued with the design of further
toolkit style products that guide call handlers through relevant questions to ensure standardisation
and improved compliance.

(cid:127)  RCRP policy re-read -  To reinforce policy understanding, the FCCO is currently conducting an audit
of  all staff who have a role  within the RCRP processes, including staff  and  supervisors within call
handling,  crime  recording, customer  enquiry unit  and  radio  dispatch to  ensure  there  is  a  record
confirming they  have  read  and  understood the  RCRP  policy.  All  relevant  staff  have  been  given
protected time  to  read the  RCRP policy and  subsequently confirm this has  been completed via  a
Microsoft Form. This audit is expected to be completed by the end of August 2025.

This audit also includes support mechanisms forthose identified as not fully understanding their role
once  the  policy has  been  read. This  includes access to  RCRP  subject matter  experts to  provide
clarification around any points of misunderstanding or ambiguity.

These plans are now  in place to mitigate the risks identified, driven by the FCCO Senior Leadership Team
and supported by the RCRP project team. The governance for progress is to be tracked within the FCCO via
a fortnightly branch meeting chaired by Head  of  Contact Management. Further governance will be via the
RCRP Silver group (chaired at Chief Superintendent rank) and RCRP Gold group (chaired at Assistant Chief
Constable rank).

FCCO  senior leaders will measure improvements by audit results, partner feedback and  ongoing project
team  scrutiny. The FCCO Senior leadership team are committed to  implementing the mitigations listed to
help ensure these risks are minimised.

 Cont.d pg  12

A robust wraparound support plan is in place to monitorthe implementation for RCRP. This includes regular
internal and partnership governance meetings at a strategic and tactical level, escalation processes in both
live and slow time and an opportunity to share partner data to assess the impact of the implementation of
the model.

Looking ahead, GMP aims to sustain signposting accuracy at or above 94% and improve toolkit compliance
to  90%  or  higher. A revised audit plan  was  implemented in  June 2025  and now  includes assessments of
supervisory  decision-making  to  strengthen  accountability  and  oversight.  These  actions  reflect  GMP’s
commitment to continuous improvement and to ensuring that the principles of RCRP are embedded across
all levels of the organisation.

I trust that the detail within this letter serves to demonstrate the considerable amount of work is underway
to  address  the  matters  of  concern,  to  improve  the  standards  of  call  handling specifically  around  the
understanding and identification of risk and work continues to ensure the Right Care, Right Person model is
embedded  safely  within  Greater  Manchester,  to  ensure  the  communities  of  Greater  Manchester  are
responded to by the right person, with the right skills, training, and experience to best meet their needs.

Yours sincerely

Chief Constable

HM Senior Coroner 
Mr T. Brennand 

Date: 15th August 2025 

Dear Mr Brennand 

LADYBRIDGE HALL 
399 Chorley New Road 
Bolton 
BL1 5DD 

nwas.nhs.uk 

We write in reference to the Regulation 28 report issued to Greater Manchester Police in connection with the sad 
death of Ms Elaine Tarbuck. 

We understand that North West Ambulance Service (NWAS) were not Interested Persons and did not receive a 
disclosure bundle therefore, we are limited in terms of the information we hold in respect of the incident.  We felt a 
response to your concern was required as we aim to provide the court with any assistance if we are able. 

In terms of NWAS we note your concern as follows: 

‘In fact, calls to the non-emergency 101 and 999 emergency lines evaluated that this was a non-critical emergency 
and a presumed medical event. This created a significant delay before it was appreciated that entry would need to 
be forced and the Fire and Rescue Service were requested to attend.’ 

NWAS received a call at 11:52hrs which was coded as a Category 3 response and arrived at 12:18hrs, which is within 
the Ambulance Response Programme timeframes set by NHS England. 

As part of the collaborative efforts between NWAS, North West Police Forces, and wider system partners in the 
implementation of the Right Care, Right Person (RCRP) model, NWAS formally provided its organisational position on 
responding to Concern for Welfare calls in 2024.  The below details our organisational response to ‘Concern for 
Welfare’ calls. 

Confirmed Location.  

• 
NWAS are not equipped to conduct inquiries or execute searches for missing individuals. Consequently, 
NWAS necessitate a verified location and assurance that the patient is indeed present at the specified location 
where an ambulance resource is being dispatched to. Additionally, NWAS rely on accurate contact information, 
ensuring that any provided contact number will connect us directly with the patient.  

A confirmed location means that the caller has evidence or good reason to believe that the patient is at the 

• 
location provided. 

NWAS does not have the legal powers, nor the equipment to force entry to properties, this should be 

• 
considered before any call for assistance is made. 

 
 
 
    
 
 
 
 
                                                                               
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Confirmed Physical or Mental Health Complaint. 

As an ambulance service, NWAS’s primary function is to prioritise and respond to the medical needs of 

• 
patients, whether this is face-to-face or via other methods, therefore, it is not the expected primary response for 
those who have no medical need to require our assistance. 

• 
A confirmed physical or mental health complaint means that the caller has evidence or good reason to 
believe that a patient or service user is currently suffering from a physical or mental health issue which requires 
either a face-to-face assessment or telephone response.  

• 
It cannot be assumed that an individual who is contactable, is in need of medical assistance. Similarly, 
patients who have left a healthcare facility have the right to do so, therefore the rationale as to what role an 
ambulance response will play and whether it is ethical and legal to dispatch one to a patient who has refused care or 
treatment must be provided.  

Whilst it is acknowledged that, in the case of Ms Tarbuck, NWAS did deploy a resource following a call made to us, it 
is important to note that this deployment was not in line with our current procedures for Concern for Welfare 
incidents. 

Based on the information provided at the time of the call, there was insufficient evidence of a confirmed location or 
a clear medical need, both of which are required criteria for ambulance deployment under the NWAS Concern for 
Welfare procedure. 

NWAS, in partnership with Greater Manchester Police (GMP), has identified a recurring thematic issue involving calls 
being passed from GMP to NWAS that do not meet the agreed threshold for Concern for Welfare as outlined in the 
Right Care, Right Person stakeholder meetings. These concerns have been formally escalated to Senior Leaders 
within GMP and to the Deputy Mayor for further consideration and action. 

In response, a number of collaborative measures have been implemented to address this issue and strengthen inter-
agency working. These include: 

• 

• 

Delivery of targeted training briefs to enhance understanding of the Concern for Welfare criteria. 

Review of incident logs to identify trends and learning opportunities. 

Visits by GMP supervisors and managers to the NWAS control room to observe triage and decision-making 

• 
processes in real time. 

Ongoing regular meetings between NWAS and GMP leadership teams to monitor progress, share insights, 

• 
and maintain alignment. 

These initiatives contribute to ongoing improved collaboration and aim to reduce the risks associated with 
inappropriate call transfers, and shared understanding of service commissioning gaps which require review by 
commissioning colleagues. 

NWAS remains fully committed to working in partnership with GMP to support their ongoing implementation of the 
Right Care, Right Person approach. Our focus continues to be on maintaining patient safety, ensuring appropriate 
use of emergency resources, and identifying further opportunities for collaboration that strengthen service delivery 
across both organisations. 

We trust that you are satisfied with NWAS’s response but please do not hesitate to contact us should you have any 
further questions or concerns and we will do our very best to assist you.